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MINISTRY OF MEDICAL SERVICES

REPORT ON THE MINISTRY TEAM TO AUSTRALIA ON AN HEALTH INFORMATION EXCHANGE PROGRAMME

24TH MARCH TO 30TH MARCH, 2012

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Table of Contents 1.0 MEMBERS OF THE TEAM ........................................................................................................... 3

1.0 BACKGROUND ....................................................................................................................... 4

2.0 Carego LiveWell Clinics ............................................................................................................. 4

3.0 ITINERARY FOR THE TRIP TO REVIEW OF CLOUD 9 HEALTH INFORMATION EXCHANGE

(HIE) SOLUTION ..................................................................................................................................... 5

4.0 INTRODUCTION TO AUSTRALIA ............................................................................................... 6

1.1 Geography and climate .......................................................................................................... 6

1.2 Environment ........................................................................................................................... 6

1.3 Economy .............................................................................................................................. 7

1.4 Demography ........................................................................................................................... 7

5.0 HEALTH CARE IN AUSTRALIA – THE NATIONAL HEALTH POLICY.......................................... 8

5.1 Health status ........................................................................................................................... 8

5.2 Medical Insurance .................................................................................................................. 9

6.0 DAY 2: - VISIT TO CLOUD 9 SOFTWARE OFFICES AT BURWOOD, SYDNEY, AUSTRALIA .. 11

6.1 CLOUD 9 APPLICATIONS ......................................................................................................... 12

7.0 INTRODUCTION TO HEALTH INFORMATION EXCHANGE (HIE) AT CLOUD 9 OFFICES,

BURWOOD, SYDNEY, AUSTRALIA ...................................................................................................... 14

7.1 BENEFITS OF HEALTH INFORMATION EXCHANGE TO THE KENYA HEALTH SYSTEM..... 15

7.2 DATA BACKUP ...................................................................................................................... 16

8.0 VISIT TO TARINGA MEDICAL CLINIC ................................................................................. 18

9.0 CONCLUSION AND WAY FORWARD ................................................................................. 27

12. CONCLUSION AND WAY FORWARD ........................................................................................... 27

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Figure 1: - CLOUD 9 OFFICES AT BRISBANE, QLD, AUSTRALIA .......................................................... 11

Figure 2: - Location of Cloud 9 Software Offices At Sydney, NSW, Australia ...................................... 12

Figure 3: - Typical Consultation Room at Taringa Clinic, Brisbane, Australia ..................................... 19

Figure 4: - Typical Consultation bed at Taringa Clinic, Brisbane, Australia ........................................ 20

Figure 5: - Dr. Esther Ogara (right) and Dr. Manya being taken through the processes at the

Taringa Clinic, Brisbane by the Clinic CEO (centre) .............................................................................. 20

Figure 6: - The Permanent Secretary, Ms Mary Ngari (right) is being shown a typical at Taringa

Clinic, Brisbane. Looking on are Dr Hellen Mbugua (centre), Ms Liza Kimbo (left) and staff from the

Taringa Clinic ............................................................................................................................................. 21

Figure 7: - A poster showing the treatment of skin tears at Taringa Clinic, Brisbane, Australia ....... 22

Figure 8: - Baby counter at the Pharmacy at Taringa Clinic.................................................................. 24

1.0 MEMBERS OF THE TEAM

1. Ms Mary Ngari - Permanent Secretary 2. Mr. David Nyambok - Chief Finance Office 3. Dr. Esther Ogara - Head, e-Health 4. Dr. Hellen Mbugua - Co-ordinator, International Relations 5. Mr Ayub Manya - Health Information Systems (MOPHS) 6. Mr. Edwin Kemboi - Head, ICT 7. Ms Liza Kimbo - Carego International

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1.0 BACKGROUND

The Ministry of Medical Services, through the invitation and support of Rockefeller Foundation and in conjunction with Carego company which operates LiveWell Clinics in Nairobi, embarked on an Health Information Exchange (HIE) trip to Australia which took them to the offices of Cloud 9 Software in the towns of Sydney and Brisbane. The purpose of the trip was to assess the application of Health Information Exchange (HIE) system in Australia in light of applying the same in the Kenya situation.

2.0 Carego LiveWell Clinics

Carego LiveWell is a healthcare organization incorporated in the USA and in Kenya in 2009. Its objectives are to establish full service health clinics that are efficient and affordable for the low to middle income groups in urban centres in developing countries. The company applies smart technologies and utilizes Healthcare Clinics, LiveWell Cards, and Outreach Programs using standard operational procedures and trained Community Healthcare Workers to provide sustainable medical services within each community they serve.

The aim of the organization is to create and deliver effective healthcare solutions to the emerging markets and uses innovative health service business model focused on delivering:

High quality, cost effective primary care medical facilities

Low cost pharmaceuticals and medical supplies

Health IT solutions optimized for emerging markets

Medical expertise and education utilizing E-Health Solutions Carego is therefore committed to delivering high quality, affordable healthcare to the communities we serve and dedicated to impacting the health, employment and economy of these communities through our self sustaining business model. Carego under the name LiveWell Clinics operates various clinics across the world including in Egypt, Vietnam, Indonesia, South Africa and Kenya among others. In Kenya, the LiveWell Clinics runs three clinics with the major one in Kayole.

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3.0 ITINERARY FOR THE TRIP TO REVIEW OF CLOUD 9 HEALTH INFORMATION EXCHANGE (HIE) SOLUTION

Day Activity Sunday, March, 25th 2012

Arrival in Australia

Monday, 26th March, 2012

Presentation (Cloud9 Office, Sydney) (i) Welcome (ii) Demonstration of software (iii) Visit to clinic at Martin Place, Sydney to see a typical

primary re clinic operating with the software. This included a tour of the facility and a demonstration of the software functionality:

1. Patient administration procedures 2. Triage and scheduling 3. A longitudinal electronic medical record 4. Medication management 5. Laboratory orders and results 6. Diagnostic imaging orders and results 7. Chronic Disease Management

(iv) Group Dinner (Location to be advised)

Tuesday - 27 Mar, 2012 -

Flight Trip to Brisbane - Visit an implementation location in Brisbane where the team was

taken through a typical primary care clinic operating with software. This will include a tour of the facility and a demonstration of the following software functionality:

1. Emergency Medicine and Treatment Room 2. Preventative Health 3. Women’s Health 4. Obstetric Care 5. Childhood Immunisation 6. Nursing

- Presentation of Operational Services (Cloud 9 Office, Brisbane) - An overview of our approach to project delivery including:

1. Business Requirements Analysis 2. Infrastructure Review 3. Business Process Reengineering - Evening Flight Back to Sydney

Wednesday - 28 March, 2012

Follow up meetings with Cloud 9 team, Cloud 9 Office, Sydney 1. Full review of HIE systems and opportunities 2. Review process/requirements for implementation with Carego

team. 3. Plan for dissemination meeting back in Nairobi

Thursday 29 Mar, 2012

1. Q & A Session – Cloud 9 Team, Cloud 9 Office, Sydney 2. Afternoon tour - Sydney

Friday – 30 March, 2012

Departure from Sydney to Nairobi

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4.0 INTRODUCTION TO AUSTRALIA

Australia, officially the Commonwealth of Australia, is a country in the Southern Hemisphere comprising the mainland of the Australian continent as well as the island of Tasmania and numerous smaller islands in the Indian and Pacific Oceans. It has a population of about 23 million people. Australia has a land mass roughly the same size as Western Europe or the USA (excluding Alaska) and is the world's sixth-largest country by total area. Neighbouring countries include Indonesia, East Timor and Papua New Guinea to the north; the Solomon Islands, Vanuatu and New Caledonia to the north-east; and New Zealand to the south-east. Settlement of Australia, by people now known as Aboriginal and Torres Strait Islander peoples or Indigenous Australians, occurred some tens of thousands of years ago. Settlement by people from Great Britain and subsequently other countries began in 1788 resulting in a present day population with a diversity of ethnic backgrounds. The population is heavily concentrated in the Eastern states and is highly urbanised with about 80 per cent of the population living in cities. There are large regions which have only small, scattered settlements or are unpopulated. Australia is a developed country with a generally high standard of living and per is the world’s 13th largest economy and 5th in per capita income and ranks highly in many international comparisons of national performance, such as quality of life, health, education, economic freedom, and the protection of civil liberties and political rights.

1.1 Geography and climate Australia's landmass of 7,617,930 square metres is on the Indo-Australian Plate. The world's smallest continent and sixth largest country by total area, Australia—owing to its size and isolation—is often dubbed the "island continent", and is sometimes considered the world's largest island. The climate of Australia is significantly influenced by ocean currents, including the Indian Ocean Dipole and the El Niño-Southern Oscillation, which is correlated with periodic drought, and the seasonal tropical low pressure system that produces cyclones in northern Australia.

1.2 Environment Although most of Australia is semi-arid or desert, it includes a diverse range of habitats from alpine heaths to tropical rainforests, and is

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recognised as a megadiverse country. Because of the continent's great age, extremely variable weather patterns, and long-term geographic isolation, much of Australia's biota is unique and diverse. About 85 per cent of flowering plants, 84 per cent of mammals, more than 45 per cent of birds, and 89 per cent of in-shore, temperate-zone fish are endemic. Australia has the greatest number of reptiles of any country, with 755 species. The Koalas, kangaroos and the Eucapytus are unique to Australia and is home to many dangerous animals including some of the most venomous snakes in the world.

1.3 Economy Australia has a market economy with high GDP per capita and a low rate of poverty. The Australian dollar is the currency for the nation, including Christmas Island, Cocos (Keeling) Islands, and Norfolk Island, as well as the independent Pacific Island states of Kiribati, Nauru, and Tuvalu. The Australian dollar is slightly stronger than the US dollar.

1.4 Demography About 80% of Australians live in metropolitan cities and coastal areas. The beach is an integral part of the Australian identity. For almost two centuries the majority of settlers, and later immigrants, came from the British Isles. As a result the people of Australia are mainly a mixture of British and Irish ethnic origin. In the 2006 Australian census, the most commonly nominated ancestry was Australian (37.13 per cent), followed by English (32 per cent), Irish (9 per cent), Scottish (8 per cent), Italian (4 per cent), German (4 per cent), Chinese (3 per cent), and Greek (2 per cent). It is important to note that indigenous Australians experience higher than average rates of imprisonment and unemployment, lower levels of education, and life expectancies for males and females that are 11–17 years lower than those of non-indigenous Australians. Some remote Indigenous communities have been described as having "failed state"-like conditions. In common with many other developed countries, Australia is experiencing a demographic shift towards an older population, with more retirees and fewer people of working age. In 2004, the average age of the civilian population was 38.8 years. A large number of Australians (759,849 for the period 2002–03) live outside their home country.

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5.0 HEALTH CARE IN AUSTRALIA – THE NATIONAL HEALTH POLICY

Medicare is Australia's publicly-funded universal health care system. Health care in Australia is universal. The federal government pays a large percentage of the cost of services in public hospitals. This percentage is calculated on:

(i) Whether the government subsidizes this service (based on the Medicare Benefits Schedule. Typically, 100% of in-hospital costs, 75% of General Practitioner and 85% of specialist services are covered.

(ii) Whether the patient is a concession or receives other benefits[3]

(iii) Whether the patient has crossed the threshold for further subsidised service (based on total health expenditure for the year)

Where the government pays the large subsidy, the patient pays the remainder out of pocket, unless the provider of the service chooses to use bulk billing, charging only the scheduled fee, leaving the patient with no extra costs. In some countries, this is commonly referred to as a copayment or what is called cost-sharing in Kenya. Where a particular service is not covered, such as dentistry, optometry, and ambulance transport, the patient must pay the full amount (unless they hold a Low Income Earner card, which may entitle them to subsidised access). Individuals can take out private health insurance to cover out-of-pocket costs, with either a plan that covers just selected services, to a full coverage plan. In practice, a person with private insurance may still be left with out-of-pocket payments, as services in private hospitals often cost more than the insurance payment. The government encourages individuals with income above a set level to privately insure. This is done by charging these (higher income) individuals a surcharge of 1% of income if they do not take out private health insurance, and a means-tested rebate. This is to encourage individuals who are perceived as able to afford private insurance not to resort to the strained public health system.

5.1 Health status The Australian population has a generally good health status, with life expectancy at birth at 75.2 years for boys born in 1994-96 and 81.0 years for girls born in that period. There are some groups with poor health status, notably Aboriginal and Torres Strait Islander peoples. Otherwise the pattern of disease is similar to that of other developed countries.

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5.2 Medical Insurance The public health system is called Medicare, which funds free universal access to hospital treatment and subsidised out-of-hospital medical treatment. It is funded by a 1.5% tax levy on taxpayers with incomes above a threshold amount, an extra 1% levy on high income earners without private health insurance, as well as general revenue. The private health system is funded by a number of private health insurance organizations. The largest of which is Medibank Private, which is government-owned, but operates as a government business enterprise under the same regulatory regime as all other registered private health funds. Most aspects of private health insurance in Australia are regulated by the Private Health Insurance Act 2007. Complaints and reporting of the private health industry is carried out by an independent government agency, the Private Health Insurance Ombudsman. The ombudsman publishes an annual report that outlines the number and nature of complaints per health fund compared to their market share. The private health system in Australia operates on a "community rating" basis, whereby premiums do not vary solely because of a person's previous medical history, current state of health, or (generally speaking) their age. Balancing this are waiting periods, in particular for pre-existing conditions (usually referred to within the industry as PEA, which stands for "pre-existing ailment"). Funds are entitled to impose a waiting period of up to 12 months on benefits for any medical condition the signs and symptoms of which existed during the six months ending on the day the person first took out insurance. They are also entitled to impose a 12-month waiting period for benefits for treatment relating to an obstetric condition, and a 2-month waiting period for all other benefits when a person first takes out private insurance. There are a number of matters about which funds are not permitted to discriminate between members in terms of premiums, benefits or membership - these include racial origin, religion, sex, sexual orientation, nature of employment, and leisure activities. Premiums for a fund's product that is sold in more than one state can vary from state to state, but not within the same state. The Australian government has introduced a number of incentives to encourage adults to take out private hospital insurance. These include: Lifetime Health Cover: If a person has not taken out private hospital cover by the 1st July after their 31st birthday, then when (and if) they do so after this time, their premiums must include a loading of 2% per annum. Thus, a person taking out private cover for the first time at age 40 will pay a 20 per cent loading. The loading continues for 10 years.

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The loading applies only to premiums for hospital cover, not to ancillary (extras) cover. Medicare Levy Surcharge: People whose taxable income is greater than a specified amount (currently $70,000 for singles and $140,000 for couples) and who do not have an adequate level of private hospital cover must pay a 1% surcharge on top of the standard 1.5% Medicare Levy. The rationale is that if the people in this income group are forced to pay more money one way or another, most would choose to purchase hospital insurance with it, with the possibility of a benefit in the event that they need private hospital treatment - rather than pay it in the form of extra tax as well as having to meet their own private hospital costs. Private Health Insurance Rebate: The government subsidises the premiums for all private health insurance cover, including hospital and ancillary (extras), by 30%, 35% or 40%.

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6.0 DAY 2: - VISIT TO CLOUD 9 SOFTWARE OFFICES AT BURWOOD, SYDNEY, AUSTRALIA

Figure 1: - CLOUD 9 OFFICES AT BRISBANE, QLD, AUSTRALIA

On the second day of the visit, the team toured Cloud 9 Software offices at Burwood, Sydney.

The team were taken through an introduction to Cloud 9 Software.

The team learned that Cloud 9 Software Pty Ltd is a private company categorized under Computer Programming Services and located in Burwood, Elsie Street, Sydney, Australia and has several other offices including Brisbane.

The company was established in 2009 and incorporated in .

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Figure 2: - Location of Cloud 9 Software Offices At Sydney, NSW, Australia

6.1 CLOUD 9 APPLICATIONS The team learned that:

The Cloud 9 software uses clinical data repository (CCDR) that provides synchronicity with integrated event processing (IEP) and thus employing centralized infrastructure.

The system is user friendly and uses statistical information to retrieve data. It is an open system that is not limited, not restrictive and uses both keyboarding, voice base opinion based medicine to evidence base medicine.

Cloud9 has built a connected health ecosystem joining healthcare organisations together and delivering patient information whenever it’s needed and uniquely combines cloud-based infrastructure, vertical applications and healthcare domain experts to create tailored end to end solutions for healthcare enterprises and regional healthcare networks.

The solutions are known work within and across organisational boundaries connecting the entire healthcare continuum.

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That it is now becoming apparent that around the world and in every neighbourhood, there is urgent need for a broadly available and pragmatic solution to an increasingly critical issue: the ability to access timely, relevant and accurate patient data in a simple and secure way.

Cloud9 as a company therefore offers healthcare organisations innovative ways to empower caregivers to perform more effectively.

Cloud9's suite of e-Health products offer standards based platform for collaboration to deliver tangible and measurable results and offers the healthcare enterprise an easy, low risk entry into the health information exchange by leveraging existing investments in systems and infrastructure. This approach means organisations can quickly reap the rewards and avoid any costly changes. This therefore represents the next generation of Health Information systems. The aim is to make available to every healthcare organisation a platform through which to provide truly tangible benefits to all stakeholders including providers and patients.

Considering that information is power and by breaking down the barriers to timely, accurate information, the company empowers healthcare providers.

The system employs the ICD 10 standard of medical classification with a reference dictionary and pharmacovigilance system. The system also employs the use of unique ID include using patient cell phone numbers, photos, parent details etc.

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7.0 INTRODUCTION TO HEALTH INFORMATION EXCHANGE (HIE) AT CLOUD 9 OFFICES, BURWOOD, SYDNEY, AUSTRALIA

On the second day of the visit, the team was also taken through the Health Information Exchange (HIE) system.

The team learnt that:

Health information exchange (HIE) is the mobilization of healthcare information electronically across organizations within a region, community or hospital system.

That Health Information Exchange (HIE) refers to the process of reliable and interoperable electronic health-related information sharing conducted in a manner that protects the confidentiality, privacy, and security of the information. The development of widespread HIEs is quickly becoming a reality. Health Information Organizations (HIOs) are the organizations that oversee HIE. For HIOs to function, they must have the capability to employ nationally recognized standards to enable interoperability, security and confidentiality, and to ensure authorization of those who access the information

That HIE provides the capability to electronically move clinical information among disparate health care information systems while maintaining the meaning of the information being exchanged. The goal of HIE is to facilitate access to and retrieval of clinical data to provide safer and more timely, efficient, effective, and equitable patient-centered care. HIE is very useful to public health authorities in assisting them in analyzing the health of the population.

That HIE systems also facilitate the efforts of physicians and clinicians to meet high standards of patient care through electronic participation in a patient's continuity of care with multiple providers.

The team also learnt that: HIE also benefit secondary health care providers in reducing

expenses associated with: -

i) the manual printing, scanning and faxing of documents, including paper and ink costs, as well as the maintenance of associated office machinery

ii) the physical mailing of patient charts and records, and phone communication to verify delivery of traditional communications, referrals, and test results

iii) the time and effort involved in recovering missing patient information, including any duplicate tests required to recover such information

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7.1 BENEFITS OF HEALTH INFORMATION EXCHANGE TO THE KENYA HEALTH SYSTEM

The team learnt that there are benefits to the use of the HIE system, among which are: -

That, considering the many desperate Electronic Medical Records (EMR) systems in use in the Kenya health care system, HIE will go a long way in ensuring that all these electronic health record systems are able to talk to each other and therefore produce information for use by the authorities without the need for standards.

That HIE assists authorities mine information from all existing EHR systems without the need for standards for the various EMR systems. This system shall be ideal for the Kenya system where there are many disjointed systems in various hospitals across the country.

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7.2 DATA BACKUP Data is backed up offsite by an outsourced dedicated company in Brisbane, Australia.

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VISIT TO CLINIC AT MARTIN PLACE

Location: Martin Place

All claims by doctors are electronic. Some services such are

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8.0 VISIT TO TARINGA MEDICAL CLINIC

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Figure 3: - Typical Consultation Room at Taringa Clinic, Brisbane, Australia

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Figure 4: - Typical Consultation bed at Taringa Clinic, Brisbane, Australia

Figure 5: - Dr. Esther Ogara (right) and Dr. Manya being taken through the processes at the Taringa Clinic, Brisbane by the Clinic CEO (centre)

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Figure 6: - The Permanent Secretary, Ms Mary Ngari (right) is being shown a typical at Taringa Clinic, Brisbane. Looking on are Dr Hellen Mbugua (centre), Ms Liza Kimbo (left) and staff from the Taringa Clinic

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Figure 7: - A poster showing the treatment of skin tears at Taringa Clinic, Brisbane, Australia

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Figure 8: - Pharmacy at the Taringa Clinic

Figure 9: - Baby counter at the Pharmacy at Taringa Clinic

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VISIT TO CLOUD COMPUTING INFRASTRUCTURE

Figure 10: - Data Rack Containing Medical Records for various Clinics within Australia

Figure 11 – From left Mr Daivd Nyambok (CFO), Mr. Edwin Kemboi (Head, ICT) and Dr. Esther Ogara (head, E-Health) (far right) listen attentively as they are being taken through the workings of Offsite data backup at Brisbane, Australia.

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9.0 CONCLUSION AND WAY FORWARD

12. CONCLUSION AND WAY FORWARD

The use of HIE will go a long way in assisting the Ministries of health make use of the many disjointed EMR systems in the country without the need of working on standards.

9.1 Way Forwad 9.2

It was agreed that the Ministry

I. The Ministry to call for a stakeholder’s meeting to discuss the idea of Health Information Exchange (HIE) and its applications in the health sector.

II. The Ministry to place for Phase Iroll-out with an identified smaller group of hospitals and clinics. The team in Australia will comprise the high-level working committee and the first phase to include:

4 acute hospitals 25 clinics (mix of health centres, dispensaries, private and

public out-patient clinics)

Once identified, hold a stakeholder forum drawing on key managers and staff from these identified facilities

III. Run the initial phase to test the HIE during 2012

IV. Call a larger, national stakeholder forum to share results from the initial phase.