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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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In my previous work using EMR, the decision support system was not advanced. The built-in CDSS are drug-drug interactions alert, patient’s allergy alert, duplicate therapy alert, duplicate service order alert and high generation anti-biotics prescription alert that need to fill detailed request form.
I think some functions help but some don’t. Most of my colleagues find it distracting.
All are valuable notifications to avoid medication errors and duplicate the tests. However, when they become too generalized (i.e. not customized alert and notification for each patient), the system becomes overwhelmed by too many pop-ups and disrupts the workflow. From my perspective, using advanced systems like AI-driven CDSS will facilitate usage and satisfaction by providing holistic overview of patient and patient-specific notifications. (information quality)
As mentioned in the video, system design is also crucial-it should support rather than disrupt workflow. For example, alerts should appear at the top of the screen instead of the center, and they should not require unnecessary clicks to dismiss. (system quality)
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If the hospitals do not use the ICD standard, the data systems would be fragmented and very difficult to integrate and so to interpret country disease prevalence and health status. If we need all disconnected systems to communicate and talk to each other, very expensive and handy middleware will be needed.
For health information exchange (HIE), we need standardization and interoperability between information systems. So, utilization of agree-on disease coding standards like ICD standard or SNOMED CT are required for disease classification and reliable health data exchange. -
Yes, I agree with this finding. From my own experience and perspectives from my peers, using EMR can lead to physical and mental burnout while it gives many advantages at the same time.
From EMR user point of view
Poor internet connection – It is very distressing when the connection is down as workflow are disrupted and delayed especially during busy hours.
Eye strains and cervical spondylosis – After using EMR for 2 years in our hospital, most of my friends increased lens power and got neck stiffness, due to too many screens time.
Increase workload – Since we cannot fully adopt EMR system (due to consultants’ nature), we also use paper-based patient’s chart. Therefore, we have double data entry and workload.
EMR design and built-in functions – our EMR system need to be fully online to operate, and it has so many steps just to note progress, order tests and prescriptions. Moreover, some medication interaction alerts are too overwhelming. (e.g. the system notifies even if a patient is prescribed dual anti-platelets)
Dependent steps – if the attending doctor is busy and cannot order a lab test in the system, the nurses cannot proceed with the following steps of drawing the blood and send the blood tube to the lab. Patients’ cares are so much delayed in these scenarios. We even sometimes face patients’ complaints and dissatisfactions due to the delay.From the patient’s point of view
Less patient interaction – as the doctors and nurses are busy in front of the screen with documentation and ordering test/medication, they have less patient exposure time, and this can jeopardize quality of care and patients’ satisfaction.
Missed important clinical signs – doctors can also miss clinical signs due to the burnout. As we are treating the patient not just the disease, more focus should be kept on the patients.Ways to reduce these problems
Increasing the manpower – Since the workload is increase, the manpower should also be increased.
Task-shifting – one of the strategy our hospital used is that they appointed nurses/pharmacist to do the EMR task so that doctors can pay more attention to patient care.
EMR design and functionality – some EMR can cache the data locally and synchronize and upload the stored data when online, this can avoid the delay of tasks when the internet connection is unstable.
EMR design should be more user friendly with few steps.
Data minimization – to avoid redundancy and duplication.
Feedback loops and review the workflow – regular feedback meeting with EMR users and adapt/upgrade the system as necessary. -
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I think EHR data from hospitals is big data. Because it has detailed information about patient’s profile, lab results, imaging results, medication history, follow-up information, admission information, allergy status, medical billings, surgical procedures and detailed progress notes. All the data is interlinked, and it can be retrieved anytime to make real-time decisions.
Volume: As I mentioned above, it has all detailed information for each patient across multiple years.
Velocity: Patient’s data can be accessed anytime when needed and can assist in real-time decision making and improve patient outcomes.
Veracity: Ensure data accuracy and consistency (by data validation, formatting and cross-checking medication interactions)
Value: It enhances patient care by reducing redundancy of procedures/tests, supporting value-based care and preventing adverse effects of medication (by built-in features notifying if any medicines prescribed can have adverse effects on each other)
Variety: It involves structured (Lab results, vitals), unstructured (physician notes, imaging reports) and semi-structured (billings) data.
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Have you ever observed a health informatics project in your (other) organization? Please provide a brief introduction.
I have observed and operated in a private hospital effort to implement EMR system. When I worked as a medical officer 2 years ago, our hospital initiated using Electronic Medical Record (EMR) system using openMRS platform. It has used the digitalized system for pharmacy department for a long time, so the hospital aimed to expand the system across all departments.
At the beginning, all staff were trained in the software and prepared for transition. In my opinion, I think the hospital did not perform readiness assessments or engaged key stakeholders including consultants and specialists for digital transformation. On the first month of EMR implementation, it was a complete disaster. Workflow disruption occurred and staff became the intermediaries between patients and consultants. In addition to the workload burdens and limited technological abilities, staff all got the blame for delayed operations from consultants and patients. The experience highlighted the importance of readiness assessment and consideration of resistance to change before implementing new digital tools.
Finally, the hospital successfully completed the digital transformation. We all now recognize the benefits of EMR system in hospital operation. This was my first experience of how information technology can enhance healthcare systems.
How can this health informatics project help to improve the current practices?
This health informatics project helps improve the current practices, for example,
Information accessibility: we can browse the relevant information of the patient, trace the investigation results and admission status of every department from anywhere in the hospital.
Reduce redundancy and cost effectiveness: Patients with lost or incomplete records are no longer needed to repeat unnecessary tests and attending doctors can also acknowledge the patients by the full record in EMR.
Coordination of care: Integrated information across departments (eg. Lab, imaging, pharmacy) enhancing patient care.
Data-driven decision-making: I believe the advantages will also be significant for hospital management team to make real-time decision-making and planning.
Quality improvement: Quality team can monitor patient outcomes and staff performance through this system more easily.
Patient safety and satisfaction: Reduce medication error significantly with the installed software and attending doctors can acknowledge full medical history of patients.
Are there any challenges or difficulties in implementing the project?
The challenge in implementing the project is that:
Staff readiness: All staff were given training but when the system completely utilizes only EMR with no paperwork backups, the operation was initially chaotic.
Resistance to change: Senior staff and consultants with busy schedules are hesitant to adopt and cooperate in the system.
Limited technical capacity: Since most of the staff with old service years are not familiar with the technical devices and systems, they are more likely to be stressed.
Weak infrastructure: The EMR system needs a stable internet connection and areas with poor connectivity delayed the operation. -
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Hi Mio, Thank you for your case and your opinion on this case. I think multifactor authentication method can help reduce the risk. Also, network segmentation as you mentioned is a good point to note for digital security. Additionally, regularly updating the software, OS and medical devices should be practiced in health care system.
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Thank you for sharing your experience. Resistance to change is a common challenge in digital transformation. Thank you for highlighting the importance of regular meetings between health professionals and developers to avoid communication gap. I totally agreed with you that continuous communication flow should be established to ensure everyone is on the same page and to make the system works.
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