Review of Related Literature

CHITS Final Technical Report: Community Based Child Injury Surveillance System - Rapid Data Collection Using Short Messaging Service (Proj Ref No: 0302A1_L41) Setting up responsive community-based health information systems is a constant challenge for any national system integrating information technology in health care. The Community Based Child Injury Surveillance System project's aim was initially to create a data collection system using short messaging service over cellphones. After preliminary investigations, however, the researchers shifted strategies and created a computer-based information system that served the needs of the health center facility primarily, and of the national public health system secondarily. The project was renamed CHITS (Community Health Information and Tracking System) and was redesigned to circumvent issues associated with the original strategy such as constraints in economics (cost of sending messages) and existing national and local health policies (only government health centers can submit official health data). By employing a combination of methods, (community immersion, systems analysis, joint rapid application development, onsite technical assistance and grassroots-oriented training), CHITS was piloted in two of thirteen health centers in Pasay City. It had two major components: [1] an extensible and customizable software engine for health facilities, and [2] a training program for health data collectors (health center staff and community health workers). It has attracted the attention of the Department of Health; its tuberculosis module has been presented to TB control program managers in the private health sector and is being considered for adoption. In the near future, there are plans of citywide implementation of the CHITS in two cities of Pasay and Marikina, two of the most progressive cities in the country that are multi-awarded and have been recipients of local and international citations; inquiries from three other municipalities have been made. The generic software engine of CHITS is now being used by a blood bank information system and a national surgical registry.

CHITS offers lessons in systems development that addresses end-user and organizational requirements as well as creates value at the level of data collection. It is proof that open source is a viable alternative to software development in health. http://www.apdip.net/projects/ictrnd/2003/L41-sms/L41-sms-FTR.pdf

Transcending the delivery of healthcare for Filipinos through Electronic Health Records in Rural Health Units At the helm of policy analysis and planning in the public health systemhierarchy in the Philippines is the data for the Field Health Service Information System (FHSIS) which originates during a patients encounter at barangay health stations (BHS), city and rural health units (RHU). With the volumes of data being collected in a typical RHU, it has always been a challenge to consolidate data into a cohesive and relevant whole. Reporting health data is still paper based, which is prone to error, destruction, and alteration. Consolidation of data on paper records is also time consuming causing severe delays which make the information stale and irrelevant. In line with its mandate to increase access to health information and services through information and communications technology, the University of the Philippines Manila - National Telehealth Center (UPM-NThC) has developed the Community Health Information Tracking System or CHITS, a low cost computerization initiative for local health centers. CHITS was envisioned to automate the core processes in the health center and contribute to effective and efficient delivery of services. CHITS is made up of several components which work together to form a cohesive whole. At the core of CHITS is its capacity-building program component that gradually introduces important concepts of information systems to health center staff. CHITS employ free and/or open source software which makes it extremely flexible and compliant to the needs of the local health center and other partners in the future such as the DOH. Once CHITS is installed in an RHU, it now serves as a platform for further enhancements such as elearning for health and telemedicine. http://www.scribd.com/doc/64364804/UPM-NThC-Community-HealthInformation-Tracking-System-CHITS-Primer CHITS makes public-private partnerships possible

As an open-source, web-based Electronic Health Record system specifically designed for government health centers, CHITS has been expanded to support data collection and reporting for all 23 of the regularly used indicators in the Department of Healths Field Health Service Information System (FHSIS). Data submitted to the FHSIS through CHITS is used for policy analysis and planning at all levels of the public health system as it improves access to quality patient records for clinicians and quality data. The project has trained 40 midwives and nurses at the rural health units in Gerona, Moncada, Paniqui, and Victoria to use computers for the first time. Utilizing CHITS has improved patient care and more efficient patient visits as the time needed to search for records are reduced to just seconds. The ability to easily view, record and share patient information simultaneously across multiple computers within a health clinic allows clinicians to complete patient consultations earlier, resulting in increased capacity to provide further support to community health workers. The project initiative was made possible through the collaboration of public-private partners: agencies of the Philippines Department of Health, including the National Epidemiology Center, the Information Management Service and the Center for Health Development for Region 3, local government units in Tarlac, the University of the Philippines Manila-National Telehealth Center (UPM-NThC), Qualcomms Wireless Reach initiative, RTI International, Smart Communications, Inc. (SMART), Tarlac State University, and the U.S. Agency for International Development (USAID). CHITS was first used in May 2004 in Lagrosa Health Center in Pasay City. It is now in 36 health centers around the country. http://www.chits.ph/web/?p=44 Navotas, UP to automate health centers Navotas City, Philippines The City Government of Navotas spearheaded by Mayor John Reynald M. Tiangco will sign a Php 2.8M Computerized Health Information System Project with the University of the Philippines Manila National Telehealth Center (UPM NTHC) to explore the potentials of UPs electronic medical record system for government health centers using Smartphones.

Dubbed as the Navotas City Health Project, the partnership between Navotas City and UP will be sealed with a ceremonial signing of the Memorandum of Agreement (MOA) on September 5. UPM NTHC Director Portia Grace Fernandez-Marcelo will hand over a BlackBerry Smartphone to Navotas Acting City Health Officer, Dr. Liberty C. Domingo as a ceremonial transfer of technology. http://www.chits.ph/web/?p=81 EMR

EMRs and EHRs by Dave Garets and Mike Davis October 2005 - Healthcare Informatics EMR: An application environment composed of the clinical data repository (CDR), clinical decision support system (CDSS), controlled medical vocabulary (CMV), computerized provider order entry (CPOE), pharmacy and clinical documentation applications. The patient's electronic record is supported across inpatient and outpatient environments; is used by healthcare practitioners to document, monitor and manage care delivery within the CDO; and is owned by the CDO. The data in the EMR is the legal record of what happened to the patient during encounters at the CDO. http://www.providersedge.com/ehdocs/ehr_articles/Electronic_Patient_Record s-EMRs_and_EHRs.pdf Electronic Medical Records Paper-based records have been in existence for centuries* and their gradual replacement by computer-based records has been slowly underway for over twenty years in western healthcare systems. Computerised information systems have not achieved the same degree of penetration in healthcare as that seen in other sectors such as finance, transport and the manufacturing and retail industries. Further, deployment has varied greatly from country to country and from speciality to specialty and in may cases has revolved around local systems designed for local use. National penetration of EMRs may have reached over 90% in primary care practices in Norway, Sweden and Denmark (2003), but has been limited to 17% of physician office practices in the USA (2001-2003) [HHS, 2005]. Those EMR systems that have been implemented

however have been used mainly for administrative rather than clinical purposes. Electronic medical record systems lie at the center of any computerised health information system. Without them other modern technologies such as decision support systems cannot be effectively integrated into routine clinical workflow. The paperless, interoperable, multi-provider, multi-specialty, multi-discipline computerised medical record, which has been a goal for many researchers, healthcare professionals, administrators and politicians for the past 20+ years, is however about to become reality in many western countries. http://www.openclinical.org/emr.html Implementation Of Electronic Medical Records: How Healthcare Providers Are Managing The Challenges Of Going Digital Rochelle Brooks, Courtney Grotz Abstract Electronic medical records (EMRs) are the newest form of documenting a patients medical record. An EMR is a system that contains a patients personal medical history, test results, dictations, and other medical and financial information. EMRs will improve healthcare by enhancing patient care, preventative health, and provider convenience and is an extreme improvement to an already highly technological healthcare corporation. The implementation wave is not happening just because it is an improvement to healthcare, but it is also moving forward because it is required by the U.S. government. President Obama recently employed a stimulus package that will assist healthcare establishments with startup of electronic medical records. Along with the great improvements and advantages come inconveniences, challenges, and high costs. For large hospitals, EMR deployments can cost the organization millions of dollars; hospitals can spend from $25,000 to $60,000 per physician to deploy a system. EMR deployment is a public policy challenge with the federal government possibly spending more than $20 billion in stimulus funds to reimburse providers for EMR implementations. EMR system implementations are like any business process reengineering project because they cause many challenges. Employees are not always accepting of change and managing change effectively is critical to successful implementation of any new technology. Additionally, new electronic technologies increase privacy issues while at the same time healthcare facilities are becoming stricter with confidentiality. Electronic medical record implementation is

complex, but the benefits of organization and improved healthcare outweigh the minor setbacks. In this study, data was gathered from two healthcare facilities through interviews of the leaders of the EMR implementation process at each facility. Trade journals and EMR vendor information was also explored. The goal was to explore the phenomenon of the EMR implementation in this short term research project. http://journals.cluteonline.com/index.php/JBER/article/view/736 Advantages and Disadvantages of Using EMR Implementing electronic health records Amanda L. Terry, PhD Cathy F. Thorpe, MA Gavin Giles, MSc Judith Belle Brown, PhD Stewart B. Harris, MD MPH Graham J. Reid, PhD Amardeep Thind, MD PhD Moira Stewart, PhD Implementing electronic health records (EHRs) in primary health care is important, yet it poses many challenges. We use the term electronic health records throughout this paper to reflect the range of providers, including family physicians, nurses, nurse practitioners, chiropodists, and others, who use EHRs. These records are more commonly referred to in the literature as electronic medical records. There is growing recognition of the role of EHRs in the provision of health care, particularly because they can enhance the quality of health care provided through decision-support functions, increase collaboration among members of care teams, and address health care providers need for information. Also, use of information technology systems has been linked to a decrease in medical errors. Using EHRs could improve patients health outcomes through enhanced disease management and increased levels of preventive care. Finally, some efficiency can be realized through eliminating routine tasks, such as pulling paper-based charts. Despite the benefits of EHRs, particularly in the areas of patient safety and improved quality of health care, adoption has been slow. Relatively few family physicians in Ontario and throughout Canada currently use EHRs in their practices.

Research on the usefulness of EHRs in primary health care has focused on practitioners performance and system efficiencies; however, there is a need for further studies to examine the effect of computerization on patient and health care team outcomes. A lack of research describing specific, individual experiences of implementing information technology in health care has been noted. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2377228/ Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, And Costs Richard Hillestad, James Bigelow, Anthony Bower, Federico Girosi, Robin Meili, Richard Scoville and Roger Taylor To broadly examine the potential health and financial benefits of health information technology (HIT), this paper compares health care with the use of IT in other industries. It estimates potential savings and costs of widespread adoption of electronic medical record (EMR) systems, models important health and safety benefits, and concludes that effective EMR implementation and networking could eventually save more than $81 billion annuallyby improving health care efficiency and safetyand that HIT-enabled prevention and management of chronic disease could eventually double those savings while increasing health and other social benefits. However, this is unlikely to be realized without related changes to the health care system. The U.S. health care industry is arguably the worlds largest, most inefficient information enterprise. However, although health absorbs more than $1.7 trillion per yeartwice the Organization for Economic Cooperation and Development (OECD) averagepremature mortality in the United States is much higher than OECD averages.1 Most medical records are still stored on paper, which means that they cannot be used to coordinate care, routinely measure quality, or reduce medical errors. Also, consumers generally lack the information they need about costs or quality to make informed decisions about their care. It is widely believed that broad adoption of electronic medical record (EMR) systems will lead to major health care savings, reduce medical errors, and improve health.2 But there has been little progress toward attaining these benefits. The United States trails a number of other countries in the use of EMR systems.3 Only 1520 percent of U.S. physicians offices and 2025 percent of hospitals have adopted such systems.4 Barriers to adoption include

high costs, lack of certification and standardization, concerns about privacy, and a disconnect between who pays for EMR systems and who profits from them. http://content.healthaffairs.org/content/24/5/1103.full Costs and Benefits of Health Information Technology A small body of literature supports a role for HIT in improving the quality of pediatric care. Insufficient data were available on the costs or costeffectiveness of implementing such systems. The ability of Electronic Health Records (EHRs) to improve the quality of care in ambulatory care settings was demonstrated in a small series of studies conducted at four sites (three U.S. medical centers and one in the Netherlands). The studies demonstrated improvements in provider performance when clinical information management and decision support tools were made available within an EHR system, particularly when the EHRs had the capacity to store data with high fidelity, to make those data readily accessible, and to help translate them into context-specific information that can empower providers in their work. Despite the heterogeneity in the analytic methods used, all cost-benefit analyses predicted substantial savings from EHR (and health care information exchange and interoperability) implementation: The quantifiable benefits are projected to outweigh the investment costs. However, the predicted time needed to break even varied from three to as many as 13 years. HIT has the potential to enable a dramatic transformation in the delivery of health care, making it safer, more effective, and more efficient. Some organizations have already realized major gains through the implementation of multifunctional, interoperable HIT systems built around an EHR. However, widespread implementation of HIT has been limited by a lack of generalizable knowledge about what types of HIT and implementation methods will improve care and manage costs for specific health organizations. The reporting of HIT development and implementation requires fuller descriptions of both the intervention and the organizational/economic environment in which it is implemented. http://www.ncbi.nlm.nih.gov/books/NBK37988/ Usability of Electronic Medical Records

Problems with EMRs: The Physicians Perspective We have been working with medical systems for several years at Human Factors International (HFI). Two of our prominent clients are the Indian Health Service (IHS), a division of Health and Human Services within the U.S. Government, and the Mayo Clinic. IHS and the Indian Tribes provide medical care to 1.9 million American Indians and Alaska Natives through a network of 45 hospitals and 288 health centers. The Mayo Clinic is a world-renowned medical practice based in Rochester, MN. Our observations on EMRs are based on visits to several IHS facilities with dozens of health care providers using a single EMR system that has been locally customized. We also base our insights on an extensive cross-facility usability review for Mayo Clinic. For this review, we visited four different clinics in Rochester, Boston, Jacksonville, and Madison and observed approximately 20 physicians at work with four different EMRs. Overall, our observations support insights from the literature. Physicians, indeed, find that EMRs take a long time to learn and often make them less productive. Physicians experience specific usability problems when working with EMRs that cause long training times and loss of productivity. Long Training Times EMRs provide an enormous range of functionality. This complexity can be bewildering for beginning users, and it simply takes time for them to understand what can be done and how to do it. This is typically a problem with the navigational structure of the EMR system. A typical EMR system contains hundreds and hundreds of screens that need to be accessed through the systems navigational scheme using tabs, buttons, and hyperlinks. Learning the right paths takes time. Loss of Productivity Even after a physician has learned to use the EMR, it often causes him or her to be less productive. The causes are many: Difficulty finding important information, e.g., Which note is the last full note? When was the patients last mammogram? Does the patient need a tetanus shot? Typing the note is slower than writing it out. Some tasks are tedious to complete with the EMR, e.g., reordering chronic medications.

The system response time can be long. Changing exam rooms requires logging off one workstation and enduring a lengthy login to a new one. Lack of integration places information needed for one task on multiple screens, e.g.,reviewing lab results as affected by a change in medications. Searching for a procedure or diagnosis can produce useless results. Physicians speak one language, but the procedures and diagnoses are sometimes based on a different set of codes. Some screens contain information that is not needed, but missing information that is. Some screens are densely packed with information, making information hard to find.

Source: Journal of Usability, Vol. 4, Issue 2, February 2009, pp. 70-84 CHITS eyed as a tracking tool for Maternal and Neonatal Health The Community Health Information Tracking System (CHITS), an electronic medical record system for rural health units, was presented during the technical working group workshop of the Joint Programme on Maternal and Neonatal Health (JPMNH) last April 19, 2011 at the Meralco Management & Leadership Development Center (MMLDC) in Antipolo. Pasay City Health District officer Dr. Marie Irene R. Sy highlighted the features and benefits of CHITS particularly targeting the maternal and neonatal health as manifested in the 7 years experience of Pasay City. CHITS has maternal and child health modules as well as an SMS (Short Message Service) appointment system for tracking mothers and babies for their health service schedule. One Health Information System for the Green City CHITS is to aggregate relevant health information from 5 health districts, 7 lying-in clinics, 3 social hygiene clinics, and 63 health centers without using papers, folders and envelopes. This enables more than 3 million residents to have their consultation and health care services record stored and retrieved electronically. Through CHITS, long waiting time for patients seeking medical services is reduced. Data management, report generation, and inventory system are

centralized to facilitate decision-making and planning purposes for the Citys health officers. CHITS has programs/modules that could store data on typical health center services such as consultation, maternal and child health, immunization, anti-tuberculosis, dental, family planning, leprosy, laboratory and notifiable diseases. CHITS also features a PhilHealth module which monitors health services rendered to its members and dependents. It automatically generates reports that are compliant with the DOHs Field Health Service Information System (FHSIS). http://www.chits.ph/web/

Reasons Why Convert from Traditional to EMR Charting Linking Primary Care Information Systems and Public Health Vertical Programs in the Philippines: An Open-source Experience Herman Tolentino, MD,A Alvin Marcelo, MD,A Portia Marcelo, MD, MPH,Band Inocencio Maramba, MD, MScA The delivery of health care services in the Philippines was devolved to local government units in 1998 under the Health Sector Reform Agenda (HSRA) carried out by the Department of Health. In the course of the devolution, there was not enough time to cede health information management functions to local government units (LGUs) for them to carry out data collection, integration and presentation in a seamless, distributed and coordinated manner. National vertical health programs remained in place, however, each with its own complement of logbooks, and reporting forms and protocols, and sometimes personnel. The Philippine vertical programs include among others, Child Care and Development, Maternal Care, the National TB Program, Family Planning, and the Expanded Program for Immunization. In busy community health centers, data entry of patient information over several logbooks can be inefficient and is characterized by redundant and inaccurate entries. As early as 1995, a case study of Philippine public health information systems by Jayasuria revealed proliferation of reports consuming 40% of the time of field personnel, high levels of duplication and delays due to manual processing, a

situation that has persisted to the present. Currently, there are no data quality control and validation procedures where paper forms are used and community health workers generally do not get feedback from reports that they submit. The collection of large amounts of health data without feedback to the collectors seems to be the practice not only in the Philippines but in other settings where national vertical programs are used Vertical programs are generally useful particularly when there is a need to urgently address a public health problem like HIV-AIDS and smallpox because they can achieve economies of scale and focus resources and manpower on a specific problem. To make information management efficient and to ensure a good supply of quality information, we needed to integrate existing interfaces to vertical programs at the community level, as we work our way upwards for higher level integration of information systems at level of the city health office. In addition to the information management situation above, an alarming trend is emerging in the Philippine health care scene. As early as 2003, thousands of physicians nationwide, including an undetermined number of government physicians, have been retraining as nurses to become part of the eligible health workforce migrating to developed countries. Intra- and intercountry migration of health workers potentially compromises the quality of health service delivery by creating uneven distributions of providers in relation to populations. The scenario of having health centers without doctors required that the community-based information system should be usable by community-based or indigenous health workers. It is in this context that in 2003 we conceptualized the project and submitted a proposal for funding to PANASIA-ICT [10]1 to implement the Community Health Information Tracking System, or CHITS (http://www.chits.info), a primary health care information system. The backdrop of this proposal is a bigger goal to build a national health information infrastructure within the next five years. The community-based information system can contribute to this bigger goal by improving information management at the community level. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1560490 Hospital-community electronic medical record As medical treatment becomes more technically sophisticated, there is a growing need for transfer of information between care sites. However, only low rates of patients present a referral letter or discharge letter that includes relevant information. Therefore, Clalit identified the need for an integrated

medical record system to facilitate access of physicians at different sites to the relevant medical information needed for providing high quality care. The integrated electronic medical record is designed to collect medical data in an automatic, on-line manner from seemingly incompatible data sources, which are decentralized. The data is brought together as information that is reliable and available for all care providers, at each site of care. The solution, developed and implemented by db motion, was based on the requirement to collect data from the existing systems without having to replace them, change their function or change the way they are utilized. In addition, the solution utilizes existing infrastructures for communication and data transfer such as the LAN and WAN networks or the Internet. The solution developed by db motion consists of an information highway between the data creators and consumers in the organization that enables an information consumer to request and receive specific patient information automatically and quickly, without the need to install any program at the end user's station (by using a standard Internet browser), and without making any changes in the existing work processes or in the organization's structure. The solution provides available, up-to-date relevant medical information to each site of care while maintaining the highest level of information security, because each physician can only access the information about his patients. In addition, the solution is capable of connecting the user to various databases needed for providing optimal care. http://www.hpm.org/de/Surveys/Brookdale_Institute_-__Israel/06/Hospitalcommunity_electronic_medical_record.html Difference of EMR and Traditional Charting EMRs vs. Paper Records A paper patient record is identified by name, some kind of medical record number, and other identifiers that make it easier to find in the filing system. An EMR provides distinct identifying information for each patient, and identifiers to locate the digital record among any number of other records. Paper charts typically contain demographic and insurance information, along with a list of medical problems, medications, and allergies. These must be readily updated and should stay current and accurate. An EMR maintains this information, and shares any updated information wherever it is needed. When updated insurance information is provided, that information is automatically passed to billing so that the information is consistent and current, without the need for duplicate data entry. In addition, clinical

information such as problem lists and medication lists are readily updated without duplicate data entry, so that changing medications within the charting application automatically updates the patient's medication list. Traditional charting contains office or progress notes in chronological sequence. These are "browsed" by literally flipping through pages, until the desired entry is located. Progress notes in a traditional paper record might be produced by dictation/transcription, free handwriting, or form completion. EMR stores progress notes and provides quick access by date of visit, provider, or other search criteria and the ability to browse by diagnosis and prescription. A full function EMR automatically creates the progress notes as the visit is produced. Laboratory and radiology reports, as well as correspondence, are filed in more or less chronological order. Access to specific entries is no more efficient than it is with progress notes. An EMR stores reports in any number of ways to provide rapid access and quick reference, such as scanned images, direct lab result posting, and even on-line lab information applications. Using common demographic and identifying information, access to specific lab results or other patient reports is highly efficient and useable. If a paper chart is filed correctly in the medical records system, a staff member must go to the stacks of charts and, using some quick identifier code, locate the correct last name. The first name is located and confirmed, and then the chart is "pulled", but not before a placeholder is inserted, in order to 1) make re-filing easier and 2) record where the chart is headed. The issues surrounding finding a chart that is "out" somewhere, or has been incorrectly filed, are easily imagined. An electronic chart is never lost, out, or misfiled. It is always exactly where it should be, even if you aren't. That is to say that an electronic record may be accessed from any point in a healthcare facility that has access to medical records. In a paper chart system, a healthcare provider typically writes a paper prescription for the patient to take to a pharmacy. There are often one or more added steps, such as consulting a reference for the commonly prescribed drugs for a given condition, verifying the prescription form or strength, verifying the patient's allergy status, checking for potential drug interactions, and verifying the patient's formulary requirements. Once this information has been satisfactorily obtained, the paper prescription is handed to the patient. It is then necessary for the provider to document the process that just took place, including the negative potential for drug interactions and allergies, as well as the drug, form, strength, quantity,

and directions for the prescribed drug. Electronic medical records with robust clinical decision support offer reference information regarding optimal treatment, such as treatment guidelines or "best practice" standards. An EMR with prescription writing capability performs the allergy and drug interaction checking, or at least provides a quick reference for manually checking, when the desired drug is selected. In addition, an EMR with electronic prescribing capability can send the prescription to a designated pharmacy directly, while at the same time documenting the prescribing process and updating the patient's medication record http://www.e-mds.com/education/articles/emr_comparison.html