Dr. Portia Grace Fernandez-Marcelo (Image credit: NTHC )

OpenGov had the opportunity to speak to Dr. Portia Grace Fernandez-Marcelo, Director of the UP (University of Philippines) Manila-National Telehealth Center (NTHC) about using ICT to provide equitable access to quality healthcare for all, specially in isolated and disadvantaged communities.

NTHC is one of the pioneers in the Philippines developing cost-effective ICT tools and innovations for improving healthcare and deploying solutions in communities where they are required most urgently. The Center partners with various government and non-government institutions  in the areas of eMedicine, eRecords, eSurveillance, eLearning and eHealth Policy Advocacy, .

Dr. Marcelo has occupied the position of Director at NTHC since 2011. She has extensive experience and deep expertise in community medicine and global health, and is concurrently an Associate Professor at UP Manila’s College of Medicine Department of Family and Community Medicine since 1993.

Can you provide us a bit of background on the NTHC?

In the late 90s, there was an emerging desire to connect with communities online. NTHC was established in 1998, as a means for UP Manila to reach out across the 7,107 islands of the Philippines, looking at new ways of supporting health professionals and engaging with communities, going beyond the conventional physical face-to-face events.

NTHC is the e-Health research and development institute of the National Institutes of Health (NIH [1]), which is also part of UP Manila. 

NTHC explores innovations in the use of ICT for health. As a state university, it is part of UP Manila’s mandate to do research for finding better ways to address the problem of inequity and offer real solutions to pressing problems.

In the initial years, people were just beginning to grapple with the use of ICT for healthcare in a non-traditional way.  Internet connectivity in Philippines was very poor. Mobile phones were just becoming popular. 

The ICT infrastructure in the university itself was being improved. Awareness raising that ICTs can help improve health became a campaign. Research opportunities were tapped in order to prove that technology works, that health workers will use it and that it will improve their efficiency and help them care better for their patients. A lot of the research began small, with pilot tests. 

At that time, NTHC was already working with government and international grant providers.  Through its initial R&D output, NTHC already raised issues of the need for ICT standards and national health ICT architecture but these were hardly appreciated.

The faculty went abroad to study in the late 1990s. Then they came home to Philippines and continued their research, and pushed for the formalisation of education in medical / health informatics in the university.

         When I came on board as the director in 2011, I built on all that work, essentially expanding footprint and building on the technologies and operations that were developed previously.  These heightened further UP Manila's national policy advocacy work for eHealth as an enabler and driver of national health development.
         
         
         

What are the areas of focus for NTHC?

Philippines’ geographic character of an archipelago of islands poses one kind of challenge for healthcare access. Filipino health professionals are world-class, yet there is mal-distribution of capacities and expertise across the country, concentrated mainly in urban centers. Other social problems and political neglect shape health inequity; the urban poor, in particular, also do not have access to healthcare.

Telemedicine is a key channel for improving access to healthcare for isolated and disadvantaged communities. We spent the first 15 years demonstrating that it can work, extending reach by rural remote communities to the clinical experts of the UP Manila, the national health sciences center. Albeit still at infancy stages, regional medical experts have come on board to serve their respective regions through telecare.

         The next step would be to formalise telehealth as a modality of care in the Philippines, specially for our remote and disadvantaged communities. Government legislation must be revised and the Medical Act of 1959  has to be updated to account for the use of ICT in healthcare. While ICT has become pervasive in all walks of life, current and future health professionals – and even those in other relevant disciplines such as engineering, computer science, and the social sciences -   have to be trained better to be capable of using the ICT tools in a safe and ethical manner.
         
         
         
         

The legislation needs to be supportive of the health system and protective of patients. Two House Bills on telehealth were filed in 2012 and 2014 Congress of the Philippines, but were not legislated. They have yet to be re-filed under this current government administration to ensure continuity and full integration in the Philippine health care delivery system.

Also among our pioneer projects is the Community Health Information Tracking System (CHITS) - an electronic medical record (EMR) system to improve tracking and improving patient care, and facility level health information management  at the primary care Rural Health Unit (RHU) level.  Its efficacy is recognized through its adoption by over 200 RHUs, as well as two international and five Philippine national awards in the last decade.

What are the projects NTHC is currently working on?

Telehealth and CHITS provided the base for subsequent research and innovations, including exploring how  mobile phones could work for health care.  

We linked CHITS and mobile phones to put together for Real-Time CHITS or rCHITS, as part of a UNICEF funded project and implemented in a few towns in Mindanao, south of the Philippines. It was meant to link midwives posted in the barangays or villages. Public health workers, such as midwives were trained in using cellphones and computers to document and report health data. We linked them to a single database, and allow real-time monitoring of maternal and child health indicators. Data is displayed in a local government health dashboard.

Immediate action can be done by respective authorities if necessary. rCHITS was intended to empower local governments. Based on rCHITS, local leaders can take evidence-based decisions to improve health outcomes in their local communities.

With partners, we modelled a telehealth-enabled service delivery network for pregnant mothers. This was a response to the major problems of transfer of patients needing more complex care across health facilities.   For the longest time, clinicians can only give a referral slip and ask patients to go to a hospital of their choice. The poor patient, who  lacks the medical expertise, decides for himself where to go.  More often than not, his decision will be driven his (lack of) monetary resources. This is actually a cop out on part of the health system.

But if the health facilities are  better governed, adequately funded, equipped and organised in a system, poor patients can receive quality care, with the guarantee he will still be cared for in the best possible way even if he transfers from one clinic to another.   The health system becomes truly accountable,   We saw encouraging results in Quezon City's campaign for better maternal and child health, aided by the Mag-Ina (mother & child) Telereferral System, or MiNTS. It draws relevant maternal data from the CHITS-EMR, alerts the hospitals of the referral of a high-risk pregnant mother, and notifies the primary care clinic where the patient originated from the outcomes of care. The Quezon City Health Office is able to monitor these high risk patients. 

On another front the RxBox research program linked a diagnostic medical device to CHITS, and from CHITS to teleconsultation. If you needed to refer certain cases to specialists, EMR data, including relevant physiologic signals drawn from the medical device,can be transmitted seamlessly. 

         We also started discussing the issue of Unique identifier. Now that the ICT has gone from demonstrating potential to delivering benefits, it is leading to new concerns. How do you ensure that the “Portia Marcelo” in one hospital is the same as the one in another hospital? Our campaign for standards and governance was driven by these issues, raised by the health workers and IT engineers.                               

We - the UP Manila - contributed to the work in setting up the National eHealth Steering Committee (NESC) in 2013. The Committee is co-chaired by the Secretary of the Department Health (DOH) and the Secretary of the Department of Science and Technology (DOST).  The Philippine Health Insurance Corporation (PhilHealth) as well as the Commission on Higher Education are members, likewise.

The eHealth community has expanded considerably in the Philippines, if one is to judge the many health “apps” that sprung in the recent years.   This governance body ensures eHealth investments contribute to national health development in a more deliberate and integrated way. The Philippine National eHealth Strategy 2014 to 2020 was articulated, a product of broad participation and nationwide consultation. Defining standards and a national health ICT architecture integrated and cognisant of the country's national eGovernance framework are among foundations of the Strategy.  More work needs to be done, but we've taken the fundamental steps. 

NTHC is also convenor of the International Open Source Network ASEAN+3, created by the United Nations Development Program in 2007, and the Asia eHealth Information Network, in cooperation with the WHO-Western Pacific Regional Office in 2012.

The Philippine Health Information Exchange

The Department of Budget and Management (DBM) controls the funding for public investments in ICT.  DBM, along with the DOST ICT Office, encouraged the various sectors to organise themselves and integrate systems. For the healthcare sector, one of the outcomes was the Philippine Health Information Exchange (PHIE). It was set up jointly by NESC to bring together all players, including health facilities, health care providers, health information organizations, and government agencies. 

PHIE became a driver for encouraging frontline primary health care centers to automate.  Whereas in its infancy, the PHIE promises to ensure seamless health information transfer to allow continuity of care and administrative efficiency.

         PhilHealth is turning out to be another important driver. PhilHealth, which runs the country's social insurance program, provides a sizable amount of money to primary care government facilities and it requires the submission of electronic information from primary care facilities through the PHIE. Those who already have EMRs are beefing up their systems. And those who have no EMRs are considering various systems that are available to them. March 2017 is the deadline. We have around 2500 government-funded health facilities in the municipalities. Around 1000 of them are using one form of EMR or another from one of 6 EMR providers. NTHC covers around 200, the Department of Health itself covers over a 1000.
         
         
         

At the moment, data integration remains elusive. Part of the discussion is about all the EMRs using the same ICT standards. The idea is that there would be one data entry and multiple uses through the information exchange. The GovCloud could hold all the data.

Can you tell us a little bit more about these cybersecurity and privacy concerns?

It is important for patients to believe we are trustworthy and that we can and will protect their information. Cybersecurity and privacy was always a part of the discussion for us. They were central to the way we were introducing and propagating technologies. Our projects are peer reviewed and they have to get clearance from the research ethics board at the university.

When the NESC was organised in 2013, a technical working group on privacy was also set up, since we want to exchange data through the PHIE. This expert group organised policies to protect the privacy of patients based on the Data Privacy Act, 2012.  In fact, one of our faculty who sits in this expert group, Dr. Ivy D.Patdu  eventually became a Deputy Commissioner of the National Privacy Commission (NPC).

The NPC was finally constituted in 2016 because the NESC campaigned for it, among others. Implementing rules and regulations were subsequently articulated. For the university, we had exhaustive discussions to discuss and disseminate the new rules and upgrading the university’ processes. This will be a continuing discussion.

Integral to all of NTHC's healthcare solutions is training and discussions on ethical use of these solutions and ethical health information management.

How does NTHC work with local administrations?

We have a small team of around 55, but our footprint appears big. That’s where local administrations come in.

As an example, we are partners with Quezon City and Navotas City, both invested in citywide CHITS; their health leaders and health workers collaborated to design what is the current version of CHITS. Pasay City was the birth place of CHITS in 2004, where the UP worked alongside health workers to shape an EMR that addressed their clinical as well as administrative reporting needs.

In Quezon City, the local government took it upon themselves to say we really want to take care of our mothers and children. Thus together, along with regional DOH office and the UNICEF,  we prototyped the MiNTS. We were able to demonstrate successful transfer of patients, moving beyond tele consultations. We began with two lying-in clinics, MINTS will now be implemented in all of its 79 facilities city-wide. 

We are going to try and replicate this in the provinces of Iloilo and Sultan Kudarat, where the RxBox and CHITs are already in place, again upon the initiative of their progressive physicians and their mayors. Now we are linking them better into the service delivery network.

Today, local governments have better awareness about the need to integrate health systems. It’s a good start. And communities themselves are witnessing success stories and appreciating the potential of these solutions. 

[1] The National Institutes of Health (NIH) was created on January 26, 1996 by the UP Board of Regents to strengthen the research facility of UP Manila, and serve as an institutional home of a network of researchers and research institutions. NIH was established as a national health research center by the Philippine Government in 1998. In 2007, NIH became one of the four core agencies of the Philippine National Health Research Systems (PNHRS). PNHRS is part of a global movement, initiated by the Council on Health Research for Development (COHRED) to establish national health research systems in country setting.