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Health care
providers apply best practices from latest researches and use appropriate tools to
enhance the quality of health care delivered.Patients appear to become more engaged
in their care, through information available on the Internet, radio, and
television. Communication problems between patients and health care providers,
brought about by geographical disparity, are easily solved by mobile phones.
Computers are used to store, retrieve, and process important health data for better
decision making. Information and Communications Technologies (ICT) ares becoming
indispensable tools in addressing some challenges in health care.ICTs are defined
as, “diverse set of technological tools and resources used to communicate, and to
create, disseminate, store, and manage information." These technologies include
computers, the Internet, broadcasting technologies (radio and television), and
services, health surveillance, health literature, telephony. This chapter explores
the actual and potential applications of ICTs geared toward improving people's
access and utilization of health care in the Philippine community health setting.
What is eHealth? eHealth is the use of ICT for health. On May 25, 2005, during the
Fifty-Eighth World Health Assembly (WHA), a resolution was adopted by the World
Health Organization (WHO) member states recognizing eHealth as the cost-effective
way of using ICT in health care services, health surveillance, health literature,
health education, and research. Given the extensive capabilities of ICT, eHealth
can be considered in any of, but not limited to, the following:
• Communicating with a patient through a teleconference, electronic mail
(e-mail), short message service (SMS).
• Recording, retrieving, and mining data in an electronic medical record
(EMR).
• Providing patient teachings with the aid of electronic tools such as
radio, television, computers, smartphones, and tablets.
eHealth, often confused with telehealth or telemedicine, is the overall, umbrella
term. According to the WHO, eHealth encompasses three main areas:
Nurses are knowledge managers. They constantly process raw patient data into
valuable information to deliver evidence-based and individualized interventions. It
is imperative for every eHealth practitioner to know the importance and difference
between the two.
Data are the fundamental elements of cognition and are defined as unanalyzed raw
facts that do not imply meaning. When meaning is attributed to data and when data
are processed and analyzed, then data become information.
Consider, for instance, the number 39. It can be an age, house number, jersey
number, etc. This is data. The school nurse noted that it was written on the
respiratory rate field of the record of Grade 5 student Rosemarie. Number 39 now
has a meaning to the nurse and has become information. Based on the nurse's
knowledge that Rosemarie's respiratory rate is above normal and considering other
findings, the nurse concludes that she is hyperventilating. The nurse gave
Rosemarie a brown paper bag to breathe into.
The health care system builds heavily on accurate recording of obtained data.
Paper-based methods may bring inconvenience especially when it comes to
interoperability of health services, information backup, and instant data access. A
number of bigger problems may also emerge:
The nursing process begins with obtaining data through assessing the patient's
signs and symptoms. These data are interpreted by the health care professional into
useful information and a diagnosis. This is then followed by necessary
interventions and again ends with gathering new data from evaluating the results.
Without data, it will be difficult for a health professional to assist the patient.
Human error, viruses, bugs, and hardware issues pose a great threat to the
integrity of data. ICT can help decrease these errors by putting safeguards in
place, such as backing up files on a routine basis and error detection. In order
for information to be valuable, data must have the following characteristics:
Based on lessons learned from the early BuddyWorks experience, the project switched
to the use of technology that is more appropriate to Filipinos—mobile phones.
"Not too long ago we had nothing to think about except the board exams. And before
that, we had to make sure we were qualified to take the exams by completing the
requirements, along with many other adversities. Sure, passing the exams was a
reason to celebrate, but I was celebrating yesterday, not tomorrow.
I knew darker days lay ahead. The United States was in the midst of trying to
reform their health care system (again). US President Barack Obama wanted to solve
their nursing shortage from within instead of importing foreign nurses. Other
countries were not accepting new graduates and required a minimum of one year's
experience. This created a domino effect no one wanted. With the foreign-bound
staff nurses choosing to keep their local jobs, the 30,000 new registered nurses of
Batch 2009 were basically left with just their Professional Regulation Commission
licenses to be proud of.“ From the article "Cleaning Up." Published by the
Philippine Daily Inquirer, September 6, 2011.
Because of logistic limitations, government hospitals and health centers are mostly
understaffed despite the estimated 200,000 underemployed or unemployed nurses in
the country.
The DOH also recognizes the valuable purpose of ICT for health and has drafted its
National eHealth Strategic Framework for 2010-2016, with the vision of ICT
supporting UHC to improve health care access, quality, efficiency, and patient's
safety and satisfaction, for reducing cost and enabling policy makers, providers,
individuals, and communities to make the best possible health decisions.
EMRs are basically comprehensive patient records that are stored and accessed from
a computer or server. Community health centers have the capacity to rapidly adapt
EMRs because they utilize a standard process nationwide. For example, the workflow
with a patient at a health center in Quezon City is basically the same as that of a
health center at Batanes.
Another reason EMRs are vital to community health centers is that each patient
record is usually used more frequently. For instance, a patient undergoing
treatment for tuberculosis needs to make regular visits to the health center for
TB-DOTS (Tuberculosis Directly-Observed Treatment Shortcourse). A young child is
brought to the health center regularly for child care health services, such as
immunizations, deworming, and micronutrient supplementation. Community health
centers make health care services available to families, enabling the community
health worker to observe familial predispositions to certain diseases and provide
appropriate health promotion and prevention measures.
Ideally, a person can utilize health center services from womb to tomb. This ideal
scenario is made more likely if each patient encounter is properly documented and
the patient recording system is set up with accuracy and efficiency in mind.
As stated earlier, community health nurses should be aware of health patterns and
health indicators within their catchment area. Vital statistical indicators such as
mortality and morbidity rates must come from reliable data, which can be derived
from accurate and thorough EMRs. EMR systems also allow computerized processing of
indicators, making it easier for nurses to focus on other important aspects of
health care.
One of the most widely used community-based EMR in the country is CHITS, which
began in 2004 and was funded by the International Development Research Centre
(IDRC). It was created by Dr. Herman Tolentino of the University of the
Philippines-Medical Informatics Unit (UP-MIU) and is currently being implemented at
health centers in Pasay, Navotas, Quezon City, and several other municipalities
nationwide. Training on how to optimize the EMR for community use and on-site
follow-ups of the health workers were done. This resulted in EMR features that are
customized to the needs of the health center and the community. More importantly,
involving the target end users in the development process of the EMR gave them a
sense of ownership of the program, allowing easy acceptance and utilization of
CHITS.
Telemedicine
One of the five strategic goals of the DOH National eHealth Strategic Framework for
2010-2016 is to capitalize on ICT. This in order to reach and provide better health
services to geographically isolated and disadvantaged areas (GIDAs), to support MDG
attainment, and to disseminate information to citizens and providers through
telemedicine and mobile health (mHealth) services.
The WHO defines telemedicine as, "the delivery of health care services, where
distance is a critical factor, by all health care professionals using information
and communications technologies for the exchange of valid information for
diagnosis, treatment and prevention of disease and injuries, research and
evaluation, and for the continuing education of health care providers, all in the
interests of advancing the health of individuals and their communities".
In collaboration with the Philippine Council for Health Research and Development of
the Department of Science and Technology (DOST-PCHRD), the BuddyWorks project of
UPM-NTHC was continued from 2007 to 2010 as the National Telehealth Service Program
(NTSP).
A specific example of how telemedicine was applied in the community was the
discovery of a rare skin disease called tinea imbricata in a tribe from Kiamba,
Saranggani in Mindanao. The Municipal Health Office of Kiamba, Saranggani referred
multiple cases of strange, ring-like formations on a patient's skin. Images were
sent to the UPM-NTHC telehealth nurse and were referred to a dermatology specialist
at the Philippine General Hospital, who gave the initial diagnosis of tinea
imbricata—which has only been reported in the Philippines three times since 1789.
The recommended treatment was effective. This eventually led to a medical mission
by the dermatology specialist and her fellow dermatologists in cooperation with the
local government of Kiamba to help the patients affected by the disease.
As can be seen from the example, telemedicine has the capacity to bridge the gaps
in the health referral system. It is understandable that this is not a universal
solution and may be applicable only in specific scenarios. The goal of a patient
receiving the best care as soon as possible despite an unfavorable location or
other adverse circumstances may be reached through telemedicine.
eLearning
eLearning can also be used to educate fellow health professionals. With eLearning,
continuing education sessions can be frequently availed of, with less time, effort
and expense involved in the process. Continuing professional education of nurses
can be undertaken by attending online and virtual seminars through teleconferences
and multiuser virtual environments.
Graphics below are the summary of eHealth projects, past and present, that target
community health. Note that some projects are a combination of EMRs, telemedicine,
eLearning, and other ways by which ICTs impact health.
The similarities among the projects and their implementations are noteworthy. Also,
they are scattered in different parts of the country. The working of these projects
usually does not interfere with each other, creating potential problems as
previously explained.
ROLES OF COMMUNITY HEALTH NURSES IN EHEALTHCommunity health nurses' roles are
significantly diversified by eHealth. With the advent of eHealth, nurses are made
available to several clients at a single time, making health care delivery more
efficient. Advances in IT may also help the nurse in optimizing efforts towards
maintaining an open line of communication with clients, paving the way for
establishing and maintaining rapport. IT literally at the fingertips of the nurse
provides greater opportunity to learn more about clients and their conditions;
eHealth, however, cannot be a replacement for actual patient care. It is best
viewed as a powerful tool for nurses—bridging gaps and improving access especially
in a resource-constrained country like the Philippines.The following are the major
roles of an eHealth nurse in the Philippine community setting: Data and records
managerAs data and records managers, community health nurses monitor the trends of
diseases through the EMR, allowing for targeted interventions for health promotion,
disease prevention, curative services, or rehabilitation. Nurses also maintain the
quality of data inputs in the EMRs, making sure that information is accurate,
complete, consistent, correct, and current. Nurses also participate in regular data
audits. Change agentNurses act as change agents by working closely with the
community and implementing eHealth with them and not for them. Change agents do not
force technology on the community, but inform and guide the community in selecting
and applying appropriate ICT tools.Change agents also collaborate with health
leaders, policy makers, stakeholders, and other community health professionals to
determine their knowledge and awareness on eHealth and appropriate ICT tools.
Nurses then build on the baseline eHealth knowledge and help develop appropriate
eHealth tools for the community. EducatorNurses provide health education to
individuals and families through ICT tools (e.g. teleconference, SMS, e-mail, and
virtual/ simulated environment). They may also participate in making eLearning
videos on specific diseases (e.g. diabetes mellitus, tuberculosis), which the
patients can watch during their waiting time at health centers. Such videos may
also be installed in the clients' personal phones (if supported) and watched at a
time convenient to them.Nurses may also use scheduled text messages to patients
among the catchment population to send important health information, reminders,
etc. TelepresenterIn the event that a patient needs to be referred to a remote
medical specialist through telemedicine, nurses may function as a telepresenter.
This means that the nurse may need to present the patient's case to a remote
medical specialist, noting salient points for case assessment, evaluation, and
treatment. This usually occurs via a teleconference. Client advocateAs client
advocates, community health nurses must safeguard patient records, ensuring that
security, confidentiality, and privacy of all patient information are being upheld.
This becomes more challenging especially because with technology, transfer of
information can happen instantly.The client must also be well informed about the
benefits and challenges of EMRs, telemedicine, and other eHealth tools. Nurses must
ensure that personal and health information handling through eHealth (i.e.,
collection, storage, and transmission) is well explained. Clients must sign an
informed consent, if necessary.Nurses must also guarantee that all eHealth
interventions are performed in a safe and ethical manner, making sure that
personnel involved in eHealth are competent and have received eHealth
training/certification. ResearcherUsing eHealth tools (e.g. EMRs), patient records
can easily be retrieved and analyzed retrospectively by community eHealth nurses.
They are responsible for identifying possible points for research and developing a
framework, based on data aggregated by the system.An eHealth nurse researcher also
pursues continuing nursing informatics education, with the goal of developing a
research framework which will be beneficial to the community.