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Currently, we are trying to implement a system change in our organization. We started introducing digital HIS last month. The first thing I focused on was helping everyone see why this change was necessary. I showed the difference between our paper-based data and the digital HIS—especially in terms of accuracy and completeness—so they could clearly see the benefits.
After that, we provided training for the health post staff and held open, two-way discussions with both end-users and regional staff. We encouraged everyone to speak honestly about their concerns, difficulties, and what they wanted to improve. Whenever possible, we made adjustments based on their feedback. Throughout the process, we made sure to consider their workload and practical limitations.
To support motivation, we also integrated performance appraisals and non-financial rewards, including simple KPIs related to data tasks. Since we didn’t want to add extra pressure on field staff, we shifted some responsibilities to the regional HIS focal person and kept regular communication, so everyone felt supervised and supported.
Right now, we are piloting the system for three months. At the end of the year, we will review how staff felt about the system, what challenges they faced, and what improvements they would like to see before we scale it up further. I also invited HIS focal persons to HIS-related meetings with partners organization and internal meetings, ensuring them that their opinions are valued and considered. -
Personally, I have not experienced breach of confidentiality, integrity or availability of information system.
I would like to discuss a case scenario that happened in Medstar health system that affected availability of information system.What happened?
Medstar health system is the Columbia-based health system, which runs 10 hospitals and more than 250 OPD clinics throughout Maryland and Washington D.C.
On Monday March 28, 2016, the health system discovered a computer virus has been installed on its computer network. The ransomware attack forced its EHR and email systems to shut down to prevent the spread of virus.How did it affect the system or users?
After the virus was discovered, the authorities acted rapidly to contain the infection and prevent its spread throughout the organization. They also reported to FBI and worked closely with IT and security partners- to know the cause and find the solutions.
Meanwhile, the health services continued. However, EHR and email systems could not be used due to computer network not being operational. Consequently, physicians and nurses had to go back to using paper records and charts to record patient health data. This affected service efficiency and caused delays.
Medical data previously stored in EHR could not be accessed, compromising information availability.And how to prevent it?
To prevent such attack to health system, the following measures can be undertaken –
1. Regular software patch management
As many attacks target outdated systems, we have to ensure operating systems, antivirus solutions and digital applications are updated regularly.
2. Strong Network Security Measures
Apply reliable firewalls, detection systems and segment networks to prevent compromising the entire system.
3. Staff Training and Awareness
Training staff regarding digital literacy and cybersecurity measures. Reporting mechanisms for any unusual computer behavior.
4. Regular Data Backups
5.Strong Access Controls
Keep access control list together with MFA.
6. Incident Response Plan
Institutionalize a formal incident response plan, so that staff are aware of what to be done during a cyberattack and promote faster response. -
Effective communication is key for open, honest and respectful communication. In my work, I put a lot of effort into communicating. As we are working as a team, seamless information flow is very important to smoothen workflow, to avoid conflict and to ensure everyone is on the same page.
Firstly, I clearly define a communication channel with a group of relevant staff to enforce continuous communication and understanding of each member. I make sure the group is active by tracing updates and asking for feedback on their work. I encourage them to express their opinions and concerns, and always make sure their feedback is always considered. Active listening and empathy are also essential for effective communication. Only if we listen carefully and show empathy, can we understand each other and find the solutions together.
I also provide constructive feedback to show interest in their task, to acknowledge their effort and to ensure they get a sense of support.
Transparency is also vital. If we do something like performance appraisal and incentives programs, we clearly communicate with every member of staff with frameworks and criteria to avoid unnecessary conflicts. -
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Thank you Ama Wah. I learned a lot from your well-structured, comprehensive presentation. Malaria remains a health crisis in our area and I have always wanted to develop a malaria surveillance system.
I would like to know, is there any practice of data sharing among Thailand with neighboring countries like Myanmar and Laos for cross-border surveillance? -
I use a mix of leadership style in my work. As I am leading a project with demanding changes and improvements of both systems and people, I need to use most of the leadership style depending on the situations.
Firstly, I use Affiliative style when I believe they are feeling down or distressed, I made a caring community with the team and listen to their concerns and restore the emotional bonds.
I often use Democratic leadership style, probably this is the mostly used method. I understand everyone is the master of their expertise, by knowledge or by practice. Leaders don’t know everything, that is every details of the context. When I have to develop new initiatives, I created a platform to raise their opinion and always ensured their opinions are welcomed and taken account. In that way, I made everyone feel they are valued as a team member, fostering their sense of ownership.
Also, I sometimes used authoritative method when I want to motivate them toward the change. Currently, I am adopting a coaching style as I want to build their skills and confidence. Their performance are appraised and non-financial rewards with professional development plans are introduced to improve their skills and confidence.
Moreover, one of the Ajarns introduce me the traditional leadership style and collaborative leadership style. I am adopting a collaborative leadership style, where everyone is responsible and the authority is shared based on the knowledge and expertise but not on position/person. -
Comparing the speech of PM Lee and President Trump, I think both are good communicators. Both illustrated that they would do the best for their nations. They are calm and credible for citizens.
Regarding PM Lee – I prefer his speech because he do not assume or claim crisis, instead he provided facts, real situations and academic evidence. He showed respect and appropriate gestures during his speech. He also linked with previous emergency of SARS for better public understanding and insight of the condition. He provided detailed response plans for citizens and clearly instructed them empathetically on how to do personal protection measures. In his speech, he also considered and tried to reduce the burden of healthcare workers, which is important to avoid the heath system collapse with over workload during health crisis.
Regarding President Trump – He is also a good communicator. He clearly promoted actions to disrupt disease transmission. But he claimed the situation and the possible outcome even though no one can know the real potential of the outbreak and consequences for sure. He didn’t show enough respect and empathy for citizens. He emphasized national strength while blaming China, which seemed inappropriate in such a sensitive context.
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The implementation of digital health has been very limited in our country. There have been instances of trying to develop digital health but due to the coup, most of them are currently static.
Most of the private hospitals start using EMR, but the systems are siloed with lack of interoperability among them.
These are the areas needed to improve and strengthen for preparedness of pandemics in our country-
Team – Team of various stakeholders (including community) should be formed to follow agreed on procedures and policies for digital health, ensuring every party is on the same page.
Collaboration and coordination platforms should be present for seamless information flow within country. Designated focal points for international communication of disease outbreaks.
Capacity building for digital literacy and data security should be given at regular intervals.
Transparency and trust – Adoption and acceptance of digital health by citizens needs transparency and trust. Empowering citizens with their data, including consideration of policies such as ‘The Right to be forgotten’. Ensure that the surveillance systems combine an effective public health response with respect for ethical and privacy principles. A clear separation between science and policy has to be made to build trust.
Technology- Leverage digital technologies to collect, analyze, utilize and share data for deeper insights for future health preparedness and interventions.
Techquity – Consider other dimensions of health (geographic, socio-economic status and education, etc) to mitigate digital inequities. These should be addressed through policy work, national investment for digital and technology access.
Transformation – As mentioned in the reading document, “Think locally and act globally” is an important aspect to consider for successful digital health transformation. We should adopt and customize technologies to be locally acceptable and to be globally interoperable to gain high return on investment.
All in all, for our country I think all five themes are needed to be developed or strengthened for future pandemics preparedness and response. -
1. Disease outbreaks that have been declared as PHEIC by WHO. As of now, seven PHEIC declarations have been made from 2009 to 2023.
Year Disease Duration
2009 H1N1 (Swine flu) June 2009 to Aug 2010
2014 Polio May 2014 to present
2014 Ebola Aug 2014 to March 2016
2016 Zika virus Feb 2016 to Nov 2016
2018 Ebola Jul 2019 – Jun 2020
2020 Covid 19 Jan 2020 – May 2023
2020 Monkey pox Jul 2022 – May 2023
Why do these outbreaks raise such concerns?
2. Why These Outbreaks Raised International Concern
Each PHEI declaration met at least 2 of the following criteria:
(1) Serious impact on public health – There is potentially high mortality and/or morbidity.
(2) Unusual or unexpected – the disease-causing agent is yet unknown or a new (emergent) pathogen
(3) Significant risk for international spread
(4) There is risk for trade or travel restrictions3. In my opinion, the disease that may potentially lead to PHEIC in the future is – Influenza. Influenza viruses are classified by their H (Hemagglutinin) and N (Neuraminidase) surface proteins, and they mutate unpredictably. There are 18H subtypes (H1-H18) and 11 N subtypes (N1-N11). We cannot estimate which strain (H & N type) will cause outbreak in the coming years and so, no prior vaccine can be given to prevent the infection until it actually happens.
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1.) Which single design limitation most threatens valid estimates of sensitivity and representativeness? How would you address it within six weeks?
Relying only on passive facility-based reporting threatens sensitivity and representativeness.
Within 6 weeks,
My plan is to combine passive and active surveillance methods.
Firstly, I will select sentinel sites for passive and active surveillance.
Train focal persons the reporting procedure for AEFI (the timing, interval, variable, channels) and close follow-up for support.
Additionally, the focal persons will conduct phone call follow-ups to caregivers of children after 7 days of vaccination to capture unreported events.
I will follow up with the focal persons about the reporting flow/active tracing flow and adjust when necessary.
I will review weekly data and conduct evaluation in 6 weeks.2.) Using the CDC surveillance attributes, propose one low-cost intervention to increase sensitivity. State the expected trade-offs, and list 2–3 indicators to detect impact from the intervention.
Low cost intervention – 7-day post vaccination follow ups with phone call at sentinel sites
CDC attributes addressed:
Sensitivity – capture more AEFI cases through active follow-ups
Timeliness- timely detection of any adverse effect
Acceptability – simple methods, easy to useTrade-offs- More workload and burden to staff, phone bill costs, more false positives
Indicators –
1.AEFI reports/ 100,000 doses
2. % of AEFI cases detected through active phone call follow-ups
3. % of serious events detected within 48 hr3.) For a newly introduced vaccine, should the AEFI case definition be temporarily broadened to maximize early signal detection?
– If yes, what trigger would you use to revert to the prior definition?
– If no, why should this change not be implemented?Yes, the AEFI case definition should be temporarily broadened to maximize early signal detection.
When to revert – after 3 months and there is no new safety signal detected
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Verification and Preparation
• Establish the existence of an outbreak: Using National/ District level surveillance database can help collection, collation, analysis and use of data for disease surveillance for detecting abnormal trends.
For e.g.
Global level – WHO’s Global Outbreak Alert and Response Network (GOARN), ProMED-Mail
National/District level – DHIS 2
Specialized disease surveillance – MIS (malaria information system)
• Verify the diagnosis: Laboratory confirmation results can be shared to relevant stakeholders, through health information systems or other digital communication channels.
• Prepare for fieldwork: Preliminary meetings with decision makers and field team can be done via digital platforms, field data collection using mobile tools.Describe the Outbreak
• Find cases systematically and record information: Data can be recorded into the information systems and store collectively in central databases to avoid fragmentation and foster real-time data-driven decision making.
• Perform descriptive epidemiology: Using visualization tools and geological mapping (GIS) to generate insights into the disease distribution, magnitudes and hotspots.Hypothesis and Testing
• Develop hypothesis: Data visualization tools can provide insight into the possible sources, mode of transmission and the offending organisms.
• Analytical studies to test hypothesis: Using statistical software (e.g., SPSS, R, or STATA) to confirm the hypothesis.
• Special studies (environmental or laboratory): Environmental monitoring tools and Laboratory management information system enhance the surveillance system.Response and Action
• Implementation of control measures and follow-up: Broadcast and follow-up the control measures through various digital platforms for community awareness.
• Communication: Through out the process of surveillance, digital communication tools play a critical role, ensu -
One technology I like most is telemedicine.
How it works: Telemedicine lets doctors and healthcare workers check on patients remotely using video calls, phone calls, or secure messages. Patients can tell their symptoms, share some health info, and get advice without going to the clinic. Many telemedicine systems connect with electronic health records so the doctor can see your history and follow up easily.
Importance: Telemedicine is very helpful during pandemics like COVID-19 because it reduces the risk of overcrowding in hospital and reduce disease transmission while ensuring continuity of care for both covid and non-covid patients. It plays a crucial role in ensuring accessible, inclusive and equity of healthcare services.
It also supports the successful implementation of outbreak response principle in case detection, contain infection clusters and interrupt community transmission. -
How can surveillance help to detect and control the disease?
As dengue is mosquito-borne infection, transmitted from person to person through the bite of Aedes mosquito, surveillance and control is important.
Using data from surveillance –
1. Preventive measures – We can enforce preventive measures to reduce mosquitoes breed in the environment, to decrease transmission, advise personal protective measures/awareness raising/early signs & symptoms especially in endemic areas.
2. Know the disease burden – to understand the distribution, nature and burden of infection nationally & sub-nationally
3. Monitor trends – we can evaluate the impact of interventions to the spread of infection
4. Detect and respond to outbreaks – early detection and preparedness plans like resource allocation, refresher training to health staff, blood bank alertShould we conduct active or passive surveillance or both for the disease, why?
I think it depends on situations-
1) During routine period – Passive surveillance is enough.
2) During outbreaks and seasonal peaks – Passive surveillance is primary and combines with active surveillance. Passive surveillance through reports is sustainable and cost-effective. But during sentinel outbreak or peaks, sentinel active surveillance is necessary to make timely interventions and preventive measures. Combination of both approaches is important because most of the infection is mild or even asymptomatic, which can be missed if we rely only on passive surveillance.Which method should be best to identify cases, why?
1. Cases in medical facilities VS community
Cases in community because most of the infected cases are asymptomatic or mild, not seeking medical care at facility, which can underestimate the disease burden.
2. Sentinel VS population-based surveillance
Sentinel surveillance because dengue is vector-borne disease and usually spread in community through the bites of infected mosquitoes. Population-based surveillance is more time and resources consuming and may compromise the quality of data.
3. Case-based VS aggregated surveillance
Case-based surveillance for contact tracing, mapping and early outbreak detection and intervention.
4. Syndromic VS laboratory-confirmed surveillance
Lab-confirmed surveillance because it mainly presents with fever & rash which are very non-specific and mimic other viral illnesses. (like influenza, zika, etc.)What dissemination tools will you choose to disseminate monkeypox surveillance information? Why do you choose this/these tools?
Through multi-media to ensure the reach of the information:
Periodic SMS in local language-since most people, including elderly, use mobile phones nowadays. Therefore, I think it ensures everyone gets the health message and alerts.
Facebook– because this is still the most popular online platform in my country.
Television – Dedicated information sessions on TV show and also footnote in popular TV programs.
Electronic dashboard – to disseminate real-time visualization, dissemination an hotspots mapping
By using this combination of approaches, we can ensure that the information is accessible, timely and inclusive. -
I would choose cloud computing due to the following reasons:
Elasticity (access to resources) – can dynamically allocate resources as needed.
Scalability – with cloud storage, we can scale up and adopt new technologies and services easily.
Remote access – cloud services ensure the availability and authorized accessibility of data wherever and whenever needed.
Integrated and coordinated care – large volume of data emitted daily from patient health care can be consolidated in cloud storage. Centralized data storage promotes data usage for decision support and interdepartmental coordination for patient care.
More focused on clinical services and system rather than infrastructure – IT technician will no longer need to consume most of the time on infrastructure and hardware. They can focus more on system development.
Security – One of the benefits of cloud technology is the ability to access resources that would otherwise be unattainable. A cloud provider will have security experts deploying the latest patches and software to its data center.
Cost saving – Although cloud technology does not equate with inexpensive technology, cloud services charge for pay-per-use model and there is no large upfront cost, and only monthly rental fee will need to be paid.
Maintenance and support – Cloud providers provide maintenance and backend support. Therefore, there is no need for organizations/hospitals to mind for data backup, infrastructure maintenance/updates. -
•Should you give the data out?
No. I must not give the individual data out.
•How do you not violate any of the General Principles of Informatics Ethics.
I cannot give the data with details at individual level. I must follow the Declaration of Helsinki and provide only data without personal identification after the relevant informed consent and ethical approval.
•If you want to provide the data to them , what and how will you do it?
I can support the research with de-identified information and provide only the minimum data they really need for the research. Additionally, we must ensure they follow the ethical principles of data usage and protection. -
•What should you do?
We should do nothing as the patient has a fundamental right to privacy.
•As a health information professional – can you tell your friend?
No. The person has full control over his own medical data, and medical professionals and informaticians must ensure that all protected health information (PHI) are handled with confidential manner. The disclosure of personal data without consent can lead to serious consequences and disrupt the trust of patients to the information systems.
•Can you interfere with other people or family issues?
No. As a health information professional, we must never disclose personal health data, especially sensitive information as it will be violation of ethical standards.
•But, should your friend not know about this because she might be at risk?
Yes, she might be at risk, but a health professional must never intervene directly into patient/family matters. Instead, we may encourage the patient (with proper clinical channels) to disclose himself, if the health condition can risk his spouse. However, the final decision to disclose is up to the patient himself.
•How will you follow the fundamental principles about right to self-determination, doing good and doing no harm to others?
I will follow the fundamental principles by:
Respect the patient’s autonomy – ensuring he has the authority to make decisions about his health information and respect of patient’s dignity, privacy and rights.
Doing Good – I must stay within my professional boundaries while promoting the well-being of all parties. If I am concerned for the spouse, I can encourage proper counseling and disclosure through clinical channels, not through personal communication. If I am still not sure of what would be the best for both parties, I can seek guidance through ethical board/committee without mentioning patient’s identification.
Do no harm- Avoid any action that could lead to harm. Disclosing patient’s HIV status without consent can lead to psychological stress, social stigma and self-harm. This can have a huge effect of patient’s trust on the health system.
•Isn’t it your obligation and the right of the subject to hold the information?
Yes, it is the right of patient to hold the information, and it is my obligation to protect the right.
I am obliged to respect the patient’s ownership of their health information, ensure the confidentiality and security of PHI, avoid disclosure without consent. -
I would like to discuss the digital HIS transformation plan in our organization. I think I can use the ADKAR model for the system change.
When I thought about the need for system change, I focused on convincing only the senior management team and our HSS members, not the other staff.
However, I realized that the success of digital HIS system depends on the efforts and active participation of regional and field staff. So, their awareness and desire are also important. Now, we are planning to provide training for HIS staff and health post staff, including hand-on training.
Since the ADKAR should proceed sequentially, I will convince them of why we need to change the system and motivate them.Awareness – I will explain them of the necessity of digital HIS transformation. (to reduce reporting delays due to logistical constraints, to make real-time data-driven decisions and resource allocation like current malaria incidence, to monitor the adherence of clinical guideline and training needs, etc..)
Desire – When they understand the benefits and necessity of the system, we would motivate them by showing how the system will reduce their workload, smoothen the workflow, enhance the visibility and impact of their work and how they will be part of the data-driven decision-making process.
Knowledge – We are planning to give hand-on training of the software usage
Ability – After the training, pilot testing will be done for 3 months, so that they have confidence to fully deploy the system.
Reinforcement – We will support them with continuous coaching and reward mechanisms, gather feedback from the user and modify the system accordingly.
In summary, we overlooked the awareness and desire among staff and the change was not planned according to ADKAR. But now, by considering and inclusion of all ADKAR stages sequentially, our digital HIS transformation has a greater chance of success.
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We are in the development phase of digital HIS in our organization. We have not deployed the system yet.
I think main factors affecting the development are:People – As we need people effort to plan and implement the system, I think people is the main factor. Therefore, we have to convince stakeholders including organization leaders and staff about the necessity and benefits of eHealth. This way we can change the attitude toward the new system and get their interest and effort. Effective communication is the key so that everyone is on common ground about the system.
Cost – As financial constraint is still present for system development, we have to find ways to adopt the digital HIS platform which will bring maximum output with limited resources. Luckliy, one of our technical support teams has already developed and customized the software relevant to our context, and they are willing to support technically, we have decided to use the software. We will only need money for server rental and IT infrastructure. Therefore, instead of developing new software which will be time and resources consuming, we reduce the risk of financial cutdown by deploying the existing software.
Operation – When we think about using the software, we also considered whether it affects the daily operation of field level since the field staff already have over workload. So, we mitigated the risk of staff burnout by entering the data into software at regional level. The system can compromise if we do not consider the operational factor.
Design – The system should be user friendly.
Data – The data quality is also important so that we can make reliable data-driven decisions. Also, the system must give the information that we need.
Overall, while our HIS is still under development, we have learned that people, cost, operation, design, and data are interdependent factors. Among them, people remain the most influential—because even the best-designed system will not succeed without staff ownership, leadership support, and effective communication.
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I have never experienced a cyber-attack on my computer.
However, I recently received a suspicious job offer from linked-in, which I have never applied to. Their pay is high with much flexibility of tasks. There is no specific information about jobs and company profile.
I thought it was scam message and fortunately I did not click on the link they provided and proceed further.
To prevent such phishing scams, I always
• Verify the company profile and job postings through official websites
• Avoid clicking on suspicious links without verification
• Check the sender’s email and the company contact information
• Report suspicious messages
• Even though I am not currently using any antivirus software, I became aware of using antivirus software and up to date browser security features. -
I think most of the patients, especially the elderly, are hesitant to go to the hospital for checkups and appointments because they have to wait for the doctor for a long time. They feel tired and not comfortable sitting on a chair for protracted time.
If I were to build a medical app, I would like to choose a mobile app that show real-time status of patient queues, doctor availability and estimated waiting times. This app would reduce unnecessary waiting and discomfort and improve patient satisfaction and health outcome.
I would choose a mobile app because it is easier and more accessible as everyone is using a smartphone nowadays. Unlike a LAN app, the real-time queues status can be accessed from anywhere even outside the hospital. Compared to a web app, a mobile app is more convenient as it does not need opening a browser or typing a web address and it can send notification and reminder for their appointment time. -
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It is very impressive how you managed system change and considered all aspects of operation: Human, Organization and System. It was one of the major steps that you introduced a simplified digital form and a high-speed data-entry interface. I had also experienced system change in my previous work. At that time, we have to manually type legacy data of all patients, which was very burdensome and time-consuming. I am really impressed by that Sayar.
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Thank you, Jen, for your comment. Myanmar currently has no specific national policy for data sharing, but related laws such as the Electronic Transactions Law (2004, amended 2021), Telecommunications Law (2013), Privacy Law (2017), and Cybersecurity Law (2025) provide partial guidance. We will continue to comply with these existing policies while aligning our future system with national legal frameworks.
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Totally agree with you Kevin. AMR has been a serious issue in our country with very limited control of drug use. Most of the antibiotics are available over-the-counter. I have even heard that one of my seniors was infected from hospital with sepsis, and his blood C&S result showed the infected bacteria is resistant to most of the tested antibiotics.
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