deliver of ehealth & telemedicine services to the philippines by katheine kuan

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INDINGS Delivery of eHealth and Telemedicine Services to the Philippines From a Sustainability Perspective City of Manila and Batanes Province Philippines Summer 2009 In Partnership with University of Philippines Manila, National Telehealth Center Supervisor Dr. Alvin Marcelo Written By Katherine Kuan Dept. Electrical Engineering & Computer Science Masters of Engineering Candidate 2010 mobile care: scalable imaging and diagnosis for the developing world

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There is a disconnect between what is happening on the ground and what those needs are compared to the policies being made in the PhilHealth headquarters. Hence, there is a tremendous need for electronic documentation of care to ensure quality care.

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Page 1: Deliver of eHealth & Telemedicine Services to the Philippines by Katheine Kuan

INDINGS

Delivery of eHealth and Telemedicine Services to the Philippines From a Sustainability Perspective

City of Manila and Batanes Province

Philippines Summer 2009

In Partnership with University of Philippines Manila,

National Telehealth Center Supervisor Dr. Alvin Marcelo

Written By Katherine Kuan

Dept. Electrical Engineering & Computer Science Masters of Engineering Candidate 2010

mobile care: scalable imaging and

diagnosis for the developing world

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2 Delivery of eHealth and Telemedicine Services to the Philippines

Table of Contents

1 Introduction

2 Project Summary

3 Community Impact

4 Personal Impact

5 Donor Recognition

6 Appendix

i. Analysis of Philippine Healthcare System

ii. Summary of eHealth Services of the National Telehealth Center

iii. Matrix of eHealth and PhilHealth initiatives

iv. Policy Proposal for PhilHealth

v. Sample Referral Forms for Workflow

vi. Usability Testing of Moca

vii. Usability Testing of OpenMRS Media Viewer

viii. Technical Support Manual for Moca

ix. Summary of Workflow in Batanes

“Catastrophic illness or ill health in general is

now widely recognized as the most powerful

poverty-converting event in an individual’s life”

- Francisco Duque III, Past President of PhilHealth

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3 Delivery of eHealth and Telemedicine Services to the Philippines

Introduction

This summer, I spent six weeks working with the University of Philippines Manila,

National Telehealth Center in an effort to further the adoption of eHealth and

telemedicine in the country. In conjunction with my Masters of Engineering research, I

first assessed and increased local capacity of the Philippines to support a deployment of

Moca. This is a cell phone platform for telemedicine that provides healthcare workers in

rural communities with the expertise of medical specialists in city hospitals. Secondly, I

worked extensively on the challenge of sustainability of eHealth, so that the poor in

remote regions would still be able to access and afford these types of telemedicine

services. This work included documenting the obstacles of the healthcare system,

identifying how eHealth could provide solutions, and collaborating with key stakeholders

such as health care facilities, universities, insurance corporations, telecom companies,

and government officials. My goal was to convince PhilHealth to promote eHealth so

that it could later potentially be the “payer” of telemedicine. Hence, they would

encourage health providers to invest in telehealth infrastructure and also be able to

extend benefit packages so that members could receive such services with zero out-of-

pocket expenses.

Project Summary

The UP Manila National Telehealth Center (NThC) is an organization aimed to provide

eHealth services to the country through 3 target areas: eRecords, eLearning, and

eMedicine. eRecords is about having electronic medical records in the system. Ninety

nine percent of the Philippines is using paper-based medical records, so there is a lot of

underreporting, fraudulent reporting, or underutilization of the medical data collected in

the policy making process. eLearning is about providing continued education and

support of remote healthcare workers through online content such as web seminars,

podcasts, or other Internet resources for the latest information on medical practices.

This increases the local capacity of health workers to provide primary care for their

community members, so that they don’t need to send patients up to regional and

provincial hospitals and overcrowding is reduced. eMedicine is about providing rural

healthcare workers with the support of medical experts in distant city hospitals using

telecommunication technologies including cell phones, computers, and the Internet.

This contributes to increased access to medical experts for citizens in remote areas and

reduces the heavy cost associated with traveling to Manila for expert consultation.

During my time in the Philippines, I was able to travel to 4 provinces outside of Metro

Manila: the Batanes, Batangas, Pangasinan, and Tarlac. I spoke with doctors, nurses,

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4 Delivery of eHealth and Telemedicine Services to the Philippines

midwives, and staff people in rural health units, hospitals, and provincial health offices.

From these conversations, I was able to identify the real community needs from the

standpoint of workers on the ground in remote areas. In many cases, I learned about

obstacles they faced in their existing workflow of caring for patients that needed

specialist attention. Also, reporting and documentation was time-consuming and not

done properly for the data to be useful to policy and decision makers. I wanted some

way to document my findings and conversations with these people, so I wrote up a gap

analysis on the Philippine healthcare system which explained the existing state of the

system, the ideal state of the system, and what the gap was to achieve the ideal state.

(See the appendix for the analysis). It was surprising to me that the single concept of

eHealth (eRecords, eLearning, and eMedicine) could be the answer to each challenge

in the healthcare system. It also further emphasized the need for us to engage the key

stakeholders and educate them about eHealth.

Figure 1. Meeting with the provincial health office in Basco, Batanes province (left) and Meeting a midwife in Anilao, Batanges province (right)

Laying Groundwork for a Moca Deployment in the Batanes Province

A good portion of my time was spent collecting requirements, performing usability tests

on doctors, and doing groundwork for a pilot study on Moca in the Batanes Province. I

heard many stories of how new technologies were used but then abandoned in the

health facilities because the equipment broke, the staff wasn’t properly trained, or there

was no technical support. I learned that in order to introduce a technology that would

successfully address a healthcare problem, the system must be customized and

integrated with the existing workflow. I realized which features would be useful,

uncovered software bugs, and received feedback on which parts of Moca were easy or

difficult to use. I collected the paper forms from their existing workflow and converted

them into an electronic teleradiology procedure loaded onto Moca for more accurate

usability testing.

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5 Delivery of eHealth and Telemedicine Services to the Philippines

Figure 2. Workflow in Batanes with paper x-rays that need to be sent to radiologist in Manila for diagnosis of TB, turnaround time is about a couple weeks

Figure 3. Current workflow in Basco with email tele-referrals to radiologist in Manila through the National Telehealth Center, No internet in Rural Health Unit so turnaround time is 1 week

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6 Delivery of eHealth and Telemedicine Services to the Philippines

Figure 4. Expected teleradiology workflow in Batanes with Moca, turnaround time is at most 24 hours

Because I would only be in the country for a short time, it was essential to train local

people on the software and hardware involved in Moca: Google Android platform,

OpenMRS electronic medical record system, G1 phone, and Moca Dispatch Server. I

delivered a presentation to the telehealth team at the NThC on OpenMRS the electronic

medical record system, its use in existing pilots across the developing world, and its

potential for a range of medical applications. This helped them begin to see how

OpenMRS could fit into their healthcare system at the hospital level of care across the

country, and this is a technology they are strongly interested in pursuing. I also worked

closely with Randy Fernandez, a research assistant in the National Telehealth Center,

to deploy a new instance of the Moca server in the Philippines and debugged the

system to upload images from the G1 phones to the server properly. One of the key

challenges we ran into was that the local telecom companies did not support Android

phones at the time, so we had to find workarounds in order to get Moca on the GPRS

network and to send large image files across the network. Out in Batanes, where the

phone would be left with the doctors, we realized that we would need local technical

support to help the doctors in case of problems with the phone. Hence, I trained the

network administrator at the provincial health officer to be our point person in case of

technical difficulties. He had no prior programming experience, so we walked through

how to download the code onto the phone, send error log reports, and debug Moca. As

a result, I came up with a technical support manual on Moca to help new users in the

future (see appendix).

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Recruiting Local Developers to Work on Moca

In addition to providing technical support for the existing system, it will be also crucial to

have developers working on new features and customization of Moca going into the

future. Hence, I delivered Moca recruiting talks at the University of Philippines Manila

campus as well at the Diliman campus to over 60 students. I spoke to classrooms of 4th

year computer science students interested in finding a project for their senior thesis.

Each student filled out and submitted an interest form, and I will be going through and

contacting them to figure out a work plan.

Figure 5. Moca recruiting talks at UP Manila (left) and UP Diliman (right)

Figure 6. Examples of some projects the students could get involved with in Moca

There is also a pair of Ateneo University students working on a windows version of

Moca, so we also had joint meetings to introduce them to the NThC researchers and

also align them with the work/progress of the US-based Moca team.

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8 Delivery of eHealth and Telemedicine Services to the Philippines

Figure 7. Collaborating on the Windows Mobile version of Moca at Ateneo University

Ensuring Sustainability in Adoption of Telemedicine

At the beginning of my project, I performed an extensive literature review of research

papers to find out how telemedicine was being incorporated in other countries by their

governments and insurance companies (with a particular focus on Southeast Asian

countries). There were many examples of pilot studies done across the world in places

like Taiwan, Malaysia, US, Canada, Peru, Japan, Peru, and so on. However, there

weren’t many countries that had telemedicine completely integrated into their healthcare

system with full reimbursements for such services. It seemed that many countries had

difficulty getting all the important stakeholders to work together and agree upon a

standard framework for telemedicine practice and to invest properly in such

infrastructure.

Figure 8. Key stakeholders

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9 Delivery of eHealth and Telemedicine Services to the Philippines

Hence, from the start, we knew that we had to engage all the stakeholders in the

adoption of telemedicine. We spoke with health service providers and health

professionals, and feedback was immensely positive. They explained the drawbacks

of the healthcare system and welcomed the potential of quality care that eRecords,

eLearning, and eMedicine could provide them. We also worked with universities as

mentioned above, as the pipeline of developers who would be supporting the

localization of the system. Since healthcare delivery and management has been

devolved to the jurisdiction of local government units (LGUs) in the Philippines, we

worked with government officials such as the Governor of Batanes to ensure that he

saw the value in putting financial resources towards this type of infrastructure. We

began to engage the telecom companies (Globe and Smart) as well because they

would be providing the cellular 3G/GPRS and internet connectivity in remote regions

like the Batanes, so their buy-in would be important. Last but not least, the support of

the insurance organizations is paramount to making it accessible by the poor, and this is

further discussed in the next section.

Figure 9. Talking about Moca in a Department of

Science and Technology (DOST) Telemedicine

Meeting with UP Manila National Telehealth

Center and UP Diliman

Figure 10. Presenting Moca at Research Triangle

Institute meeting with NThC and people from

Tarlac Province

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Convincing PhilHealth to Prioritize and Invest in eHealth

I worked extensively with PhilHealth, the national social insurance corporation, in the

Philippines. Although they are intended to provide everyone in the country with health

insurance, only 80% of the population is covered leaving about 18 million uninsured. For

their members they create benefit packages for diseases like malaria, TB, H1N1 and

cover fixed amounts on inpatient hospitalization. However, they come up with these

numbers without knowledge of what the actual cost of care to patients is, what services

patients need the most, benefit utilization rates of members, and other health status

information on patients (see Analysis of Philippine Healthcare System in Appendix).

There is a disconnect between what is happening on the ground and what those needs

are compared to the policies being made in the PhilHealth headquarters. Hence, there

is a tremendous need for electronic documentation of care to ensure quality care.

Figure 11. Presenting Moca and business plan for venture-backed corporation for telemedicine to

University of Philippines Manila Dean of the

College of Medicine with NThC and Moca team

member Ted Chan

Figure 12. Presenting Moca at MIT Alumni Club of the Philippines lunch at Enderun College with

Ted Chan

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11 Delivery of eHealth and Telemedicine Services to the Philippines

We wanted to emphasize how their interests and goals (PhilHealth Medium Term Plan,

universal coverage by 2010, Millennium Development Goals, and disease control) were

strictly aligned with those of eHealth and the National Telehealth Center. With

eRecords, PhilHealth would be able to figure out what services were being used by

members, measure health indicators such as maternal mortality, perform disease

surveillance, ensure continuous drug supplies to health facilities, reduce fraud, and

obtain accurate reports for policy making. With eLearning, PhilHealth would be able to

ensure accredited health professionals received continued education to provide the

highest quality of care to the members of their community. eMedicine would help

PhilHealth reach its target of universal coverage because it would provide access to

specialist care for the most remote individuals.

I started off with the connections that Dr. Marcelo introduced me to at PhilHealth (Ms.

Gitch Diaz of the CorPlan Department), and from there I was referred to other

individuals in other departments who could help me. What worked well for me was to

stop by people’s offices, do informational interviews, ask for more references, and

repeat the same process. In this manner, I was able to speak with members from all the

departments integral in incorporating eHealth into PhilHealth: accreditation, health

informatics, standards and monitoring, benefit development, corporate planning, fraud,

IT, and legal. Through these meetings I was able to organize presentations where I

educated department heads and executive officers in PhilHealth on the value of

eHealth. Throughout the whole process, Dr. Marcelo and the team at the NThC

provided very valuable insight along the way on how I could communicate and engage

the interests of those who work at PhilHealth most effectively.

Individual Meetings

Ms. Gitch Diaz (CorPlan) Ms. Jennifer Enriquez (CorPlan) Dr. Israel Pargas (Accreditation) Dr. Rizza Herrera (Accreditation) Dr. Art Alcantara (Health Informatics) Mr. Arnold Quijano (Health Informatics) Dr. Giovanni Roan (Benefits Development) Dr. Ceferino Banaga (FFIED Fraud) Dr. Neri Santiago (Actuary) Attorney Pineda (Legal) Mr. Mario Matanguihan (IT) Mr. Rommel Isaac (ITRMD) Ms. Ann Marie San Andres (Physical Resources and Infra.)

Presentations

7/8 Presentation with Chief Operating Officer and Operations Grp

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Improving Access to Healthcare for PhilHealth Members Dr. Marcelo introduced the National Telehealth Center and its initiatives in eHealth throughout the country. Then I presented my research on how eHealth could be integrated into PhilHealth through their initiatives P4P, Capitation, and Contracting. I had a matrix that explained the spectrum of involvement in supporting telemedicine from just written policies (no cost) to continuous financial investment in building telehealth infrastructure in their facilities.

7/20 Presentation with Senior Vice President and her Quality Assurance Group

Extracting P4P from an RHU-Based Electronic Health Record At this meeting, I presented how electronic medical record systems could directly make an impact on their quality assurance of care delivered in PhilHealth accredited facilities. Then Alison Perez, lead developer/implementer of CHITS for the NThC, did a live demo of CHITS and answered specific capability questions.

7/22 Follow-up Presentation with COO and Operations Grp Operations Perspective on Using eHealth for Capacity Building in PhilHealth In this presentation, I updated the COO on her concerns and requests for more in-depth research on legal issues, policy proposals, and IT initiatives. I also emphasized how eRecords in RHUs are a good fit for the PhilHealth framework using reasons from Figure 14.

7/22 Presentation with President and Chief Executive Officer Strategic Perspective on Using eHealth for Capacity Building in PhilHealth With Dr. Marcelo and Ms. Gitch Diaz from CorPlan Dept, we presented an overview of the NThC and eHealth services to the CEO. Then I recapped the work I had done in his organization for the past 6 weeks, highlighted how eHealth fit well with PhilHealth’s operations of quality assurance monitoring, generating reports for decision making, and benefit development. Then we discussed the future actions he could take to utilize eHealth to help his members to the fullest.

7/23 Presentation with Sector on Out-Patient Benefit Package OPB Monitoring using an RHU-Based Electronic Health Record The group went over their new out-patient benefit guidelines, which included specific policies allowing RHUs to spend their funding on technology infrastructure. I presented how eRecords and CHITS could be specifically tailored to fit their information needs on monitoring the outpatient benefits’ usage. This is already an existing initiative, and the need for eRecords is very apparent, so this was the most concrete discussion with realistic short term goals among all my presentations.

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By speaking with so many individuals on their role in the corporation and obstacles faced by their department, I found many ways that eHealth would build capacity for the corporation. Each presentation was tailored for the target audience and focused on how eHealth could specifically integrate with existing initiatives in PhilHealth and serve to streamline efficiency in the company. First I researched about 3 new initiatives in PhilHealth and identified areas for integration: Capitation is the money that PhilHealth provides to accredited rural health units (RHUs) (as reimbursements on the premiums paid) to run their operations and upgrade their facilities. Each RHU receives 300 pesos per household that is an indigent sponsored family in their community (the poorest level in society meaning the government pays for their health insurance). Hence for 1000 indigent families, an RHU may receive 300,000 pesos to operate their facility. This money is allocated towards bonus compensation for health workers, administrative expenses, equipment, drugs and supplies, and facility upgrades. In a policy proposal (see appendix) I wrote, we recommended that the RHUs be allowed to spend their capitation on telehealth infrastructure (computers, Internet connectivity, and web conferencing equipment). We also recommended stricter requirements for the release of funds including documentation on how the capitation funds were spent in the past and electronic reporting of what services were delivered to patients. This information reported to PhilHealth would be more accurate than the current paper forms that people fill out to the minimum extent so that they can receive funds. With electronic reporting and CHITS (community health information tracking system created by the NThC for RHUs), PhilHealth would be able to directly receive real-time data on the actual patients visiting the center and which services were provided - valuable information to base benefit package policies on. Pay for performance (P4P) is a new initiative aimed at using incentives to promote certain behavioral practices in healthcare by service providers, health professionals, and patients. These incentives can come in the form of money, transportation vouchers, faster claims processing time, earlier release of funds, and etc... PhilHealth is doing a baseline study in several provinces in preparation for a P4P pilot on maternal care. They want to reward mothers when they comply with their 4 required prenatal visits, postpartum visits, and delivery of the child at a health facility instead of at home. eRecords can make a big impact in reducing maternal mortality by tracking mothers throughout the pregnancy process, figuring out baseline statistics on maternal care (exact statistics on maternal mortality are ambiguous and different between PhilHealth and the Department of Health), and monitoring for improvement in these health indicators. CHITS the RHU-based electronic medical record system already has a maternity module to keep track of a woman's health record throughout her pregnancy: risk factors, date of visits, trimester dates, vital signs, position and size of fetus, blood pressure, FPAL, GP, vaccines/services rendered, and postpartum visits (date of

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14 Delivery of eHealth and Telemedicine Services to the Philippines

delivery, outcome of pregnancy, facility where mother gave birth, nutrition of child, breastfeeding) as well. Because the program rewards good performance, accurate monitoring of the patients and of the service providers is important otherwise it gives people an easy way to report false behavior to earn incentives. Contracting is another initiative still undergoing negotiations. This is a method for contracting with certain facilities for certain health services at a standard quality, price, and performance. (Currently, health facilities and doctors can charge whatever price for a service and PhilHealth will only reimburse a fixed amount). This moves towards zero out of pocket expenses for poor patients on certain outpatient diagnostic services. eRecords also plays a big role here in monitoring the health providers to ensure they are following the contract. In return, the facility will receive faster claims processing, which PhilHealth can deliver much more easily if the claims are submitted electronically. PhilHealth Fraud Department does random checks on hospitals and claims by

tracking down the patient and verifying the service was performed. To increase

operational efficiency, they are interested in a way for the hospital log book to be

electronic. In real time, they could see which patients are being served and send a

representative to check the hospital to ask the patient immediately about the services.

PhilHealth Legal Department says that there are no legal limitations in using

PhilHealth field offices as a place for teleconsultations or sending teleradiology referrals

because of the existing computer infrastructure and Internet connectivity already setup.

There are concerns about malpractice or lawsuits, but this can be addressed by (1)

requiring patients to sign an informed consent form waiving liability of the doctor, and (2)

amending PhilHealth’s warranties of accreditation for doctors and health facilities.

PhilHealth Health Informatics Department currently encodes the paper reports from the RHUs into the computer. It’s a tedious process and they are about 7 months behind on entering data. They are in charge of the analysis and summaries of claims data, so they are already telling management that they need integrated analytics software systems to make their job easier. They are also involved in new initiatives dealing with interpretation of data (geographic information system GIS, profiling of health facilities, and information auditing), where interfacing with CHITS at the RHU level would be valuable. PhilHealth Accreditation Department is in charge of accrediting health facilities and professionals (and coming up with the guidelines for it). We would work with them to define what type of accreditation or certification professionals would need to be able to perform telemedicine services. They are also involved new initiatives like contracting with service providers. PhilHealth Benefit Development Department determines the amount of coverage in benefits for members such as through benefit packages (maternity, H1N1, malaria,

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etc...) They have the new guidelines for what diagnostic services PhilHealth will cover for outpatient procedures. We would work with them for determining coverage of telemedicine services (which AMA codes would map to PhilHealth case codes). PhilHealth IT Department will be important in determining whether the corporation could handle electronic communication and data storage needs of the health facilities. IT capacity must be developed to support electronic billing, medical records, and reporting. The department is also currently working on some business intelligence systems for computing analytics to present to upper management.

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Figure 14. Excerpts from the PowerPoint presentations made for PhilHealth that highlight how PhilHealth can benefit from eHealth services

Community Impact

In the Philippines, the National Telehealth Center has already made good headway on research and development of eHealth and telemedicine systems. However, their largest need was to figure out how to scale these solutions across the country in a sustainable manner. My work helped open many doors in PhilHealth as a source for telehealth policy decisions and funding. I was able to identify for the NThC and PhilHealth where the possible departments and programs could collaborate for mutual gains (see PowerPoint slides in Figure 14). The biggest thing holding PhilHealth back from promoting and practicing telemedicine was being unaware about what telemedicine is. To make the conversations more concrete with action steps, I researched the implementation details of what would be feasible in terms of PhilHealth’s support of eHealth – benefit development, accreditation, legal issues, IT capabilities, and health informatics systems – and summarized these findings in presentations. Through 5 formal presentations as well as countless one-on-one meetings with the department heads, I was able to educate over

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15 key PhilHealth leaders (including the COO and CEO) about eHealth and seek tangible ways to move the effort forward.

Figure 16. Meeting with PhilHealth Head of the Corporate Planning Department

Figure 17. Presentation to the PhilHealth COO and Operations Working Group

Figure 17. Presentation for the Senior Vice President and her Quality Assurance Group

Figure 18. Follow-up Presentation for the COO and Operations Working Group

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The response was very positive. The Head of the Corporate Planning Department was eager to support us through continual feedback on the best way to navigate the corporation, as well as access to internal documents and help setup meetings for us with top executives. The COO and operations group also were very enthusiastic about the potential applications of eHealth and came up with many ideas we could explore – using service offices for teleconsultations and having PhilHealth donate old computers to the RHUs. The COO said that they could not afford to go further without moving forward with eHealth because they currently made decisions by looking up at the sky (there is no data to go off of). The Senior VP of the QA group assured us that the group realized the value of electronic documentation and would be committed to working towards ensuring IT systems were in health facilities. The Sector on OPB already issued new guidelines to allow RHUs to use their money from PhilHealth for technology infrastructure. In their meeting, they came to a point where they needed to discuss monitoring of the usage of the benefits and they saw CHITS (community health information tracking system designed by NThC) as something with much potential. Because 6 weeks was a short period of time to create huge changes to a big corporation, I identified 3 major action items that the NThC could work on to carry on collaboration with PhilHealth. I transitioned the NThC team members as well with all my information and introduced them to the correct points of contact at PhilHealth to begin the work immediately.

1. Introduce people from Pasay City (site with 5 years experience of using an electronic medical record system in an RHU setting) to PhilHealth OPB team to answer questions about usage of CHITS

2. Analysis of CHITS data for PhilHealth Actuary Study with VP, Deputy Chief Actuary office to study how PhilHealth can utilize the information from the rural health unit level:

• Profiling of patients (disease, gender, age)

• Utilization rate of benefits in OPB package

• % of RHU patients not covered by PhilHealth

• Services of those who are not PhilHealth members

• Most popular services for all members

• Most popular services for non PhilHealth members

3. Integration of CHITS with PhilHealth National Telehealth Center to enhance the PhilHealth module in CHITS to keep track of health indicators needed for reports/decision making by PhilHealth. Ideally, PhilHealth would like the following to be tracked by CHITS:

• OPB Labs/services

• Drugs prescribed, drugs dispensed

• Referrals (where referred, why, how) ...another module maybe?

Figure 20. Presentation for the President and CEO of PhilHealth and the Head of the Corporate

Planning Dept

Figure 19. Presentation for the Sector on Out Patient Benefit Package Monitoring

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• Targets from PhilHealth

To quantify the people/organizations influenced, we can look at the number of health service providers that PhilHealth accredits. From the actuary study on CHITS, if PhilHealth realizes how valuable the information from the health facilities is and will start requiring electronic health record systems, 1,531+ hospitals and 1,217+ rural health units will be affected (in addition to the other types of clinics, see below). These systems will affect the 21,143 professionals working in these facilities, so that they become technology literate to be able to use these telecommunication technologies. In addition, in the future if PhilHealth incorporates telemedicine services into their outpatient benefit package, then their members, approximately 80 million Filipinos, would experience tremendous improvements in healthcare delivery.

Figure 15. Number of PhilHealth accredited facilities from PhilHealth’s Annual Report 2007: Bridges, Reaching out for Universal Healthcare

I made sure to transition others on the project to take over my work after I left. Dr. Marcelo will primarily be taking over my work at PhilHealth. He will work as a consultant for PhilHealth for 4 months, so he will interact closely with the teams I presented/discussed eHealth with in order to ensure that they have the necessary information and policies to make smart decisions on expansion of membership and benefits in the future. I also had another teammate from Moca also go to the Philippines with me this summer. Ted Chan, who is a 2009 graduate from MIT Sloan, worked in parallel on a business plan for a venture-backed corporation aimed at implementing and scaling telehealth in the Philippines. The corporation would provide the infrastructure to scale telemedicine services across the country and the work at PhilHealth would hopefully move towards paying for such services. Overall, with valuable help from many local people especially at the National Telehealth Center, I was able to educate many people about eHealth and telemedicine both on a policy level at PhilHealth and also at a technical/implementation level at the universities to begin a base of local developers working on Moca for the potential to influence millions of people’s access to healthcare in the Philippines.

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Personal Impact

Being in the Philippines was more different than I ever imagined. The trip definitely

changed my perspective on things and was one of the most amazing experiences of my

life. My trip was continually filled with unexpected adventures, new friendships, and

amazing people. I found the Filipino culture to be incredibly inspiring. The people have

faced many difficult times including the long struggle for democracy in their country and

it’s frustrating to hear about all the corruption entrenched in the political system. I

walked through the streets of Manila every day to get to work. I saw poverty that I had

never witnessed firsthand before. Small children would rush up to me and walk beside

me with their hands open begging for money or food. They would be knocking on your

window in the taxi cab or coming into the restaurant and wait next to your table. It was

heartbreaking. I could feel it in the air – a heavy feeling in the atmosphere that life was

hard. Even for the people that had full-time working positions, it was a struggle to

provide a living for them and their family. I remember seeing squatters for the first time

and was floored by the idea of how many people would live in such small quarters.

Yet despite it all, the people are extremely resilient - proud of their country and culture

for what is has become. I found them to have certain fervor for life, something that

Americans do not always have. Children in the streets played with joy and the people in

general laughed with friends and had a good time. Being fully immersed in the Filipino

culture, I was able to see their strong sense of values rooted in family and religion. They

love having large, happy families and remain close-knit with the children living at home

until they get married. Even for people not related to them, Filipinos have an undeniably

warm sense of hospitality to welcome any and all guests.

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I had a chance to go to the Batanes for work and it was a paradise there. The views we

saw, hills we trekked, waters we swam, and beaches we rested on were absolutely

breathtaking. Every photograph I was able to take was so picturesque. I loved visiting

the provinces. There, life was simple and peaceful. It was mostly rural, where small

homes lined the one main road that passed through the entire city. People planted their

own food for eating, fished in the sea, raised chickens, or owned a small store to make

a humble living. They would gather in small groups and sit by the main road, watch their

kids play, or just talk. They helped neighbors out as if they were family with tasks like

building a house or delivering a baby. It’s quite eye-opening when I contrasted the

province lifestyle with the one in America filled with material and superficial concerns. It

felt like a different world out there in Batanes, an escape from reality where you could

just sit and reflect on life.

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22 Delivery of eHealth and Telemedicine Services to the Philippines

Last semester, I worked for months on Moca but had very broad and vague ideas about

who the technology would actually help. As a result, being able to meet the healthcare

workers and patients on the ground was motivating and unforgettable. This entire

experience solidified my interest in working for technology solutions for healthcare. Had

I not gone to the Philippines to work on this project, I think I would’ve settled for any old

software job sitting in an office 40 hours a week. Now that I’m starting to look for a

career, I know that there are jobs out there like this that are engaging, rewarding, and

multidisciplinary and I’m determined to find them!

Donor Recognition

Thank you so much for the opportunity to travel to the Philippines to perform this work. This trip has opened my eyes to the harsh realities people must face in developing countries. It gave me a concrete reason to work hard every day to do any small part that would help make the lives of the people I saw every day better (those on the sides of the street, those in the hospital wards, and etc…). I feel that I’ve been sheltered for much of my life in America, but this experience (going to the Philippines, speaking to the locals, understanding what their needs were) confirmed my choice for a career path. I want to pursue mobile healthcare applications for developing countries and get very involved on the policy side of these issues. These issues need as many people working on them as possible, and I am excited to learn more about how I can take part of this in the future!

Acknowledgements

Much of my work couldn’t have been made possible without the counsel and

opportunities provided by the team at the National Telehealth Center – Dr. Alvin

Marcelo my supervisor, Dr. Alex Gavino, Dr. Raymond Sarmiento, Alison Perez, Xandra

Bernal, Randy Fernandez, and Coy Caballes. The Moca team, especially Ted Chan, Dr.

Leo Celi, and Gari Clifford, also provided me with great guidance along the journey in

terms of the focus of my work in the Philippines as well as professional growth. Thank

you all so much for everything!

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23 Delivery of eHealth and Telemedicine Services to the Philippines

Appendix: Analysis of Philippine Healthcare System

University of Philippines Manila, National Telehealth Center - July 8, 2009 Written by Katherine Kuan, Moca

QUALITY OF CARE

Current System Ideal System Proposed Solution Methodology

Epidemics (H1N1, malaria, dengue) spread rapidly, Policies are created after the spread has occurred

Disease tracking and immediate management of epidemics, Anticipate health events and define protocol before anything happens

Health facilities register the diagnoses of patients so that those with certain diseases can be geographically pinpointed and quarantined

eRecords

Health facilities sitting without anymore supplies/drugs for the quarter, Heavy influx of patients when drugs are delivered but rapid drop-off when they run out

Continued supply of drugs at health facilities without requiring patients to buy drugs outside, Forecast drugs required and ship them to health facilities to arrive on time when needed

Electronic management of supplies/drug logistics, Track drug usage at each facility over time

eRecords

Expensive prescription drugs with high mark-up price

Doctors should prescribe generic drugs and promote community pharmacies

Ensure doctors are prescribing generic (not branded) drugs, Electronic record keeping of prescriptions

eRecords

Patients forgo visits to doctor because of cost/distance until they become sick and require hospitalization (i.e. if not treated, TB can spread to 10 other people each year)

Preventive medicine, diagnosing sickness before it becomes a major health problem

Affordable access to specialists in a timely manner

eMedicine

Long latencies in diagnosis when patient data is physically mailed to specialist

Immediate turn-around-time in diagnosis and patient referrals, immediate start of treatment, improved health outcome of patient

Teleconsultations with specialists through email, audio/video conferencing, mobile phones

eMedicine

Possible misdiagnosis by general practitioners in remote areas when patients don’t have access to specialists

Immediate access to second opinion from network of specialists, DTTBs learn from their mistakes for future cases when specialists correct them

IT infrastructure to link health facilities through Internet or cellular network

eLearning, eMedicine

18 million Filipinos not covered by PhilHealth

Hit 2010 target of achieving universal coverage (85%) of the nation’s population

Increase service offerings with telemedicine to provide healthcare access for the poor in rural areas

eMedicine

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24 Delivery of eHealth and Telemedicine Services to the Philippines

REPORTING AND MONITORING

Current System Ideal System Proposed Solution Methodology

Unsure how capitation funding is spent

PhilHealth can view breakdown of how an LGU spent its capitation and ensure it was wisely spent on long-term improvements in healthcare

Strict requirements for allocation of funds, Strict monitoring of how the funds were spent

eRecords

Lack of effective methods for PhilHealth to enforce requirements on health facilities because control of health facilities devolved to LGUs

PhilHealth can influence behavior changes through pay-for-performance and verify such performance with tangible evidence before distributing rewards

Method to monitor the actual performance of members & service providers without room for fraud

eRecords

Handwritten reports with calculation or data entry errors (1 error per midwife x 44,000 barangays= 44,000 total errors for that month)

Automatically calculated reports and statistics available at any time

Electronic medical record system customized to output health statistics and official reports as defined by the DOH

eRecords

Some facilities use spreadsheets (Excel) to keep patient records (insecure place to store data without back-up, high potential for error in spreadsheet formulas)

Secure centralized database of patient medical records with workflow customized to fit the needs of the different levels of hospitals, Fast retrieval of patient files

Open-source electronic medical record system with software development of features custom to workflow

eRecords

Quotas are much higher than the actual # of people eligible for that vaccine/service in a province

Quotas/performance indicators calculated based on local characteristics of the region

Keep up-to-date records of demographic makeup and health status of a local population

eRecords

Report false information to meet quotas

Accurate reports for feedback on how to target improvements in PhilHealth services, and for nationwide policy decision making

Eliminate manually written reports, Require computer generated reports (from medical record system) on actual number of services provided

eRecords

POLICY AND DECISION MAKING

Current System Ideal System Proposed Solution Methodology

Most recent available FHSIS/DOH health data from 2006, decision makers can’t make health policies based on data from 2-3 years ago

No need to wait for reports to trickle from the bottom up (from barangay to district hospitals to regional and provincial hospitals), Auto-generated reports available at any time

Electronic medical record system customized to output reports/statistics to DOH

eRecords

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25 Delivery of eHealth and Telemedicine Services to the Philippines

Unsure about utilization rate of member benefits

Track which benefits are being used by which patients, identify successful programs and create more targeted ones for the future

Make patient data anonymous, Perform data mining on database for program feedback

eRecords

Unsure about cost of care (cost of procedure to patient, salary of doctors) because power is delegated to LGUs, Difficult to set price points for packages

Contract standard rates with service providers, No out-of-pocket expenses for patients

Electronic billing eRecords

ADMINISTRATIVE LOGISTICS

Current System Ideal System Proposed Solution Methodology

Wait for up to 6 months for reimbursement claim to be processed

Reduced overhead in processing transactions, More efficient process to verify member eligibility and benefits’ status

Electronic billing to automatically generate claims and incorporate checks for data validity

eRecords

Each health facility has own medical records, filing system, and ID numbers for patients (redundant databases w/ related info and waste of multiple ID cards)

Integrated medical record systems where patient can visit any accredited PhilHealth facility and their unique medical file will be easily retrieved for continuity of care

Electronic medical record system accessible from any health facility to make patient transfers easier

eRecords

Hospital or PhilHealth manually encodes the diagnosis of the patient, allows room for errors in misunderstanding written notes of doctors

Doctor, who actually interacts with patient, writes diagnosis and assigns ICD10 code immediately

Data validity checks on patient visit, requires doctor to assign a code before moving on

eRecords

HEALTH PERSONNEL

Current System Ideal System Proposed Solution Methodology

Training of medical professionals limited to what they learned in school years ago

Continued medical training on up-to-date practices and latest technologies, specialty training outside the formal classroom (i.e. x-ray reading)

Training sessions conducted through webcasts and video conferencing, IT infrastructure in remote locations to receive training

eLearning

Reliance of rural health professionals on books that are expensive, out-dated, and with limited information

Access to online repository of latest information and medical advances, discussion forums and communities to share information and help each other on cases

IT infrastructure in remote locations to receive this training

eLearning

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26 Delivery of eHealth and Telemedicine Services to the Philippines

Appendix: Summary of eHealth Services of NThC

University of Philippines National Telehealth Center Written by Katherine Kuan

Obstacles to Quality Healthcare in the Philippines

• Shortage of trained medical professionals, recruiting/retaining qualified staff

• Shortage of quality health facilities, urban areas have more and better facilities than rural areas

• Limited transportation accessibility and infrastructure

• High cost of medicine compared to other countries

• Barriers of distance, isolation of rural health practitioners

• Lack of data standards for health records

• Lack of unique national ID system

“ONeHEALTH is the flagship program of the University of Philippines’ National

Telehealth Center developed to address such obstacles. ONeHEALTH stands for “One

Network on eHEALTH.” With advanced new technologies comes much potential to

deliver quality health services to remote areas of the country.” - NThC

eRecords: electronic health records essential for quality management of patient and

treatment information, for use at all levels of health system (existing services: CHITS,

BuddyWorks, ISIS)

• Collect and integrate patient data from many remote sites, enable smooth patient transfers

• Monitor patients over long period of time, especially for those with chronic diseases

• Minimize information loss/error (i.e. from regional language differences in symptom/treatment terminology), improve data quality with guidelines/alerts if wrong data entered

• Bridge communication gaps among levels of health system

• Reduce costs with proper drug prediction, ensure uninterrupted supply of drugs

• Enable disease surveillance and rapid response (i.e. for the H1N1 virus)

• Auto-generate standard reports at any time

• Track which PhilHealth benefits are utilized by members

• Drive policy making process with systematic information and evidence

eLearning: a form of education/support for health workers - doctors, nurses, midwives

and health volunteers - through online content on community healthcare (existing

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27 Delivery of eHealth and Telemedicine Services to the Philippines

services: videos for Stroke, Avian Influenza, Basic Management of Childhood

Poisoning, TB)

• Provide opportunities for barangay healthcare workers (BHWs) to acquire and utilize new knowledge

• Increase local capacity for proper patient care, decreased hospitalization time and faster recovery

• Create collaborative social network of health facilities and universities

• Empower healthcare workers through demonstrated improvements in competence, confidence, and morale

• Promote discussion and sharing of ideas among staff on site

eMedicine: draw on expertise of medical specialists far away using telecommunications

technology, telereferral services for general medicine, pediatrics, surgery, radiology,

dermatology, ophthalmology, psychiatry (existing services: BuddyWorks, SMS, MMS,

email telemedicine)

• Provide critical clinical decision support for BHWs

• Increase access to specialized care for rural citizens

• Reduce need for patient transfers, decreased travel time and cost

• Decrease cost to patients and hospitals with improved accuracy of diagnosis and quicker recovery time

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28 Delivery of eHealth and Telemedicine Services to the Philippines

Appendix: Matrix of PhilHealth Initiatives with eHealth

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29 Delivery of eHealth and Telemedicine Services to the Philippines

Appendix: Policy Proposal for PhilHealth

Policy Proposal on Improving PhilHealth Services Through eHealth Infrastructure

Katherine Kuan, UP Manila National Telehealth Center

1 Executive Summary

At no cost to PhilHealth, the Corporation can provide increased quality of healthcare to its members by

supporting the practice of eHealth services in its accredited facilities:

• eRecords: electronic medical records

• eLearning: continued education of medical professionals through online content

• eMedicine: draw on medical expertise far away using telecommunication technology

The first steps to integrate eHealth services into PhilHealth are outlined in this paper:

• Amend policy on capitation:

o Allow RHUs to spend their capitation on eHealth infrastructure

o Require RHUs to submit accurate electronic documentation/reports for full payment

• Incorporate eRecords into P4P monitoring

o Select an existing CHITS (Community Health Information Tracking) site for the P4P pilot

site

o Use CHITS data on site for baseline analysis and for progress tracking

Electronic documentation of care will vastly improve the ability of PhilHealth to track progress on its

programs and create more targeted initiatives to improve specific health indicators.

By streamlining claims processing, tracking package utilization, ensuring Bench Book standards are

followed, reducing fraud, improving drug delivery, and also providing detailed reports about health

outcomes and benefit utilization, PhilHealth will soon be able to reach its short and long-term goals

(universal coverage, Millennium Development Goals, and disease control).

2 Introduction

PhilHealth membership has been successfully increasing, but access to quality healthcare still remains a

challenge for millions of Filipinos. To figure out whether 300 pesos per indigent family is enough for

capitation, it’s important to examine how LGUs are spending their funds. In addition, questions still remain

such as: What is the utilization rate of the OPB? Does it cover the services that are really needed in

communities?

To ensure quality outpatient care is provided to PhilHealth members, there needs to be documentation on

what services were provided and what the outcome was. Electronic medical record systems (i.e. CHITS)

are the solution to a number of challenges facing PhilHealth today:

• Unsure how capitation funding is being spent, if it’s sufficient to support RHU operations

• Unsure about utilization rate of PhilHealth member benefits

• Need method to monitor performance for programs like P4P, contracting

• Fraud and calculation errors from handwritten reports

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30 Delivery of eHealth and Telemedicine Services to the Philippines

• Tedious data collection process, FHSIS/DOH reports come out 2+ yrs later

• Claims reimbursement process can take long time

Instead of relying on information from claim forms, PhilHealth will be able to use electronic medical record

systems to monitor and manage the type of care being delivered on the ground. CHITS is an electronic

medical record system designed specifically to adapt to the workflow of RHUs in the Philippine healthcare

system. Implemented in 20 sites across the country over 5 years, the system is highly recommended for

obtaining electronically documented care at PhilHealth accredited facilities. As a result, PhilHealth

management will be able to base decisions on real-time data, in order to create targeted programs that hit

performance targets on health indicators for the country.

By encouraging RHUs to utilize capitation to invest in CHITS and other eHealth infrastructure (computers,

Internet connectivity, video conferencing), their capacity to provide quality care at the local level will

rapidly increase.

In summary, eHealth and telemedicine have the potential to help the Corporation in the following ways:

• Increase access to quality care (i.e. telemedicine to reach specialists) for members

• Allow service providers to submit claims electronically for faster processing

• Allow facilities to track their patients over long time, quantitatively measure performance

improvements

• Allow system to monitor supply & demand, gather empirical data for health system performance

analysis

3.1 Policy Recommendations Regarding Capitation

1 Modify disposition of PhilHealth Capitation Fund (PCF)

Current Policy Proposed Policy

80% Drugs, medical supplies/equipment,

referral fees, site improvement

20% Administrative expenses (50% for

physicians, 50% for personnel in OPB

services)

65% Operational expenses

Drugs

Medical equipment/supplies

Referral fees

Site improvement

20% Administrative expenses

Health personnel salaries

Training for workers (eLearning sessions

through video conferencing or online

resources)

10% Technological Infrastructure

Computers

Internet Connectivity

Electronic medical record system (CHITS)

Camera, video conferencing equipment

5% Telehealth services payable to National Telehealth

Center, subscription for fixed # telemedicine

referrals to specialists

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31 Delivery of eHealth and Telemedicine Services to the Philippines

2 Create stricter requirements on release of PCF funds in article 2.3 PhilHealth capitation fund

Current Policy Proposed Policy

Capitation amt released with following

conditions:

Initial release within first 2 weeks of

applicable year, RHU accreditation and

payment of premiums required

Successive releases on third week of first

month of quarter, reports and payment of

premiums required

Capitation amt released with following conditions:

Required electronic submission of Monthly OPB

Report Form (if paper report submitted, deduct 10%

of capitation in successive quarters)

Required budget proposal on how capitation from last

quarter was spent (proposal subject to auditing)

Random audits by PhilHealth on the validity of

reports, phone calls to the patient, visit RHU, flag

fraudulent cases

Initial release within first 2 weeks of

applicable year, RHU accreditation and

payment of premiums required

Successive releases on third week of first

month of quarter, reports and payment of premiums

required

3 Specify details on reporting/monitoring mechanisms required at RHUs, modify article 3.1 of Reporting, Monitoring, and Evaluation

Current Policy Proposed Policy

RHU required to submit Monthly Report

Form, Transmittal Form, Patient Treatment

Summary, Tally Sheet for OPB Services

Rendered

Health Finance Policy and Services Sector,

Benefits Development Office, Accreditation

Dept, Quality Assurance Unit monitor and

evaluate the package

For information systems management, the Corporation

strongly recommends the RHU to install the CHITS

electronic medical record system (to monitor OPB

services delivered by RHU for PhilHealth)

RHU required to submit electronic Monthly Report Form,

Transmittal Form, Patient Treatment Summary, Tally

Sheet for OPB Services Rendered

Health Finance Policy and Services Sector, Benefits

Development Office, Accreditation Dept, Quality

Assurance Unit monitor and evaluate the package

4 Modify referral system to include teleradiology referrals and teleconsultations in article 2.4 Referral System

Current Policy Proposed Policy

In case of inability to take x-ray, RHU can

refer patient to another facility, paid by

capitation fund

In case of inability to take x-ray, RHU can refer patient to

another facility, paid by capitation fund

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32 Delivery of eHealth and Telemedicine Services to the Philippines

In case of specialist care or higher level of

care, refer to PhilHealth accredited hospital

(hospitalization qualifies for in-patient

coverage)

In case of specialist care (including radiologist), refer to

specialist (without travel) using telemedicine

If telemedicine can’t resolve the case, refer to PhilHealth

accredited hospital

5 Extend outpatient benefits for indigent program members to include telemedicine services in article 2.1 of OPB Guidelines

Current Policy Proposed Policy

Primary consultations with GPs

Lab fees: chest x-ray, complete fecal blood

count, fecalysis, urinalysis, sputum

microscopy

Preventive services: cervical cancer

screening, BP measurement, rectal exam,

body measurements, breast exam, smoking

counseling, lifestyle change counseling

Primary consultations with GPs

Tele-consultation with specialist (with GP referral) **

Lab fees: x-rays for teleradiology referrals, chest x-rays,

complete fecal blood count, fecalysis, urinalysis, sputum

microscopy

Preventive services: cervical cancer screening, BP

measurement, rectal exam, body measurements, breast

exam, smoking counseling, lifestyle change counseling

** Must be at telemedicine certified facility, Can be out-

of-pocket expense for patient (at first) but later to be

included in standard outpatient benefit package

3.2 Pay-for-Performance Pilot Study Recommendations

3.2.1 Select a CHITS site as a P4P pilot site to facilitate monitoring of performance in order to distribute incentives. Choose from 20 existing sites:

Lagrosa Health Center, Pasay City

Malibay Health Center, Pasay City

Marikina Heights, Marikina City

Sto Nino Health Center, Marikina City Taniong Health Center, Marikina City Quezon Rural Health Unit, Quezon Province Sigma Rural Health Unit, Capiz Cuartero Rural Health Unit, Capiz Tapaz Rural Health Unit, Capiz Dumalag Rural Health Unit, Capiz

3.2.2 Require performance at pilot site to be reported using electronic medical record system to:

• Prevent fraudulent data that says performance target achieved

• Track progress of pilot sites as feedback loop on whether P4P incentives are effective

• Utilize data for statistical analysis on maternal care to provide to management for decision making

Pagsanjan Rural Health Unit, Laguna

Mendez Rural Health Unit, Cavite

Alfonso Rural Health Unit, Cavite

Orion Rural Health Unit, Bataan

Real Rural Health Unit, Quezon Province

Child Hope Foundation Inc.

Labuan Rural Health Unit, Zamboanga del Sur

One municipality in Zamboanga Sibugay

Batanes PHO , Basco, Batanes

Uyugan Rural Health Unit, Batanes

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33 Delivery of eHealth and Telemedicine Services to the Philippines

3.2.3 Perform baseline analysis on the P4P site by using previous years of CHITS data for that site, will be able to show quantitative improvement directly as a result of the P4P program

3.3 Recommendations for Using PhilHealth Service Offices for

Telemedicine

PhilHealth service offices, which are widely established across the country, already have existing

telecommunication infrastructure such as computers, Internet, and perhaps video conferencing.

3.3.1 Draft up a Memorandum of Agreement between PhilHealth and LGUs

• Teleconsulation: Allow local health professionals to refer patients to

specialists using teleconsultations, to be held in the PhilHealth field office

• Store-And-Forward Telemedicine: Allow local health professionals to send

images, audio, video of the patient to a specialist for diagnosis, using

PhilHealth field office Internet connectivity

3.3.2 Draft up a Memorandum of Agreement between PhilHealth and UP Manila National

Telehealth Center (NThC), allow NThC to coordinate telereferrals and teleconsultations

between patients and appropriate specialist

3.3.3 Require all patients utilizing telemedicine services to sign an informed consent form to

waive liability from PhilHealth

3.3.4 Amend Warranties of Accreditation for Health Professionals, certify specialists to answer

telemedicine referrals

4 Roadmap on Providing eHealth Services for PhilHealth Members

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34 Delivery of eHealth and Telemedicine Services to the Philippines

Appendix: Sample Referral Forms for Workflow

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35 Delivery of eHealth and Telemedicine Services to the Philippines

Appendix: Usability Testing of Moca

Batanes Provincial Office and General Hospital Written by Katherine Kuan

Directions for Users

1. Turn on G1 phone using red button

2. Hit the gray arrow to unveil the list of applications

3. Select the Moca application by using your pointer finger to touch it on the screen

4. Perform a "Radiology examination" procedure using Moca

5. Use the patient with

ID number: 22222

First Name: Peter

Last Name: Smith

Birthdate: 01/03/1985

6. Perform a "Surgery follow-up"

Directions for Moderator

1. What is your goal in referring a patient?

2. Can you tell me what your usual procedure for seeing a patient and taking an x-ray is?

3. What problems come up with this type of workflow?

4. From scale of 1-10, Easy to use?

Batanes Provincial Health Office

Goal

• Increase quality of x-rays compared to previous status

• Clients have access to affordable, quick reading of their x-rays

• Better management of patients

Existing Workflow

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36 Delivery of eHealth and Telemedicine Services to the Philippines

• Patient comes in, received by nurse at registration area

• Interviewed for general data: name, birthdate, occupation, where they live

• Nurse interviews them for chief complaint, basic symptoms, history of illness, vital signs (bp,

heart, BMI, heart rate), past family history, OBGYN history, others (alcohol use, exercise)

• Doctor asks them for history of present illness, physical exam, do other lab tests

• Give x-ray request form, go to BGH, come back

• Take picture of x-ray and send to Manila

• Take contact number, while awaiting the x-ray results

• Administer drugs, final instructions

• Signs/symptoms for immediate follow-up

• For teleradiology, don’t write a lot, just important details

• Save all replies in email

• Not yet protocol to write the reply of the email down in the patient record

• Can take up to half a day for 1-2 images to be uploaded

• Hard to use own email to store data, need to find a way to store data

• Use digital camera 3MB

Usability

• Not too hard to get used to, looks daunting, lots of tabs

• “After I went through the process of filling out data, it was quite easy. Much easier than sitting

in front of the internet and typing it all.”

• “Very user friendly for people to use this technology”

• Okay with leaving it on the table to wait for it to upload

• Doctor in Batanes also wants to learn how to read x-rays for emergency cases when can’t

wait for the image to be uploaded for a diagnosis

o Will look for old x-rays to see similar cases

o Library to compare x-rays, teaches them what to look for

o WHO donated book of expert labeled x-ray images

o See where in the x-ray are the densities/haziness

o Learning tool for the doctors in Batanes

Difficulties

• Easier if had a pen for the touch screen

• Keyboard small but okay

• Taught them to use tip of finger, not fingernail

Issues

• Not all patients have medical ID number, usually list them alphabetically based on household

head

• Slash character for birthdate should be automatic

• Verbal notes

o Clarify what the verbal notes are, who records them (patient or physician)

o Didn’t need to record a verbal note, but can leave it in

o Not all doctors used to recording their notes, more comfortable typing them

• Written comments

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37 Delivery of eHealth and Telemedicine Services to the Philippines

o Daunting to see little space, think they can’t write a lot, will have to scroll down a lot

to read all the data, can only read one line at a time

o Make ½ or ¾ of the screen filled with the text box

• Didn’t really need to use the GPS coordinates

• Hard to hold it and tap it, kind of hard to use, right handed, hold it on top of the camera

• Telehealth format has chief complaint, quick history of illness, rundown of physical exam

findings, purpose of referral, what has been done to the patient, signs/symptoms

• “Why do I have to go back?” to review the pages

• Don’t have fixed number of options for the diagnosis, have a free text entry box for diagnosis

• Took about 5 mins to learn and talk through the workflow

• Send back SMS or PDF file, whichever is faster (priority is speed)

• PDF radiology report of patient for clearances, to see actual reading (most patients don’t

care)

• Will likely be sending 2 or 3 images at a time

• Personal data

o Barangay

o Municipality

o Middle name/initial (many similar first/last names)

o Date

o Gender

o Chief complaint

o Short history of present illness (1 or 2 lines) “Include all data significant to case at

hand, OBGYN, alcohol, smoking, medication taken”

o Physical findings (empty text box)

o Diagnosis (large empty text box)

Batanes General Hospital

Existing Workflow

• See patient, ask why they came, symptoms, physical exam, lab exam

• If need more diagnostic exam, may refer to telehealth

• Send to Manila

o Send x-ray plates through relatives or someone they know, just drop it off at airport to

give to radiologist (turn around time 1+ week)

o Radiologist will write findings, sometimes send back official report, relatives relay

information back

Usability

• Willing to enter data using the phone

• Cannot carry around big computers

• With computers, have to login to the net

• “It’s nice, much better than just ordinary paper” (faster)

• Prefer phone over writing it down

• Could use it to take picture of ECG print out, video recording of ultrasound, OB/GYN (Cervical

cancer), external eye exam

Issues

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38 Delivery of eHealth and Telemedicine Services to the Philippines

• Couldn’t select the option “female” for gender

• Click next/prev goes too fast

• Force close during camera app

• X-ray procedure

o

o Part to be x-rayed: upper extremities, lower extremities, chest, skull, neck, cervical, back

� Upper extremities: arm, forearm, hand, shoulder, elbow, wrist

• Choose side: right or left

o Choose view: antero-posterior, lateral, postero-anterior, oblique

� Lower extremities: hip, thigh, knee, leg, ankle, foot

• Choose side: right or left

o Choose view: antero-posterior, lateral, postero-anterior, oblique

Back: thoracic, lumbar, thoracolumbar, sacrum, coccyx

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Appendix: Usability Testing OpenMRS Media Viewer

Philippine General Hospital, National Telehealth Center, Batanes General Hospital Written by Katherine Kuan Radiologist

Usability test done on radiology oncologist (for radiation therapy for cancer patients) at Philippine General

Hospital (PGH). He is a consultant with the radiology department at PGH and teaches residents. He

voluntarily answers all teleradiology referrals for the National Telehealth Center by email.

Existing Workflow

• Uses Mac image viewer called “Preview”

• Uses Preview to modify darkness/brightness, white balance

• “Eventually we want it like this (the OpenMRS image viewer). What we do now is difficult

because I open the email, read it, etc..”

• Receive only a few films by email, 10 per week

• Willing to read up to 100 plates per day

• Problems w/ x-rays (patient is breathing), radiology technician not properly trained

• Send notification to cell phone to check the web

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• Will check email when get home, 1x per day, sometimes 2x

• Each takes on average 1 minute to diagnose, chest x-ray 2 mins, max 5 mins

• Slow internet at hospital

• Doing telehealth referrals for pro bono now

• 1 patient per email so don’t mix up names with images

• Takes 1 min to download the image, 2-3 minutes to diagnose

Take proper chest x-ray image (to retrain radiology technician)

• Angulated by 15 degrees

• See apex

• Top part of chest should take up 50% of the x-ray

• Female patient should remove bra

Features Needed

• Zoom magnification

• Vary contrast and brightness

• Just save original image (not modified version)

• Panel of information: symptoms, clinical diagnosis, clinical history

• View past x-rays (2 side by side, previous and latest)

• Access to older films (zoom and brightness capabilities on those images too)

• Radiologists need box for “findings/interpretation” and for “notes”

• Clinicians should be able to write diagnosis, treatment, notes (some fields can be blank)

• No drop down box for diagnosis, no fixed reading (except for “normal chest”)

• No cancel button needed, will read it then

• If not sure of diagnosis, will leave it blank or refer to someone else � put case on “hold”,

assign it to another doctor, allow both doctors to be on the case

• Output an official report, type report next to image, then go directly to an editable version

of the official report (auto populate the official report and then make it editable, preview +

edit report)

• Don’t need to annotate image, maybe a circle/arrow/pointer if clinician wants to see

lesion (dermatology cases may require annotations)

• List of on-call doctors, typically on-call all day from 7am-11pm, diff person per day, a

doctor is on-call 2-3 times per week

• Could charge 30-50 pesos per x-ray plate reading

• If bad image, disappear from queue until need it again, don’t need the bad pics

• Personal digital signature

Nurse

Difficulties

• Double click to annotate

Workflow

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• Clinician needs to incorporate the radiologist reading with other data from patient (ECGs,

other labs)

• Once sure about interpretation, don’t need to go back and save, only compare, won’t

return to edit it

• Clinician � rad tech � radiologist � clinician

• Time diagnosis 48 hrs

• Use Windows default image viewer

Features Needed

• Make the image DICOM compliant (Open binary file, first part is text (key value pairs in

header), parse into fields, latter part is image

• Embed in file the doctor who interpreted the data

• Click on annotation to edit again

• Zoom (enlarge it so one lung is screen width, 3-5 MP)

• Don’t need to rotate it

• Label it as “user” or “patient”

• Add doctor’s name as the one interpreting the data

• Annotation box can be fixed to a corner of the screen

• Don’t need other info from medical record of patient besides the summary

• Compare with previous x-ray films, click to see previous plates, side by side comparison

• If not sure, need to refer to another doctor (residents may be unsure about diagnosis)

• Clinician needs diagnosis, treatment, other notes box

• Clinician may not need to annotate image

• Can have another system for clinician, pull out radiology image for same visit of patient

• Change brightness, contrast, sometimes can see shadows

• Date is fine, don’t need timestamp

• Bad image quality -> comment why bad image, want another view

• Retake shot (i.e. top of chest)

• Save original ones with new images

• Drag image around, zoom to click, scroll image like Google maps

Doctors in Batanes

• Need annotations for clinicians and radiologists

• Blank spot for clinical diagnosis

• Blank spot for radiologist (i.e. there were no densities, diaphragm is intact, heart is not

enlarged)

Doctor in Manila

• Spell checking for the boxes

• Findings, diagnosis boxes

• Make sure it’s embedded in the workflow (see surgery system by National Telehealth

Center)

• Separate screen for diagnosis of patient, not in the image viewer

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42 Delivery of eHealth and Telemedicine Services to the Philippines

Appendix: Technical Support Manual for Moca

Batanes Provincial Health Office - July 1, 2009 Written by Katherine Kuan

1 Setup Basic Tools

1.1 Download Eclipse

From USB key, Copy Eclipse folder into Program Files folder on computer Launch eclipse.exe Hit the icon that says “Go to workbench” Install plug-ins by going to Help > Install New Software > Click “Add…” Button SVN plug-in

Help > Install New Software > Add… to add site Name: http://subclipse.tigris.org/update_1.4.x Location: http://subclipse.tigris.org/update_1.4.x Click OK Click Next, I agree to terms and conditions, Finish

Android SDK plug-in Help > Install New Software > Add… to add site

Name: http://dl-ssl.google.com/android/eclipse/ Location: http://dl-ssl.google.com/android/eclipse/ Click OK Click Next, I agree to terms and conditions, Finish

1.2 Setup the Android SDK

From USB key, copy Android folder into My Downloads folder My Computer > Right click > Properties > Advanced Settings > Environment Variables Under system variables, find “Path” > Edit > Add semicolon Find system path location of the android SDK TOOLS folder Copy this path into the Path variable

1.3 Install the Android phone device onto computer

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Click “No not this time” for Windows Auto Installer Driver located in Android folder directory under usb_driver, x86 folder Under Eclipse, Click Windows > Preferences > Android > Browse for the Android SDK location (select the folder that has the tools folder located inside it)

2. Download Moca Code into Eclipse 2.1 Import the Moca project into Eclipse from the server

Right click in the left hand side panel (Package Explorer) > Import Click on SVN folder > Checkout project from SVN Create new repository location Location: http://dagny.mit.edu/svn/moca/trunk/clients/moca, Click OK You’ll see the folders show up under http://dagny... Click http://dagny.mit.edu/svn/moca/trunk/clients/moca Click Next, Next, Finish

2.2 Undo changes in Eclipse and get the version from the server

Right click the file or folder > Replace with > Latest from Repository 2.3 Save changes onto the server (only commit changes that are applicable to all

deployment sites) Right click the file or folder > Team > Commit 2.4 Back up your data Go to C:\Doc and Settings\PHO Main\workspace Copy the project folders onto hard drive or something else

2.5 Update Code in Eclipse for MoCa

Right click on MoCa > Team > Update to Head

2.6 Create new procedure for the phone

Under the code branch, MoCa > res > raw Right click raw > New > File Create new xml file (ex: radiology.xml) To rename, Right click the file > Refactor > Rename Copy surgery.xml and create pages according to the doctor’s wishes (http://www.mocamobile.org/development/index.php?title=How_to_Define_Your_Own_Procedures) Add this procedure to the list of procedures by going to MoCa > src > org.moca.util > MocaUtil.java

2.7 Open Logs for Android Window > Open Perspective > DDMS (android icon next to it), Find logcat window

3 Setup Moca on Android Phone

3.1 Install Moca application

In Eclipse, Right click the folder > Run > Android Application

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On Phone, Hit Menu > Reload Database Menu > Settings

Moca Dispatch Server URL: http://moca.mit.edu/mds-dev Initial Packet Size: 1 kb Username: admin Password: moca!mobile Enable Upload Hack

3.2 Uninstall Moca application

Home > Settings > Applications > Manage Applications > Moca Uninstall > OK

3.3 Change APN settings on Android Phone for GPRS to work in Philippines

Go to Home > Settings > Wireless Controls > Mobile Networks > Access Point Names > Smart WAP

Correct Settings (starts automatically using your minutes): APN: internet Proxy: 10.102.61.46 Port: 8080

Incorrect Settings (to save minutes): APN: internetq Proxy: 10.102.61.46q Port: 8080

3.4 General Tips

Always need to enter an ID number (no dashes allowed)

If it crashes, hit close, and then launch the application again > Saved Procedures > continue and try to upload again

If you hit upload to server and it doesn’t go back to the main Moca home screen, then it didn’t upload. Try to upload again

4 Login to OpenMRS to Check Uploads

Access OpenMRS Electronic Medical Record System Go to URL http://moca.media.mit.edu:8080/openmrs/

Username: admin Password: ******** Click Administration > Moca > Moca Queue

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Appendix: Summary of Workflow in Batanes

For Singapore Lien i3 Challenge Application Written by Katherine Kuan

The governor of Batanes was very enthusiastic about Moca and said it was “very, very

applicable.” He said it was easy to use and clear to follow. He said that there are only

general practitioners in Batanes and no specialists available, so telemedicine would

provide access to specialists and quality healthcare for his community. He said that cost

wasn’t really an issue and that they want to make the investment. Also, local technical

support wasn’t an issue. He said that “Filipinos are fast learners” and that they would

work it out. In general, he is proud of the culture and heritage of the province (especially

since Batanes Day celebrations just happened) and proud to have such a healthy

community. They have KSK a local social health insurance program, and I believe all

citizens in Batanes are covered by insurance (either just PhilHealth or PhilHealth plus

KSK).

From my impression, the people in Batanes were very peaceful and hospitable. They

lead simple lives, some live in huts by the beach, and they help each other out a lot. For

example, if someone is building a house, there are no construction workers around to

hire, so they ask their neighbors to help them out. During Batanes Day celebrations you

can just walk into people’s homes when they have a party and they will feed you even if

you are a stranger. We met the governor by going to his house one night because he

had a party for his wife’s birthday, and all the neighbors, family, and friends were

invited.

Rural Health Units

For some health services, some people pay. RHU services are free for people who live

in that municipality. If you’re from outside, depending on your income class, you can pay

from 25 pesos to 100 pesos for the consultation with the doctor. At the RHU they

perform minor surgeries, a dentist comes in once a week, and other primary care

consultations. Sometimes they ask if they can pay later (sometimes they do, sometimes

they don’t). Sometimes Dr. Lariosa (municipal health officer) gets paid for services with

a chicken, fish, other food or homemade goods. That’s the culture there because the

neighbors help each other out (i.e. you can always get eggs from your neighbor if they

have chickens).

Teleradiology

When doctors don’t know how to diagnose the patient from the x-ray, they either send

the plate to Manila or sometimes refer the patient to Dr. Lariosa or Dr. Thea. This is a

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46 Delivery of eHealth and Telemedicine Services to the Philippines

problem because Dr. Thea at the provincial health office isn’t really supposed to be

receiving many patients anyways. They say that the doctors (like at the Batanes

General Hospital) and staff are a little hesitant to use telereferrals. They’ve been trained

already multiple times, but they really aren’t motivated to use telemedicine. It’s mostly

Dr. Lariosa or Dr. Thea who do the telereferrals. Even with telereferrals through email, it

can be slow. In the provincial health office, internet connectivity is really slow.

Sometimes it can take up to half a day to upload an image to an email, so Dr. Thea is

definitely willing to wait until it finishes uploading (half an hour to half a day) via GPRS

with Moca. It’s not urgent that she does it right after each other, since it’s just the x-ray

plate, she can just upload one, set the phone down, and wait till it finished uploading.

Then come back later. Sometimes the x-rays are sent to Cagayuan (sp?) but it takes 1-

2 weeks before they get a reading.

Dr. Thea says that they only received basic training on radiology, but just to be sure,

they like to send the x-ray to Manila to make sure they’re reading it correctly. It’s also

practice for them because then they can see whether they read the x-ray correctly and

learn from their mistakes. Sometimes if a similar case comes up again, she will go back

and find the email from the previous case. It’s disorganized though because she has to

search her email. Once they receive the diagnosis from PGH, they just tell the patient. I

don’t think it’s officially recorded anywhere, they don’t require an official report to be

printed out. She thinks that a revenue opportunity would be if the official report was sent

by PGH so that they could charge the patient money if they want a copy.

eLearning

There’s definitely a good case for a database of expert-labeled images here to be used

as training material for them. They have some books donated by WHO (see attached

image) where they can see examples of what sample chest x-rays are and how they

were diagnosed. Books are expensive and limited in the number of examples they

provide. It’s necessary to develop this capacity at the local level because in the case of

an emergency if the patient can’t wait for a teleradiology referral or for the snail mail

way, the general practitioner has to make the call. At that time they can only use what

they know from experience and the examples of past telereferral cases to try to find a

similar image.

Insurance

In terms of insurance, there is insurance from PhilHealth, where it is mandatory for them

to pay 100 pesos per month. For the formally employed sector, they pay 100 pesos per

month for coverage of the whole family. They can avail of inpatient services, but if they

come to the clinic they cannot reimburse services/medicine. Even for inpatient services

though, PhilHealth will cover maybe 50-70% (don’t quote us on this number) of the bill

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depending on what the hospital charges. Basically hospitals can charge whatever they

want and PhilHealth will always reimburse up to a flat amount according to what

service/case it is. With telemedicine though, people will be able to pay less out-of-

pocket expenses for even better care.

There is an informally employed (or self-employed group). They are not mandated to be

enrolled because there is no employer giving them a salary. They are the most

vulnerable group in terms of not having insurance coverage.

The indigent program in PhilHealth is where people with income class < 14,000 pesos

per month for a family of 6 receive free healthcare coverage. Indigents receive inpatient

and outpatient benefits. For inpatient benefits, they don’t have to pay. The facility can

submit the claim straight to PhilHealth, but they can wait up to half a year to be

reimbursed. This is where eRecords can come into play and automate billing for faster

turnaround time from PhilHealth (latencies in verification of member benefits can be

done faster electronically). The money to provide indigents with PhilHealth insurance

comes from governors, mayors, congressmen, or the province itself.

There is also KSK, a local social health insurance (community-based). It’s not

mandatory, so they have to work on marketing for people to buy it. There are about

1000 households enrolled in KSK out of 3000 in Batanes. Reimbursements are quicker

because it’s only run by a couple of people in the provincial health office. KSK was

setup by a German NGO partner. The NGO did a survey to see how much people can

afford for healthcare. I think they found about 50 pesos per month to be affordable.

Another consultant pegged it at 90 pesos per month. For KSK, members pay 92 pesos

per month for coverage. They receive 5000 pesos for hospitalization per family per year,

and 500 pesos for outpatient services.

Benefits of Telemedicine

For telemedicine, we can save the amount of money it costs someone from Batanes

traveling to Manila. It’s about 16,000 pesos for airfare, 1,000 pesos per day for

board/lodging, so it comes out to be 18,000 for 1 person but usually they travel with

more than one person. If someone does actually fly out to Manila, if the illness is not an

emergency, PGH will send the patient back home and ask them to follow up in 6 months

for a surgery later. Even if the person needs an operation, they may have to come back

after 6 months to actually have the operation. Basically they have to fly in first for

advice/consultation/diagnosis and then later come for the operation. This initial

consultation can be done through teleconsultation and save lots of money!

Teleconsultations are also valuable in cases where rehab is needed or surgery follow-

up.

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In terms of volume, there are about 20-30 x-rays taken per day for the 3 health facilities

in Batanes. For the provincial health office, the max they requested was 4-5 x-rays per

day, but not all of these are referred to a specialist.

An officer in the Provincial Health Office in Batanes says that it’s hard to compute the

health statistics manually from all the provinces. If data looks incorrect, they have to go

track down the RHU to figure out where the error came from (simple calculation error or

misread handwriting). Hence, they made an Excel spreadsheet with formulas (but these

are also prone to error). Everything is compiled into 1 spreadsheet (where each sheet

has all the statistics for a different city/municipality – see attached picture). So one file

has statistics for each month of the year for each city/municipality and I’m not sure if it’s

backed up regularly or in a secure place (anyone can access the files if they go on that

person’s computer in the office). They really want software that can generate these

reports easily, to save time and minimize errors.