Bridging Healthcare Gap through Digital Health
Addressing a problem is one thing but selecting the “easiest” problem to solve is quite the challenge. Why? Because for you to define what is easy, you have to be aware of the problem’s current landscape. What is current state of health informatics in the Philippines? How has health informatics advanced from its introduction to the present time? What has changed all throughout these years? Read through as we answer this week’s driving question:
“How will you solve what you think is the easiest health informatics challenge for the Philippines?
The signing of Republic Act No. 10844 or the Department of Information and Communication Technology Act of 2015 (DICT Act) on May 23, 2016 was a milestone for the country’s information technology. The Department of Transportation and Communications (DOTC) was restructured and its functions related to communications along with other agencies were abolished and transferred to the DICT. This was the government’s effort to harmonize the ICT initiatives and spur the development of the country’s ICT sector under one executive department.
In accordance to the law, the DICT shall be the primary policy, planning, coordinating, implementing, and administrative entity of the Executive Branch of the government that will plan, develop, and promote the national ICT development agenda. Section 5 of the law lists down the power and functions of the Department:
1. Policy and Planning: Creation of national policies, plans and programs and guidelines that will promote the development of use of ICT in coordination with DepED, CHED, and TESDA.
2. Public Access: Creation of rules and regulations for the establishment, operation and maintenance of ICT services in unserved and underserved areas in consultation with LGUs, CSOs, private sector and academe; establish free internet service in government offices and public areas.
3. Resource-sharing and Capacity Building: Harmonization and coordination of all national ICT plans and initiatives, development and protection of government IT infrastructures, and assist in the provision of technical expertise to government agencies.
4. Consumer Protection and Industry Development: Protection of privacy rights, extend support in the promotion of trade and investment opportunities in the ICT and ICT-ES sectors, establish guidelines for public and private partnerships; promote alliance between local and international ICT.
5. Cybersecurity Policy and Program Coordination: Formulation of cybersecurity plan that would minimize security risks.
6. Countryside development: Development of policies, plans and programs with LGUs to ensure universal access to ICT services and infrastructures.
Aligning with the current administration’s ICT Agenda, the DICT prioritized the following:
- Development of a National Broadband Plan to accelerate the deployment of fiber optic cables and wireless technologies to improve internet speed.
- Provision of Wi-Fi access at no charge in selected public places including parks, plazas, public libraries, schools, government hospitals, train stations, airports, and seaports.
- Development of a National ICT Portal.
4 years after the law’s enactment, how has DICT been successful in carrying out their priorities?
National Broadband Plan
Fast and affordable internet is what DICT’s National Broadband Plan (NBP) is promising for the Filipinos. In the recent report by Ookla Speedtest, the Philippine average download speed for fixed broadband improved from 7.91 Mbps (July 2016) to 25.07 Mbps (July 2020), while average download speed for mobile broadband also improved from 7.44 Mbps (July 2016) to 16.95 Mbps (July 2020). It’s quite an improvement, however, comparing it to the global fixed broadband internet download speed of 39.62 Mbps, the country is still far from a reliable and efficient internet connection. What seems to be the problem?
Well, the main reason for this problem is the lack of infrastructures. Compared to 70,000 cell sites of Vietnam or over a million cell sites of China, the Philippines has the lowest cell site density in Asia. The Philippines only has a measly 18,000 active cell sites that serve up to an estimated 67 million internet users. What exacerbates the problem is that private sector intended to construct the cell sites are hindered by the barriers set by the government. At least 25 necessary permits and documents needed to secure a single cell site construction. According to Globe, a major provider of telecommunications services in the Philippines, it can take up to eight months before getting approval.
As the demand for connectivity is being highlighted by the new normal, the DICT recognizes the need for improved IT infrastructures. The department is focused on promoting faster telecommunications tower buildup by reducing tower permitting requirements. In relation to these efforts to ease permitting requirements, the department also launched an online portal in order to facilitate the digital application and registration of interested ITCs. Presently, the DICT has received letters of intent from thirteen (13) additional tower companies who wish to register as ITCs. This was a welcome improvement to the Department’s existing agreements with the twenty-four (24) tower companies, which are mostly foreign-owned (dict.gov.ph, 2020).
Furthermore, the DICT has established Philippine Integrated Infostructure (PHII) to address the bottlenecks in telecommunication, as well to serve the augmentation of bandwidth requirements of today’s digital society. This project details the country’s ideal network starting from the international submarine cable connections, going to the domestic routes, and finally the individual access networks we know as Super WiFi, local fiber-optic provisions, and LTE. Satellite and TV White Space (TVWS) are also some of the emerging technologies being shaped up to distribute broadband. This proposed architecture will ensure that unserved and underserved rural areas in the country will be given access points to the Internet at affordable costs.
It was in May 2020 when the Philippine government announced a deal with technology giants Google and Facebook to push through an international submarine cable project by August or September 2020. The project which was initially targeted to commence in 2019, will put a 12,800k-kilometer undersea cable system also dubbed as the Pacific Light Cable Network (PLCN). The PLCN project was launched in 2017 and is targeted to connect Los Angeles, USA, Taiwan, the Philippines, and Hong Kong.
The PLCN has a Philippine branch that is connected to Facebook’s expansion in the country. An agreement to provide the Philippines with an annual internet capacity of two terabits per second (Tbps) free of charge in exchange for using the government’s P975 million Luzon Bypass Infrastructure has been made. The said project is expected to grant the Philippines access to lower cost of internet services to bring internet connectivity to barangays even in far-flung towns.
Furthermore, the DICT has plans to tap unused fiber cables of the National Transmission Corp. and National Grid Corp. From here, internet service providers and cable television operators can invest in infrastructure to their customers in exchange for bandwidth coming from Facebook. If this plan was successful, the government could offer bandwidth to smaller internet providers at lower prices, making these competitive to the rates offered by the big telcos. Currently, there is no recent news whether the project has commenced already. However, in July this year, the DICT proposed to increase the budget of the NBP from P296.5 million this year to P13.491 billion in 2021 as it continuous prioritize digital connectivity and access in the country.
The NBP has structured its plan on building and enhancing ICT broadband infrastructure into six components: National Fiber Optic Cable (FOC) Backbone, Cable Landing Stations, Accelerated Tower Build, Accelerated Fiber Build, Satellite Overlay, and Broadband Delivery Management Service (BDMS).
Among these components, the National FOC Backbone has successfully tested 158 dark fiber segments of the National Grid Corporation of the Philippines (NGCP). The backbone aims to cover the entire Philippine territory to reach unserved and underserved areas by targeting the installation of a 2,295 km FOC in 2021. The department, together the Bases Conversion Development Authority (BCDA), has also completed the construction of the Cable Landing Stations at Baler, Aurora and Poro Point, La Union under the second component.
The construction of the 240-km fiber highway is also underway and expected to improve access to 2Tbps capacity by 2021.
Component 2 shall also cover the operations and maintenance of the 2 Cable Landing Stations and the 4 Repeater Stations.
The Accelerated Fiber Build Component had connected 792 agencies in 13 GovNet sites as of date. For the rest of the year 2020, a total of 463 agencies in six GovNet sites shall be connected, and a total of 810 agencies in fourteen new GovNet sites are expected to be connected by the end of 2021. The NBP will replace ICT equipment for 300 GovNet sites; expand seven existing sites; and provide IP Transport Services for eight GovNet sites.
The sixth component, Broadband Delivery Management Service (BDMS), is a recently added feature for 2021. The BDMS was developed in response to the accelerated NBP implementation and shall ensure uniform service delivery and promote healthy competition among Internet Service Providers (ISPs) to drive better quality Internet at lower costs.
Provision of Fee WiFi Access at Selected Public Places
DICT’s plan on the provision of free WiFi access on selected public places are currently on the roll. The installation of free Wi-Fi hotspots is inline with Republic Act 10929, otherwise known as the “Free Internet Access in Public Places Act”, which mandates the DICT to provide free internet access in public places.
Since starting the Free WiFi for All Program in June 2016, the agency has managed to roll-out nearly 3,500 WiFi hotspots so far. Places included are schools, libraries, plazas, government hospitals, train stations, airports, and seaports.
List of live sites can be accessed through the website here: freepublicwifigov.ph. As of Sep 20, 2020, there are currently 5,232 areas.
Development of a National ICT Portal
A national ICT portal also known as ICT knowledge portal (IKP) was developed to serve as a dissemination platform of the Department of Information and Communications Technology (DICT) on statistical information consolidated from different sources.
The portal includes a number of statistical data sets contributed by different government agencies. The website also includes short press releases, feature articles, multimedia resources, and links to key ICT resources and benchmarking reports located in other websites. This allows the centralization of national ICT data and metadata collections for ICT planning and policy formulation, research and general information.
It was in July 2013 when the Department of Health, Department of Science and Technology and PhilHealth formed the National eHealth Governance Steering Committee to evaluate, direct, and monitor the use of information and communications technology in healthcare. In their first meeting on October 2013, they approved the Philippine eHealth Strategic Framework and Plan 2014–2020 which sets the road map for the country’s digital health policy. Prior to the creation of the eHealth Steering Committee, there was no clarity on how major decision on eHealth were made and there no standards and no privacy guidelines.
The vision of the eHealth is that “by 2020, eHealth will enable widespread access to health care services, health information, and securely share and exchange patients’ information in support to a safer, quality health care, more equitable and responsive health system for all the Filipino people by transforming the way information is used to plan, manage, deliver and monitor health services.”
Despite the presence of different policies and well-defined frameworks, the implementation of a Health Information System in the Philippines is still at its first stages. Although we could say there have been a large improvement on the presence of eHealth and telemedicine in our country (e.g., RxBox, CHITS, EHR/EMR adoption in some private and government hospitals), it’s still not widespread enough, is fragmented, and gaps still exist in the exchange and use of information between different health information systems (interoperability). And this is particularly exacerbated by our devolved health services — local government units, national policies and vertical public health programs are retained in the DOH, and provision of health services is dominated by the private health sector.
Moreover, it’s also a given that most of our RHUs, clinics, pharmacies and hospitals are still using the traditional way of data collection and storage: papers.
With the passing of the Universal Healthcare Act in the Philippines, we see the need for an efficient and effective health care delivery system. The implementation health information systems (HIS) is one of the solutions that could facilitate this what we call “seamless transition of care.” In fact, the law provides that all health care providers should maintain a HIS.
This won’t be an easy mandate because although HIS fosters improvement of care, it also introduces unintended consequences and new challenges. Luna et al. (2014) lists them down as:
- Resources and infrastructure limitations
- Development of IT agendas
- Overcoming uncertainty, ethics and legal considerations
- Lack of use of common interoperability standards
- Lack of trained workforce
- Regional integration
Now, all of these are somehow connected with each other. But personally, if we’re talking about the easiest (and most urgent) challenge to solve, it would be the problem of uncertainties, legal and ethical issues which could lead to the resistance to adopt HIS.
Adoption of new technology could result to some degree of uncertainty. When it comes to implementation of health information systems, the concerns of the end-users (e.g., organizations, health care providers, and patients) should be considered. There are two main issues that could lead to their resistance to comply: (1) HIS integration in health care workflow and (2) Legal and Ethical Issues.
HIS integration in health care workflow
Understanding the complexity of clinical routines and recognizing the importance of end users being involved in the implementation process could result to a positive organizational performance of the HIS and staff confidence in the system. It is crucial to consider the harmonization between organizational and individual clinical goals in day-to-day practice to ensure a successful implementation.
Furthermore, it is important that hospitals and primary care organizations are trained to utilize the system. Knowledge on safety, ethical and legal frameworks must also be emphasized in their training for them to be aware on how to handle patient information in the context of eHealth.
Legal and Ethical Issues
“The evolution of technology is changing the landscape of privacy and confidentiality within the context of health information.” (Antonio, Patdu, and Marcelo, 2016)
Implementation of any system that would collect, transmit and store private patient information should be secured. As HIS improves data sharing which allows data to be more accessible, concerns on data privacy poses a risk not only for the patient but also the provider. Leakage of personal information could lead to legal actions.
Therefore, we need technical safeguards for organizations storing protected health information including transmission security, authentication protocols, and controls over access, integrity, and audition. Security procedures such as using up-to-date anti-virus software, setting up firewalls, encrypting sensitive data, and using multi-factor authentication. Moreover, there must be protocols in place in case of security or other technical problems. Duties and responsibilities of data collectors and handlers must be specified in order to evaluate accountability.
In the Philippines, several laws and policies have been passed to protect the confidentiality of personal data.
Republic Act 10173: Data Privacy Act of 2012
Under the Data Privacy Act, protection of patient privacy and confidentiality is protected under the following:
“Section 13. Sensitive Personal Information and Privileged Information. The processing of sensitive personal information and privileged information shall be prohibited, …except in the following instances: data subject consent; existing laws and regulations; to protect the life and health of data subject; lawful and noncommercial objectives of public organizations and associations; medical treatment; protection of lawful rights and interest of natural or legal person in court proceedings; or the establishment, exercise, or defense of legal claims; or, when provided to governments or public authority.”
Sec 19. Non Applicability. The …preceding sections are not applicable if the processed personal information are used only for the needs of scientific and statistical research….the personal information shall be held under strict confidentiality and …used only for the declared purpose.
Republic Act 10175: Cybercrime Prevention Act of 2012
Under the Cybercrime law, pertinent sections that protects patient privacy are under Chapter II, SEC. 4. Cybercrime Offenses. — The following acts constitute the offense of cybercrime punishable under this Act: (a) Offenses against the confidentiality, integrity and availability of computer data and systems: (1) Illegal Access. — The access to the whole or any part of a computer system without right. (2) Illegal Interception. — The interception made by technical means without right of any nonpublic transmission of computer data to, from, or within a computer system including electromagnetic emissions from a computer system carrying such computer data. (3) Data Interference. — The intentional or reckless alteration, damaging, deletion or deterioration of computer data, electronic document, or electronic data message, without right, including the introduction or transmission of viruses. …”
Administrative Order No. 2016–0002 Health Privacy Code of the Philippines
The Health Privacy Code of the Philippines or officially known as Administrative Order No. 2016–0002 titled “Privacy Guidelines for the Implementation of the Philippine Health Information Exchange” is a joint administrative order by the Department of Health (DOH), the Department of Science and Technology (DOST) and Philippine Health Insurance Corporation (Philhealth) created to promote information exchange in health care service while also protecting and promoting the right to privacy of data subjects in a healthcare setup. The code details the collection, processing, and access of health information (e.g., informed consent, information processing, data retention.
While these laws impact the implementation of health information systems in the Philippines, a law that specifically regulates telehealth or eHealth is much needed. Procedures and policies to address the requirements and repercussions of implementing an eHealth system must be developed. Last year, a substitute bill seeking to establish the National eHealth Systems and Services was approved by the Philippine House Committee on Health. The proposed “National eHealth System and Services Act” provides for an organised and structured application of electronic health or “eHealth” integrated in the regular workflow of healthcare facilities. Furthermore, the approved bill details violations of the Act and corresponding liabilities and penalties.
With all that’s been said, without proper regulation and support from the government, it will be hard for health care providers to comply. United States of America for example, had to enacted a law called HITECH or Health Information Technology for Economic and Clinical Health Act in 2009. This took a carrot-and-stick approach in encouraging US health providers to adopt certified EHR software. The carrot being incentive disbursements and the stick, penalizing providers not using EHRs. This emphasis on financial penalties and rewards makes EHR usage especially attractive in the US. Initial investments will be costly but digital care will definitely enhance UHC implementation.
Implementation of health information systems more or less brings in a cultural change in the organization than a mere technological upgrade. Hence, it needs to be strategically planned and commitment is expected from all stakeholders.
References:
Antonio, C.A., Marcelo, A.B. (2016). Health information privacy in the Philippines: Trends and challenges in policy and practice. Acta Medica Philippina, 50(4), 223–236
Conrad, A. (2019). The health privacy code of the Philippines part 1. Retrieved from https://privacyph.net/2019/07/09/the-health-privacy-code-of-the-philippines-part-1/
Pauline, A. (2014). Protecting the Filipino’s patient’s privacy and confidentiality. Retrieved from http://eyes.health-channel.com/protecting-the-filipino-patients-privacy-and-confidentiality/
Patdu, I.D., Tenorio, A.S. (2016). Establishing the legal framework of telehealth in the Philippines. Acta Medica Philippina, 50(4), 237–246
Rahimi, B., Timpka, T., Vimarlund, V. (2009). Health information system implementation: A qualitative meta-analysis. Journal of Medical Systems, 33, 359–368. DOI 10.1007/s10916–008–9198–9
Umali, T. (2019). House panel approves proposed “Nation eHealth System and Services Act.” Retrieved from https://opengovasia.com/house-panel-approves-proposed-national-ehealth-system-and-services-act/