Instructional Module in NCM 111a (Community Health Nursing lecture)

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TECHNOLOGY AND COMMUNITY HEALTH

INTRODUCTION OF THE LESSON

AND PRESENTATION OF OUTCOMES

Health Information Technology (Health IT) is a broad term that describes the technology
and infrastructure used to record, analyze, and share patient health data. Various technologies
include health record systems, including personal, paper, and electronic; personal health tools
including smart devices and apps; and finally, communities to share and discuss information.

The purpose of Health IT is to provide better care for patients and help achieve health
equity. Health IT supports recording of patient data to improve healthcare delivery and allow for
analysis of this information for both healthcare practitioners and ministry of health/government
agencies. This data is used for the implementation of policies in order to better treat and prevent
the spread of diseases. Furthermore, Health IT improves the quality of healthcare delivery,
increases patient safety, decreases medical errors, and strengthens the interaction between
patients and healthcare providers.

This chapter will present vital information about the eHealth, the power of data and
information, the Current State Of Philippine Healthcare and the Development Of eHealth In The
Philippines As well as the Roles Of The Community Health Nurse In eHealth.

LEARNING OUTCOMES FOR THIS CHAPTER

At the end of this chapter, you must have:

1. Discussed the importance of information technology and community
health;
2. Discussed the e-health and its component;
3. Described the Power of Data in information;
4. Discussed the E-health situation in the Philippines and;
5. Discussed and enumerated the Roles of Community Health Nurse in e-
health.

WARM-UP ACTIVITY. Based on your knowledge and observation,

why is information technology so important in healthcare setting?
Enumerate at least 4 benefits of e-health.

CENTRAL ACTIVITIES
This part of the lesson includes five learning inputs and five activities. You need to
accomplish the activities and submit them in the designated folders of this lesson.

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Learning input 1.

The eHealth

e-Health is the use of information and communication technology to reinforce health and
health care. It refers to forms of prevention and education, diagnostics, therapy and care
delivered through digital technology, independently of time and place. As an umbrella concept,
it includes associated notions such as telemedicine, mHealth, tele-care, e-Public health, e-Mental
health or tele-health. These new forms of delivery produce new contents of care such as
‘blended’ care where conventional mental health care is combined with online interventions.

Furthermore, they produce new behavior, affect and thinking since we intensely interact
with technologies. Of course eHealth also denotes the IT-supported secondary process of care,
such as quality systems and e-administration; finance, procurement, logistics, medical records,
case management, appointments etc. Societal and scientific expectations of eHealth's potential
are flying high. eHealth allegedly strengthens the opportunities for self-care, self-management
and patient participation. It supposedly increases the range and impact of disease prevention
and health education. It drives dearly needed global healthcare innovation and curbs rising
expenditures. In short, eHealth consolidates the public interests of affordability, quality and
accessibility of health care.

Storage

The Electronic Health Record (EHR) is an electronic system used and maintained by
healthcare systems to collect and store patients’ medical information. EHRs are used across
clinical care and healthcare administration to capture a variety of medical information from
individual patients over time, as well as to manage clinical workflows.
EHRs contain different types of patient-level variables, such as demographics, diagnoses,
problem lists, medications, vital signs, and laboratory data. According to the National Academies
of Medicine, an EHR has multiple core functionalities, including the capture of health information,
orders and results management, clinical decision support, health information exchange,
electronic communication, patient support, administrative processes, and population health
reporting.

Retrieval

eHealth Record Retrieval Service transforms the ordeal of tracking down referral care
records, full diagnostic imaging, and pathology—which can often drag on for weeks—into a quick,
simple turnkey service that can be initiated a nurse. Broken and delayed appointments and non-
reimbursable duplicate exams are eliminated as all data requested through the eHealth Record
Retrieval Service will be delivered in a secure digital format either on eHealth Technologies'
secure online system and/or directly into your existing systems, providing a unified view of the
patient's complete record.

With one electronic request of the patient support specialists, the system collect, digitize,
index, and securely deliver complete electronic packages of all external historical records,
images, and pathology directly into the Hospital Information System (HIS), Picture Archiving and
Communication System (PACS), and Electronic Medical Record (EMR) systems.

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❖ Hospital Information System (HIS). is an element of health informatics that focuses mainly
on the administrational needs of hospitals. In many implementations, a HIS is a
comprehensive, integrated information system designed to manage all the aspects of a
hospital's operation, such as medical, administrative, financial, and legal issues and the
corresponding processing of services. Hospital information system is also known
as hospital management software (HMS) or hospital management system.
Hospital information systems provide a common source of information about a
patient's health history. The system has to keep data in a secure place and controls who
can reach the data in certain circumstances. These systems enhance the ability of health
care professionals to coordinate care by providing a patient's health information and visit
history at the place and time that it is needed. Patient's laboratory test information also
includes visual results such as X-ray, which may be reachable by professionals. HIS provide
internal and external communication among health care providers. Portable devices such
as smartphones and tablet computers may be used at the bedside.
❖ Picture Archiving and Communication System (PACS). A picture archiving and
communication system (PACS) is a medical imaging technology which provides
economical storage and convenient access to images from multiple modalities (source
machine types). Electronic images and reports are transmitted digitally via PACS; this
eliminates the need to manually file, retrieve, or transport film jackets, the folders used
to store and protect X-ray film.

❖ Electronic Medical Record (EMR). EMR stands for Electronic medical records, which are
the digital equivalent of paper records, or charts at a clinician’s office. EMRs typically
contain general information such as treatment and medical history about a patient as it
is collected by the individual medical practice.

Transmittal

E-health makes use of a wide array of digital technologies. The Internet, for example,
allows e-health users to communicate with health care professionals by e-mail, to access medical
records, to research health information, and to engage in person-to-person exchange of text,
audio, video, and other data. Interactive TV, also known as polycom, provides both audio and
visual transfer of a variety of information between two or more individuals at two or more
locations in real time. Kiosks, which are freestanding devices (usually computers), are used in e-
health to provide interactive information to the user. Most information is provided through a
series of interactive prompts on a touch screen. Kiosks can also be used to collect data and
information from users. DVDs, USB flash drives, and other media are used to store data digitally.
Many modern mobile devices are designed with personal computing and Internet capabilities
and are compatible with downloadable applications (or apps) that allow users to instantly access
health information. Many of the technologies employed in e-health are accessible to all users,
including those with impairments such as blindness or deafness.

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ACTIVITY 1. Based on what you have learned so far, what are the
benefits of using e-health services?

Submit your output for this activity in the submission folder 1 of this
lesson.

Learning Input 2.

The Power of Data and Information.

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 differences between the two.

Data are the fundamental elements of cognition (Gudea, 2005), 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 age, house number, jersey number, etc.
this is data. The school nurse noted that it was written on the respiratory rate field of 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 back-up, and instant data access. A number of bigger problems may also
emerge:
1. Continuity and interoperability of care stops in the unlikely event that a record gets
misplaced.
2. Illegible handwriting poses misinterpretation of data.
3. Patient privacy is compromised.
4. Data are difficult to aggregate.
5. Actual time for patient care gets limited.
Likewise, for both clinical and community settings, the overall impact of the problems related to
manual/ tradition data-gathering is articulated as follows:

1. The ability to manipulate large amounts of data.

2. The ability to relate data to cohorts of people who share similar health problems.
3. The ability to link to genomic data.

In contrast, having a well-managed patient information system can have the following
benefits:
1. Data are readily mapped, enabling more targeted interventions and feedback.
2. Data can be easily retrieved and recovered.
3. Redundancy of data is minimized.

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4. Data for clinical research becomes more available.

5. Resources are used efficiently.

Good data qualities

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 professionals
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 (McGonigle & Mastrian, 2009). In order for information to
be valuable, data must have the following characteristics ( Abdelhak et al., 2012):

1. Accuracy. This ensure that documentation reflects the event as it happened.

2. Accessibility. This is data characteristic which ascertains data availability should the
patient or any member of the health care staff needs.

3. Comprehensiveness. Data inputted should be complete.

4. Consistency/Reliability. Having no discrepancies in data recorded makes it consistent.

5. Currency. All data must be up-to-date and timely.

6. Definition. Data should be properly labeled and clearly defined.

ACTIVITY 2. Based on what you have learned so far, Discuss potential

problems eHealth may pose in relation to the delivery of community
health services. Give examples.

Submit your output for this activity in the submission folder 1 of this

Learning Input 3.

The Current State Of Philippine Healthcare And The Development Of eHealth In The Philippines

In 2019 alone, four house bills on eHealth were filed with the House of Representatives
of the Republic of the Philippines ('the House'). The most prominent of these measures is House
Bill No. 8 ('HB 8'), which seeks to establish the national health passport system. Mary Thel
Mundin, Partner at Gatmaytan Yap Patacsil Gutierrez & Protacio (C&G Law), discusses the
benefits and concerns surrounding the development of an eHealth infrastructure, and considers
why this infrastructure may be deemed necessary.

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When it comes to the availability of healthcare services, Filipinos often experience a crisis
in confidence brought about by various factors, such as high cost, poor accessibility, and lack of
patient data or information.

❖ High cost

A recent study shows that 40% of Filipinos are unsure whether they can pay for their
medical bills, while 35% do not know whether they can afford regular checkups. In a country
where more than half of health spending comes from out of pocket payments2, this uncertainty
greatly deters citizens from getting necessary healthcare.

❖ Poor accessibility

According to the Philippine Department of Health ('DOH), only 13% of all healthcare
providers and 40% of all tertiary hospitals are located in rural areas. As a result, 70% of the
population in these places have little to no access to healthcare services. However, even where
health care is available, access is not so easily obtained. On average, it takes a Filipino 39 minutes
to travel to the nearest health facility- minutes that can mean life or death in the worst instances.

❖ Lack of patient data or information

Moreover, even assuming healthcare is affordable and accessible, a problem still stems
from the fact that patient data or information, which are necessary in order to provide adequate
healthcare, is often incomplete, inaccurate, misplaced, or at times, simply unknown. Different
healthcare providers all too often fail to harmonize their different data formats, therefore
compromising the quality of information. Additionally, bureaucracy exacerbates the poor
processing of data, with some estimates pegging data validation at more than a year to reach
various levels.

❖ Decentralized government

Under RA 7160 or the Local Government Code of 1991, local government units (LGUs) are
autonomous, and therefore in control of their own basic health services, including the budget.
Because of this , it is typical to see diverse and unrelated eHealth projects developing all over the
country such as the Wireless Access Health Information and Network Exchange (SHINE) in Iloilo,
and the numerous CHITS installations in municipalities all over the Philippines. LGUs may develop
their own systems. These efforts have accelerated the development of eHealth in community
health. however, to maximize advantages derived from these systems and to produce a
nationwide impact, the different health information systems will eventually need to connect with
each other. Having one EMR system for all health centers will make consulting in different
facilities easier. But unifying and harmonizing the different existing systems for this future
benefit, though not impossible, will expectedly difficult.

❖ Proposed solution

One key solution to the healthcare problems that has recently been gaining traction, is
the development of a framework for eHealth in the Philippines. The DOH has taken the lead on
this front, spearheading initiatives such as the Philippine eHealth Strategic Framework and Plan

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2014-20206 and National eHealth Program, which aim to capitalize on IT to provide better
healthcare services. On the back of these efforts, the DOH has also issued administrative
issuances, which set mandatory health data standards to ensure interoperability and to identify
the respective roles and responsibilities of the relevant government agencies.

On the legislative side, lawmakers have introduced several bills to develop the country's
eHealth system and services. Under HB 8, all Filipino citizens will be entitled to a health passport
that shall contain their medical history, health-related benefits, and patient rights and privileges.
Additionally, the health passport can be used for free medical and dental diagnostic tests in
government hospitals. HB 8 also provides for other health infrastructure programs, such as the
digitization of health center records and monitoring of rural health units.

Benefits of the eHealth System

Considering the current status of healthcare in the country, developing a framework for
eHealth infrastructure can lead to a host of benefits, namely:

1. Improving communication and responsiveness within the health care system.

Developing eHealth infrastructure improves the flow of health information. The

common thread of the above-mentioned measures and bills is the push towards
standardizing and consolidating information for easier access by healthcare providers.
These measures will institutionalize the sharing of health information among
stakeholders, ideally leading to more responsive and coordinated services.

2. Addressing obstacles to equitable access of health care.

eHealth infrastructure leads to equitable health care access. As earlier mentioned,

HB 8 intends to use the health passport in connection with free services from public
hospitals. In addition, investing in eHealth can lead to a better IT infrastructure for health
information. Initiatives that diagnose and treat patients using telecommunications are
thus more likely to succeed, improving the delivery and the speed of services, especially
in geographically isolated and disadvantaged areas. A robust eHealth framework can also
avoid duplication of services and efforts among government agencies with the private
sector. Efforts, such as the interoperability of systems and a health sector enterprise
architecture, prevent duplication by granting agencies and healthcare facilities access to
the same health information. For patients, this avoids unnecessary costs brought about
by different facilities repeating the same service. For the general public, this means more
unified and data-driven public health initiatives from government agencies.

3. Supporting other health initiatives, such as universal health care.

eHealth infrastructure supports other health legislation, such as the Universal

Health Care Act, which implements a host of health-related measures including expanding
immediate eligibility and access to health services to all Filipinos. Critical provisions of the
Universal Health Care Act require the integration of local health systems into province-

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wide and city-wide systems, and facilitating a health information system that respects
patient privacy and confidentiality in accordance with the Data Privacy Act of 2012
(Republic Act No. 10173) ('the Act'). These measures all require the integration of new
existing systems with IT capabilities, hence, the necessity for a framework for eHealth
infrastructure.

Concerns for the introduction of an eHealth system.

Despite the benefits promised by eHealth advocates, concerns have been raised
regarding the introduction and implementation of such a system in the Philippines. The country's
emerging data privacy and cybersecurity regulatory framework, coupled with the limited IT
capabilities and geographic landscape, makes rolling out an eHealth system difficult. To
overcome these, the Philippine government must think of a way to systemically implement the
changes while maintain the integrity of the system.

The Philippine eHealth system moving forward.

A quick glance at the issues above may give the impression that the Philippines has
inadequate mechanisms, both legal and infrastructural, to support eHealth initiatives.
Nonetheless, the different eHealth initiatives show promise in curing longstanding ills of the
Philippine healthcare system, and are well worth exploring. Implementing the eHealth initiatives
in a way that benefits the Filipino people requires a concerted effort, not only among lawmakers
and regulators, but also healthcare providers and ultimately the general public itself.

ACTIVITY 3. Based on what you have learned so far,

what is the possible pitfall of eHealth
implementation?

Submit your output for this activity in the submission

folder 3 of this lesson.

Learning Input 4.

Using eHealth in the Community

Universal Health Care and ICT

In the Philippines, making health care accessible to all remains a great challenge. Lack of
financial health care coverage leads to high out-of-pocket expenses. The marked mass migration
of health professionals leaves the remote and rural areas of the country with limited access to
specialized health care. The archipelagic distribution of the country-with 7,107 islands- makes
health care delivery system more challenging.

A series of health reforms have been implemented. The DOH, though Administrative Oder
No. 2010-0036, outlined the policy directions of Universal Health Care. Also known as kalusugan
pangkalahatan (KP), this reform agenda has three priority health directions:

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a) Financial risk protection through expansion in National Health Insurance Program

enrolment and benefit delivery.
b) Improved access to quality hospitals and health care facilities.
c) Attaintement of the health-related Millennium Development Goals (MDGs).

One of the aims of KP is to attain efficiency using IT in all aspects of health care. One pf the
key instruments it underlines is the use of the Health Information to establish a modern
information system that shall provide evidence for policy and program development and support
for immediate and efficient provision of health care and management of province-wide health
systems.

Electronic Medical Records

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.

In contrast, EMRs are more difficult to implement in hospitals because each hospital has its
own set protocols coupled with its own system documentation. Even government-owned
hospitals do not have a standard system health services provision and of maintaining patient
records. This difficulty in implementing information systems in the health sector highlights the
importance of creating standards.

Another reason EMRs are vital to community health centers is that patient record 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 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.

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 Center (IDRC). It was created
by Dr. Herman Tolentino of the University of the Philippines-Medical Informatics Unit (UP-MIU)
and is currently 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.

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Telemedicine

One of the strategic goals of the DOH’s National eHealth Strategic Framework fro 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
(DOH, 2012).

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”.

WHO further underscores four elements that are specific to telemedicine:

1. Its purpose is to provide clinical support.

2. It is intended to overcome geographical barriers, connecting users who are not in the
same physical location.
3. It involves the use of various types of ICT.
4. Its goal is to improve health outcomes.

eLearning

Health education, which is essential in health promotion and maintenance, can be

faciliatated by ICT. ELearning is basically the use of electronic tools to aid in teaching. It can be
doe synchrously, asynchonously, or in a combination of both. This can be in a form of simple
instructional videos and information textblasts to social network help groups and interactive
simualations. eLearning can be especially useful in correcting misconceptions about health and
health care. It permits access to reliable information about health.

eLearning can also be used to eduacte fellow health professionals. With eLearning ,
continuing professional education of nurses can be undertaken by attending online and virtual
seminars through teleconferences and multiuser virtual enviroments.

ACTIVITY 4. Based on what you have learned so far, search for other existing
community-based electronic medical records and telemedicine projects that may
be applicable in the Philippines.

Submit your output for this activity in the submission folder 4 of this lesson.

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Learning input 5.

The Roles of Community Health Nurses In eHealth.

Community 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:

1. Data and records manager

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 the information is accurate, complete, consistent, correct, and current.
Nurses also participate in regular data audits.

2. Change agent.

Nurses act as a change agent 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.

3. Educator

Nurses provide health education to individuals and families through ICT tools (e.g.,
teleconferences, 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 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 and etc.

4. Telepresenter

In 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.

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5. Client advocate

As clients 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 the personal and health
information handling through eHealth is well explained. Clients must sign an informed
consent, if necessary.

6. Researcher

Using eHealth tools, 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.

ACTIVITY 5. Based on what you have learned, as a student-nurse,

what is you role in the implementation of the eHealth?

Submit your output for this activity in the submission folder 5 of this
lesson.

WRAP-UP ACTIVITY. Considering what you have learned in this

chapter, if you were to initiate an ICT project that can improve
community health, what features would be installed? What
community health problems would it address? How can you ensure
that the target end users would use this technology?

This ends our discussion in chapter 6. Check your understanding of the topics by
answering the 30-item short quiz in the learning management system (of this course.
Feedback will be given after the examination is closed.

Good luck!

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References:

Aspden P, Corrigan JM, Wolcott J, et al. [2004]. Key Capabilities of an Electronic Health Record
System: Letter Report. Institute of Medicine of the National Academies.

Famorca, Z, Nies, M. & McEwen, M. (2013). Nursing Care of the Community. Elsevier Mosby

Gunter, T.D. & Terry, Nicolas, P. (2005). "The emergence of national electronic health
record architectures in the United States and Australia: models, costs, and questions".
Journal of Medical Internet Research. Retrieved from
https://en.wikipedia.org/wiki/Electronic_health_record#cite_note-1.

Ossebaard, H. & , L.V. [2016]. International Journal for Quality in Health Care, Volume 28, Issue
3, Pages 415–419. Retrieved from: https://doi.org/10.1093/intqhc/mzw032.

https://www.ncbi.nlm.nih.gov/books/NBK551878/

http://ehealth.doh.gov.ph/index.php/phie/overview

https://www.dataguidance.com/opinion/philippines-developing-ehealth-infrastructure

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