Topic Discussion 1 : Improving health system

[Wirichada Pan-ngum]

Please providing an example of health system improvement in any health setting and discuss the possible barriers that could occur in that system improvement process. (10 Marks)

—————————- Deadline 16 January 2023 Pls reply before ————————————

[Zarni Lynn Kyaw]

One example of a health system improvement in Myanmar is the implementation of a national electronic health information system (EHR) to improve the quality and accessibility of health services in the country. District health Information System Version 2 (DHIS 2) is approved as a national platform during AeHIN 2016 General Meeting in Nay Pyi Taw. The EHR is designed to provide a centralized platform for collecting, storing, and sharing patient data across different levels of the health system, including hospitals, health clinics, and community health centers.

One of the main goals of this system is to improve the quality of health services by providing health care providers with more complete and accurate information about their patients, which can help to guide clinical decision-making and improve patient outcomes. Additionally, the EHR is intended to improve the accessibility of health services by providing patients with more convenient and efficient care, and by reducing the need for patients to travel long distances to access health services.

However, there are several possible barriers that could occur in the process of implementing such a health system improvement in Myanmar. One major barrier is the lack of infrastructure and resources to support the implementation and maintenance of the EHR system, which can limit its reach and effectiveness. Another barrier is the lack of technical and data management expertise among health care providers, which can make it difficult to effectively use and interpret the data provided by the EHR.

Other potential barriers include:

-Limited access to digital technology in remote and underserved areas
-Lack of consensus or ownership among stakeholders in the implementation process
-Limited access to reliable and consistent internet and electricity to support digital data collection
-Cultural, linguistic, and social barriers that limit understanding and adoption of the system
-Lack of financial resources to sustain the system and its upgrades.

Additionally, the political and social context of Myanmar, with ongoing armed conflict and displacement in some areas, further complicate the implementation process. Such conditions may require additional measures to ensure safety and security for the project staff and participants, as well as to ensure continuity of services in case of disruptions.

The situation in Myanmar highlights the importance of understanding the context and carefully planning the implementation process to address these potential barriers and ensure the sustainability of the health system improvement.

[Boonyarat Kanjanapongporn]

Thank you for sharing an insight view from Myanmar. I agee with you that EHR would create the huge benefits to healthcare related units. However, because of the massive affected, it would come with many obstacles. I also agreed with your suggestion on tightly planned and measurd while implementing new systems to keep pushing forward under complicated governmential situations.

[Wirichada Pan-ngum]

In addition to planning the implementation process, building capacity in the long term would make a strong foundation. That is why you guys are here 🙂

[Kansiri Apinantanakul]

I agree with prof. and all of you that the implementation of EHR is a project that impacts the stakeholder at all levels.
For me, the modern EHR system is the door to the next opportunity including the improvement of service, research data collection and so on.

[ABDILLAH FARKHAN]

Let me brief an example of health system improvement in the aspect of health financing supported by the role of information system in my own country.

Financing for health, particularly health care service delivery has uplifted since the implementation of mandatory social security insurance (called JKN) at the beginning of 2014. Before JKN scheme, beneficiaries of social security were ambiguous, undefined, and unequal. With funds that was depending only on the public sector, it was not easy to cover a free healthcare service delivery to the hundred million inhabitants. Of course, a big country with big inhabitants is a big burden. After the JKN has been being implemented, financing for health is sourced from public sector, private sector, and from individual monthly contributions. So, this is a big transformation in health financing.

Under JKN, all Indonesians are now covered by National Social Security. JKN tries to actualize mutual cooperation principle where every people are encouraged to help others, so the participation of citizens is the key to leading to universal health coverage. To increase participation and support health financing, a mobile app called mobile JKN was introduced with special functions to register new family members, update and generate personal data, inform about billing and contribution payment, and register patient to the healthcare.

No significant challenge about the app, but barriers that remain the source of controversy during transition period are how to increase individual participation and how is the implementation in hospital. Since this scheme is mandatory national health insurance that obliged every individual to share their monthly contribution, contrary opinions and refusion always come. Another barrier is JKN’s mechanism implemented in public and private hospital which is complained by most people because this social security scheme uses a tiered referral mechanism in order to provide appropriate, selective, and efficient service delivery. But apart from those barriers, I argue that implementing JKN is an improvement in health financing as the health system is becoming more well-directed.

[Zarni Lynn Kyaw]

Thanks for sharing about JKN, I’m very interested to learn more about how JKN has started and it’s challenges, could you share some papers discussing about this transition? Thanks.

[ABDILLAH FARKHAN]

Sure.
Here is the link to download the file:
https://apps.who.int/iris/bitstream/handle/10665/254716/9789290225164-eng.pdf
This provides more comprehensive challenges than I mentioned above.

And this one is also worthwhile:
https://digilib.esaunggul.ac.id/public/UEU-Article-13220-5_0131.pdf

[Zarni Lynn Kyaw]

Thanks, this is amazing. I’m learning a lot. 🙂

[PREUT ASSAWAWORRARIT]

I would like to introduce you to an example of innovation that can improve the health system. The clinical decision support system (CDSS) is one of the powerful innovations that leads to changes in healthcare delivery. The CDSS is a tool to enhance medical decision with clinical knowledge, patient information, and research. The CDSS can be developed from both conventional software, which we input codes and algorithm in the computer, and artificial intelligence generated CDSS, whose algorithm is generated by machine learning.
There are many advantages of CDSS. First, it improves patient safety. The system can detect several medication errors can be detected by the system. Second, the CDSS can increase adherence to clinical guidelines. It can alert physicians that ongoing management is harmful or does not have significant benefits for patients. Another advantage is increased cost-effectiveness. The CDSS can reduce test duplication, suggest cheaper alternative medications, decrease hospital stay, etc.
However, there are many challenges and barriers to implementing CDSS in our practices. First of all, CDSS needs infrastructural system to support CDSS development, for example, all documents, orders, clinical notes should be on an electronic platform. The speed of central server must be sufficient to handle a tremendous amount of information and sophisticated processing. On the healthcare provider aspect, the CDSS developer should inform their users about the application and limitations of the system to avoid overuses and fear to follow the instructions generated by the CDSS.

[Wirichada Pan-ngum]

I wonder about the user acceptance of CDSS. People is the hardest component to change sometimes.

[Tanatorn Tilkanont]

Recently, the new health system was announced by the National Health Security Office (NHSO) with regards to free drug dispensing in the drugstore setting. Patients who have common illnesses, such as fever, cough, sore throat, headache, dizziness, stomachache, diarrhea, constipation, etc., can receive treatment according to their rights (Universal Healthcare Coverage) for free of charge at the nearest registered drugstore. This system aims to improve both the hospital system and patients.

For hospital aspect, the system
– decreases the burden of healthcare providers in the hospital
– reduces crowded condition in hospital
– less risk of infection spreading

For patient aspect, the system
– reduces time-consuming
– reduces traveling cost
– increases treatment accessibility
– increases the health awareness

In case more patients decide to visit a drugstore, the barrier that could occur would be
1. insufficient pharmacy resources, including both approved drugstores and trained pharmacists
2. Possibility of missing claims data, causing difficulty in claims reimbursements
3. Increasing of drug store pharmacists workload per patient
4. If the drugstore doesn’t have standardized electronic medication records that can be interoperable to hospitals, it would be almost impossible to track medication history.

Please feel free to share the idea on this topic.

[Zarni Lynn Kyaw]

Although I am familiar with the old 30 baht scheme, this new change to the NHSO is new for me. Could you share some papers about this change? Thanks.

[Tanatorn Tilkanont]

Hi Zarni, Unfortunately, I could not find any paper written in English.
There’s only in Thai, which is a news/announce from Thailand NHSO website.
>> https://www.nhso.go.th/news/3809
If you are interested, you can visit the website and use translation tools. Sorry for inconvenience.

[Zarni Lynn Kyaw]

Thanks for sharing the link, I used Google translate to check the link.

[Boonyarat Kanjanapongporn]

I did shared the same topic with you. This development has been one of the current and big improvement in Pharmacy industry. Interoperability is the great recommendation point to generate greater outcomes for this program.

[Zarni Lynn Kyaw]

Thanks, your points about Pharmacy industry and Interoperability are well noted as well. 🙂

[Kawin Wongthamarin]

Nowadays, our society is gradually becoming an aging society. The problem of falling among the elderly is the second leading cause of death from unintentional injuries, especially among empty-nesters and elderly living alone. However, as technology improves, developers have tried to create solutions to this problem, producing cameras and AI systems that detect falls and send alerts to caregivers.

As far as I know, some hospitals, nursing homes, and personal users are starting to adopt these technologies. I think barriers to getting this technology into the health system are as follows.

– It is a new technology that is not well known yet.
– The accuracy is not very high, sometimes there are false alarms.
– Users need to have some level of technical knowledge to be able to understand and use the system.
– The problem of infringement of privacy rights
– It is a technology that is still expensive and has a high installation cost.
– Concerned about the security of the data because if outsiders access the stored images, the user may be compromised.

[ABDILLAH FARKHAN]

Thank you for elucidating a best practice to detect and monitor falls among elders. I agree that one of the cons arises from this concept is patient privacy which limits their movement.

[Kansiri Apinantanakul]

Thank you for raising such an interesting topic.
The expansion of an aging society is definitely trend since 2020 moving forward.
I agree with the barriers you mentioned.
Moreover, I personally feel that the culture of each region/country quite affects the pattern of healthcare to be developed in each country.
In Thailand, I think most of us have the culture/norm of taking care of the elderly by ourselves.
We might tend to accept the healthcare technology that facilitates taking care of the elderly at our homes.
On the contrary, some people in other countries may prefer nursing home.

[Boonyarat Kanjanapongporn]

My healthcare settings are pharmacy stores which are private organizations. Recently I have seen and experienced the improvement for the healthcare system to wider medicine counseling and dispensing services.
Previously pharmacies weren’t involved with governmental units and customers had to use their own budget to receive the service. Moh-Prompt, PaoTang Health wallet and New Pharmacy Common Illnesses are examples of system improvement which connected private healthcare pharmacy store to social security scheme and universal coverage scheme of Thailand. Because of data networking, patients could get some basic services from pharmacy stores by the support from their health schemes. Free contraceptive and medication for 16 common illnesses are examples of expanded services.
This support could reduce the crowded hospitals and distribute mild symptom patients to pharmacy, therefore patients could get quicker treatment. Moreover, this could generate income to small health units and position pharmacy stores in national health management.
During this service expansion, I could see some issues which could reduce the capability of these system improvements.
First, Financing issue. After providing services for customers, pharmacy units would receive the reimbursement from the government organization. Somehow, the reimbursement was slow and some pharmacy stores didn’t want to continue the service without money in return. This could affect the number of units which need to have the flow of income.
Workforce resourcing is also the barrier. The variety of services had expanded but number of staff were limited. In some situations, staff available might not able to handle all the work which could affect the quality of outcomes.
From these two obstacles, it might be a struggle to continue the programs without adapting the system and pharmacy units.

[Kansiri Apinantanakul]

Thank you for sharing.
I also heard about the free medication for 16 common illnesses program.
I think it is quite a challenge for the stand-alone pharmacy store whose resource (pharmacist, pharmacy assistant) is limited.
I think there would be major change for pharmacy business in upcoming 2-3 years.

[Tanyawat Saisongcroh]

Workforce resource really is the issue in every new implementation. Since medication for common illness might not be that complicated, the particular training program for local non-pharmacy healthcare providers in primary care unit might be helpful and reduce pharmacist’s workload.

[Kansiri Apinantanakul]

Hi All,

Please allow me to share the health system improvement, particularly in research perspective. I’m working as a Clinical Research Associate (CRA) in one of pharmaceutical company.
My company launched the use shared investigator platform (SIP) for about two years and the new features have been updated regularly.
The pros of the platform is that the investigators (physician who oversight the clinical study) and site staff could registered themselves once and use this platform as the document exchange portal, GCP training portal among all sponsors.
The barrier I faced during my work:
1) The lack of user acceptance: site staff and investigator only registered once, and they never visit the website again since they did not understand the important and the features provided in this portal.
2) For document exchange feature which is quite convenient for sponsor and site staff to exchange the document. However, site staff preferred to send the document photo via LINE or other platform based on their familiarity
3) The platform only available in English, the site staff feel difficult the access each feature

All portal functionality training relies on CRA. This training required for all site staff and it is considered as the additional task for use. As we are super busy, we only could train them to register properly and provide training only on basic features (and some of them forgot how to do it very quickly after training T^T).

In the conclusion, the important step of implementing any systems is the proper training (which may required repetition) and the user acceptance.

[Tanatorn Tilkanont]

Thanks for introducing a new health system. I never experienced this kind of SIP. But I understand its advantage. This system is more formal than using LINE and all the evidence could be captured with SIP, unlike LINE.
I agree that the most important thing is the training and explain the importance of using SIP since Site Initiation Visit (SIV). While the new features updated, all the stakeholders should test and evaluate before it launch.

[Siriphak Pongthai]

Let me introduce you to the system when I worked at a hospital particularly in Oncology Pharmacy Department. Most of oncologists are familiar in writing chemotherapy order regimen as well as progress note. However, chemotherapy and biotherapy are considered as highly toxic and hazardous drugs to cytotoxic classification.

This kind of drugs need safety handling since transporting, preparing, and administering. As oncologist prescribed by writing, then assistant pharmacist and pharmacist are helping in transcribing an order (drug name, dosage, route of administration, frequency, etc.) into computer system. This step of transcribing can easily bring on medical error “Transcription Error” due to illegible handwriting or human error thus consequently caused harm to patient.

Therefore, the department has developed an electronic ordering system by creating classification of cancer, cancer stages, standard chemotherapy/biotherapy regimen, automatically calculated dose by BSA, next cycle date, provided pre-medication, home medication, follow-up date, and prerequisite blood testing.

In the early stage of system implementation, the rate of using are very low because oncologists were not familiar with electronic version but we extremely encouraged them to use because this is not only reduce medication error but also enhance standard care and safety for the patient. Two years passed by, the rate of electronic order used is gradually increased.

I think the barriers were stability of the system, familiar of the system to users, user friendly, completeness of regimens available for physicians, and the most important is how users accept the system.

Lastly, by implementing electronic ordering system, we can analyze data and speculate trend as well as rate of drug dispensation. We can also use this information as part of drug inventory management to prevent drug shortage that caused delayed treatment for patients.

[SIPPAPAS WANGSRI]

I will discuss about health system in Thailand, particularly in remote areas, or any health care services outside university hospital and/or smaller than provincial hospital.

Here are lists of main concerns and potential improvement

1. Available resources and budget distribution
– Personnel/health care workers — this topic has been an issue over decades, no matter how many new doctors and other health care providers are being graduated every year, there will always be spaces in the system to be filled. Mainly because we aim to provide as much healthcare coverage as possible to everyone. The solution is straightforward — you just have to create more personnel, yet the barriers are also about budget (in training , salary and so on..) and quality control.
– Laboratory technician and equipments — many small hospitals lack an instrument as simple as a CBC (complete blood count). Speaking of the root-cause, it all comes down to “insufficient budget”. The workaround in my opinion is probably by establishing some laboratory nodes in some common area and provide ways for smaller hospitals to collect samples and send them to the nodes. The potential barrier that comes with having many health care institutions would be about an interoperability across the system, which I’m going to talk about in the next bullet.

2. Interoperability and unified health care HIS/EHR
– Imagine that you are a health care worker in a remote hospital. What if the patient is referred out to your hospital from the provincial hospital? You can only see the discharge summary and a brief summary of treatment and vice versa. You can not look for the real-time and up-to-date information about the treatment using a different EHR.
– Firstly, every hospital has each own HIS system. All of them are separated and all of the data is stored locally within the hospital itself in a distributed manner. In Thailand, we do not currently have a unified health care system because it is a big change and will certainly affect a lot of stakeholders, especially the company who created a particular HIS system, the cost of creating a whole new system and infrastructure. Also, the employees are used to the old, classic program that has been used for many many years and the point is that they don’t want to change! They always say as long as the old system works, don’t fix it. That’s the challenging barrier — to make people accept the change.

[Tanyawat Saisongcroh]

I would like to share an example of improving quality care in clinical practice from my organization, called “Early hip surgery fast track”.

Morbidity and mortality of elderly hip fracture are quite high. These patients have complicated medical condition and trend to need special pre/postoperative care, delayed surgery and prolong admission with complication. With multidisciplinary care team including cardiologist (assessment, echo) radiologist (doppler US screening DVT), anesthesiologist (regional block), orthopedist/trauma unit and operative team (additional available schedule), we developed project called “Early hip surgery fast track” which aim to surgery within 72 hrs using developed protocol system and particular clinical practice guideline. This project reduces morbidity and mortality rate, improves service quality and safety, reduce hospital cost and improve bed occupancy rate and resource management.

This facility setting commonly occurs in private practice. Fortunately that we successfully run this protocol in public hospital under UC coverage. We did face the barrier at the beginning especially “people” since they have to do an extra work. As the project continued, everyone start to use to it and gain more skill in every steps.

[Hazem Abouelfetouh]

An example of a health system improvement is the implementation of a telehealth program in a rural area. By allowing people living in remote or underserved areas to consult with healthcare providers remotely, such as via video conferencing, can improve access to healthcare.

Implementing a telehealth program may be hindered by the following barriers:
cost and lack of funding, as well as a lack of infrastructure and technology in rural areas, concerns about the privacy and security of patient information, and a lack of reimbursement for telehealth consultations all contribute to patients’ resistance to the change.

[Wirichada Pan-ngum]

Thank you all for sharing your stories and discussing others’ posts. I learn a lot from all of you who probably have more relevant experiences of different innovations in health!

[Author]

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