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As we frequently seen in hospital setting whatever provincial or rural hospital. Today trend is established electronic medical record system. With this improvement, we can provide more service to the patient with more efficiency and safety. EMR could change how we store medical records into privacy and secure platform. EMR also guide healthcare personnel to perform service harmoniously. However, change always create barriers. Possible barriers could occur are investment, data migration and change management. In some setting, investment might be the most important issue even you plan to set on-prem or cloud platform. You have to convince the executive board to comply with your project. Data migration is later consideration, how you migrate paper-based data to electronic-based; manual entry or another. Lastly, change management is how to convince all level of healthcare personnel to believe this system is boosting routine efficiency and willing to implement this system in routine workflow.
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In Thailand, the national health coverage system has been deemed to be a successful project and it is recommended by World Health Organization. However, the financial aspect is still the main problem in which many hospitals suffered from an operational deficit and in debt due to government policy.
Currently, the government hospitals received monetary reimbursement from National Health Security Office (NHSO) or สำนักงานหลักประกันสุขภาพแห่งชาติ (สปสช) in Thai. The policy is to distribute yearly government health budgets to each hospital per capita, for example, in 2020, each Thai people has 3,719.23 THB maximum spending per year that means a hospital with 10,000 coverage will get only 37,192,300 THB per year. Normally, this method might work if most people are not using healthcare services and the rest of the budget will go to more required patients as in private health insurance.
But the problem occurred as Thailand has gradually become an aging society, where most of the patients are elderly and suffering from non-communicable diseases such as diabetes, hypertension, and chronic kidney disease. The hospital has to manage its budget to fit all required costs including healthcare workers, medicine, laboratory, instrument maintenance, etc. According to the news, many hospitals are already in debt and at risk of bankruptcy.
In my opinion, we can resolve this issue by implementing health IT reimbursement which provides both direct (medicine, doctor’s fee, disposable instrument) and indirect cost (hospital fee, lab test, instrument maintenance) reports, by this way, both NHSO and the hospital can determine the real cost of each treatment which will help to allocate health budget proportionally.
The main barrier of this project is the difficulty to implement at the national level as all government hospitals in Thailand will be subject to the same system.
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Financial support on UC is problem in many countries because it is a large amount of government budget and as you said more and more when we go into aging society. I think we need to think in the long term how we can maintain this. Most countries pay UC from income taxes. Surprisingly, rich country like the US don’t do UC!?!
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As we knew that there are many gaps or improvement needed in health service system at all levels in Thailand. One of a common example that we (may be everyone) may have seen/met were “the waiting time” to receive the service at the Out Patient Department (OPD).
The example to reduce the waiting time to receive the services is the drug delivery to home (ส่งยาถึงบ้าน) system that developed by the Siriraj Hospital since 2014. The reasons to develop this system were;
– They have more than 650,000 OPD cases per years or more than 3.88 million times of services per years
– There were more than 1.6 million orders of prescriptions per year or more than 5,000 orders per day.
From data that they collected and analyzed, it was found that during 10.00-13.00 was the highest number of patients that were waiting for the services/ prescriptions (1 prescription per 30 seconds, preparing the drug 40 seconds for 1 order). That caused the patient to wait for the drug for approximately 45-60 minutes each.The proposed solution to this issue was to reduce the drug preparation (spent a lot of time to find the drug) by send the drug to the patient at home by post. The drug will be prepared and packed in to the packaged with the controlled label under temperature control if required. They also have the QR code system created for tracking that patients have received the drug yet. In case that the system is notified that patient has not yet received, the hospital staff will call to follow up wit the patient to ensure that patients have received the good quality of services (quality and quality). The cost of this service is 150 baht per orders for all area in Thailand.
This health service is improved the health services system by reducing the service waiting time, cost of travelling (transportation and meal).However, in my opinion think that there are some gaps/ barriers/ issues that need to be improved are:
– The understanding or knowledge of the patients; this may affect to some of patient who are the old generation and don’t have/ limit of communication devices.
– Limited to patients who don’t have their own address/ house.
– The quality of delivery service (package, controlled temperature, delivery time)There are some examples that I would like to present are:
– The health services that developed by the Regional Health 2 and Naresuan University to provide the health service using the big data technology (Internet of Things: IoT) called “หมอรู้จักคุณ”. This application will provide the service to the patients who require the services or supports; consultation, emergency.
– The National Tuberculosis Indicators Project (NTIP); to provide the services for those who were diagnosed to TB infection.
So, the gaps/barriers of these services are the available technology (communication networks and devices), understanding or knowledge of the patients or who receive the services, supports from government; policy and budget.
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Now the policy of 30 baht treatment in anywhere of the MOPH was established. In my regional of health will be enabled this policy in 1st March 2021. This policy must have three major components.
1. EMR of every HIS data from hospital in regional health.
2. The new claim system for extra condition such as walk in from other provincial patient that not emergency (in term not UC-AE in E-claim system of NHSO).
3. The new referral system that can improvement by pooling of HIS data.The above topics look difficulty and must take a long time to create them but it’s the policy from regional health director that must finish in time. In the last 4 years ago our IT team in regional health was study the essential tools and method for this policy then our team can finish this work. Now I can watch the visiting history patient, drug, lab in hospital in regional health from anywhere and anytime. The method was divided in many part and integrated together. The backend was create by python script that collect data to cloud system (GDCC). The data set was generated to one common dataset. The HIS that can use this system are HOSXP, HOSXP PCU, JHCIS, and HOMC. The database was collected by document database system not relational database system. The API that connect to the DB is Loopback API (Node.js). The frontend was created by React.js that the one of best language for PWA. The login system was identified by Line UDID.
The claim system have new condition for walk in patient not emergency that have extra funding from NHSO. From this system was used three component of six building box, service delivery, IT, and Financing and I this that this system can improve health outcome, patient satisfaction, and equity of health service.
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The Digital Transformation In health system improvement.
-Appointment service systems in the hospital.
-Paperless systems related to health.
That provides more service to the patient with more efficiency. These systems can serve patients more efficiently, but the potential obstacle is that the facility’s investment in providing a service information technology system and the need for patients to learn and adapt. Built-in information system applications.-
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According to the six building blocks, information system is one of the six important components, when all components have its interaction to each other. If we improve one component, it have a good effects to the whole system. I do agreed with you on improve health system by using the advance of digital technologies. I personally believe that if we have an effective information system, the system will be able to perform and achieve the goals of the health system.
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The improvement of a health system that is significantly improved is telemedicine. Telemedicine helps health care professionals to evaluate, diagnose and treat patients at a distance using telecommunications technology. It has many advantages such as no travel expenses or time, reducing waiting time in the hospital, and Avoiding contact with other patients who may be sick. However, it can be expensive to set up, maintain and access this system in some areas. Moreover, certain types of illnesses and problems require a face-to-face physical assessment and cannot be diagnosed through telemedicine.
The possible barriers that could occur in this system improvement process are investment and adaptability. Firstly, the cost of setting up and maintaining telemedicine is quite expensive and it needs special techniques or people who know the system very well. Moreover, the doctor, health care professional, and the patient will adapt to telemedicine and it is not only the IT aspect but also work procedure and the service delivery as well. It can be hard for people who like face-to-face relationships and certain diseases that need physical assessment.
In my opinion, the pros of telemedicine seem to outweigh the cons. A patient will be treated, receiving medical support and information from their home.
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Thank you for sharing this good idea/example of Thai Health Service System. I do agree with your comments/ barriers for the successful in implementing this service. To add, one of the issues in all areas/ setting is HUMAN RESOURCES.
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Thank you for your comment. I agree with HUMAN RESOURCES are crucial for developing a good health system.
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There have been attempts to eradicate measles, and these actions also has good effects on health system improvement. Health system can be strengthened by trickle-up effect from routine vaccination. Measles eradication dedicates funding and efforts to strengthen routine vaccination services, which can have a positive trickle-up effect on the overall health care system. Vaccination services are viewed as the backbone of primary health care to prevent many diseases. Because a stronger routine vaccination program could be used to attract patients to other child health interventions, preventive as well as curative.
Barriers of health system improvement should be identified, analyzed, and addressed. The most common and serious vaccine-preventable diseases tracked by the World Health Organization (WHO) are: diphtheria, Haemophilus influenzae serotype b infection, hepatitis B, measles, meningitis, mumps, pertussis, poliomyelitis, rubella, tetanus, tuberculosis, and yellow fever. These diseases are killing kids and adults every single day even we have vaccines to prevent. Because it involves with several health system’s components. For example, in the case of measles immunization, there are barriers that hinder eradication such as intelligence/information, collaboration, synergies in financing, synergies in delivery, and vision/oversight. -
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The development of village health volunteers or VHV is one of important health system improvement of Thailand. Although the example has been developed for 30 years, but the village health volunteer is primary step of the public health system and it is the strongest point of Thailand health network. The project create human resource from the local people who have good understanding about local information and people in the community, by educate them about public health and personal health knowledge. VHV play important role to communicate, transfer health information, knowledge, news, public relation between health care provider to people in local community, promote, and support health care provider in other sectors. It improve health distribution and health level from central or provincial level to the village level. The response from health care provider also faster through the VHV communication way.
The barriers of the project is human and financing. Because everyone have different basic knowledge, how to develop them into the standard is necessary and challenge. The financial for supporting activities of VHV and develop them is also important.
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For me, it is difficult to be able to improve the health system in our country, because there are manyof factors that can slow down development, such as:
Cooperation for both personnel and stakeholders As you know Everyone can help to develop a better health system. But it is often found that most people do not cooperate.such as Medical staffs who do not want to learn and develop themselves
Patients who do not cooperate with medical personnel etc.
Everything must be gradually evolving so that everyone can access and use technology to the maximum benefit.
Training and educating both personnel and stakeholders is another way to help develop a better health system. The dissemination of knowledge to villagers to know and know about the Thai health system will help everyone to have access to good health systems.Government funding was also another factor delaying its development. The development of the health system needs government support. Thailand has a very good health system from around the world. But still found that Most of the good health systems in Thailand are concentrated in large hospitals such as provincial hospitals. City hospital, etc.
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I would like to provide national electronic health system as an example for improvement of tuberculosis care. Proper electronic health system is needed for drug adherence and safety, reduced transmission, outcomes, etc. Without proper follow up, there will be grave consequences such as drug resistance, rise in incidence, poor outcomes, and finally, loss of money and human resources to the country. However, there might be barriers which need to be considered upon improvement of the system (according to the lecture):
– Drug adherence: with traditional methods of patients recording, it is usually late to recognize when the patients fail to take the treatment. With modern methods of directly observed treatment such as, electronic drug dispensers with alerts, wirelessly observed treatment for patients from remote areas. The challenging issue here is cost. For the sake of efficiency, newer methods for making sure of drug adherence are needed without much cost.
– Drug safety: recognizing anti-TB treatment side effects early is essential for reversibility of those effects. With poor resources of money and caregivers, it cannot be reached. So, the barrier here is human resources and training of all level of staffs.
– Coverage of the system: Recording and reporting of the conditions of the patients in the remote areas without internet coverage is a challenge for improving the system. -
During the last couple of years, our organization has been implementing a system which is OpenMRS medical record system to improve the ongoing health system setting of the organization especially in the information sector which is one of the main six blocks in a health system. As an overview, this system allows our organization to have a better information management system which then leads to making informed decisions for the ongoing health system.
Anyway, there are many challenges and barriers that occur in that system improvement process.
The first one is the data legacy transfer. The previous recorded medical data have to be transferred to the newly implemented one, and that has been a great challenge for us till now.
Another one is end users’ attitudes and skills towards computerized medical record systems. Though this issue could be tackled with the change management process, however, it still stands as a possible barrier to the process. The third one is the financial challenge. Computers, tablets, and other electronic devices have to be purchased on a large scale to cover all of the service delivery sites. And in some areas where the electricity outage is frequent, power generators and inverters are needed for the OpenMRS system to function well. -
As our country is still using paper based records and reports in almost all places, it is quite difficult to correct reports in time for data analysis. So, we developed electronic recording and reporting system for TB project in our organization. Our team discussed the possible barriers as follow.
There are some challenges in service provision and resource generation as below.
Each management level should involve in change process. Unless, there will be more difficulties in changing paper based to electronic system.
Users need some digital literacy skill and require mobile phones with some specification. It is also linked to financial challenge which we might need to purchase digital devices such as mobile phones and tablets.
Reliable internet connection is required as it is vital in electronic recording and reporting.
Constraints related to leadership/governance include political stability and interest and leadership from policy makers in government sector. We do not have political stability in our country which impact hugely to our new system.
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