Deliver of Ehealth &amp Telemedicine Services To The Philippines by Katheine Kuan

mobile care: scalable imaging and
diagnosis for the developing world
INDINGS
Delivery of eHealth and Telemedicine Services to the

Philippines From a Sustainability Perspective
City of Manila and Batanes Province

Philippines
Summer 2009
In Partnership with University of Philippines Manila,

National Telehealth Center
Supervisor Dr. Alvin Marcelo
Written By Katherine Kuan

Dept. Electrical Engineering & Computer Science
Masters of Engineering Candidate 2010
2 Delivery of eHealth and Telemedicine Services to the Philippines
Table of Contents
1 Introduction
2 Project Summary
3 Community Impact
4 Personal Impact
5 Donor Recognition
6 Appendix
i. Analysis of Philippine Healthcare System
ii. Summary of eHealth Services of the National Telehealth Center
iii. Matrix of eHealth and PhilHealth initiatives
iv. Policy Proposal for PhilHealth
v. Sample Referral Forms for Workflow
vi. Usability Testing of Moca
vii. Usability Testing of OpenMRS Media Viewer
viii. Technical Support Manual for Moca
ix. Summary of Workflow in Batanes
“Catastrophic illness or ill health in general is

now widely recognized as the most powerful
poverty-converting event in an individual’s life”
- Francisco Duque III, Past President of PhilHealth
Introduction
This summer, I spent six weeks working with the University of Philippines Manila,
National Telehealth Center in an effort to further the adoption of eHealth and
telemedicine in the country. In conjunction with my Masters of Engineering research, I
first assessed and increased local capacity of the Philippines to support a deployment of
Moca. This is a cell phone platform for telemedicine that provides healthcare workers in
rural communities with the expertise of medical specialists in city hospitals. Secondly, I
worked extensively on the challenge of sustainability of eHealth, so that the poor in
remote regions would still be able to access and afford these types of telemedicine
services. This work included documenting the obstacles of the healthcare system,
identifying how eHealth could provide solutions, and collaborating with key stakeholders
such as health care facilities, universities, insurance corporations, telecom companies,
and government officials. My goal was to convince PhilHealth to promote eHealth so
that it could later potentially be the “payer” of telemedicine. Hence, they would
encourage health providers to invest in telehealth infrastructure and also be able to
extend benefit packages so that members could receive such services with zero out-of-
pocket expenses.
Project Summary
The UP Manila National Telehealth Center (NThC) is an organization aimed to provide
eHealth services to the country through 3 target areas: eRecords, eLearning, and
eMedicine. eRecords is about having electronic medical records in the system. Ninety
nine percent of the Philippines is using paper-based medical records, so there is a lot of
underreporting, fraudulent reporting, or underutilization of the medical data collected in
the policy making process. eLearning is about providing continued education and
support of remote healthcare workers through online content such as web seminars,
podcasts, or other Internet resources for the latest information on medical practices.
This increases the local capacity of health workers to provide primary care for their
community members, so that they don’t need to send patients up to regional and
provincial hospitals and overcrowding is reduced. eMedicine is about providing rural
healthcare workers with the support of medical experts in distant city hospitals using
telecommunication technologies including cell phones, computers, and the Internet.
This contributes to increased access to medical experts for citizens in remote areas and
reduces the heavy cost associated with traveling to Manila for expert consultation.
During my time in the Philippines, I was able to travel to 4 provinces outside of Metro
Manila: the Batanes, Batangas, Pangasinan, and Tarlac. I spoke with doctors, nurses,
midwives, and staff people in rural health units, hospitals, and provincial health offices.
From these conversations, I was able to identify the real community needs from the
standpoint of workers on the ground in remote areas. In many cases, I learned about
obstacles they faced in their existing workflow of caring for patients that needed
specialist attention. Also, reporting and documentation was time-consuming and not
done properly for the data to be useful to policy and decision makers. I wanted some
way to document my findings and conversations with these people, so I wrote up a gap
analysis on the Philippine healthcare system which explained the existing state of the
system, the ideal state of the system, and what the gap was to achieve the ideal state.
(See the appendix for the analysis). It was surprising to me that the single concept of
eHealth (eRecords, eLearning, and eMedicine) could be the answer to each challenge
in the healthcare system. It also further emphasized the need for us to engage the key
stakeholders and educate them about eHealth.
Figure 1. Meeting with the provincial health office in Basco, Batanes province (left) and
Meeting a midwife in Anilao, Batanges province (right)
Laying Groundwork for a Moca Deployment in the Batanes Province

A good portion of my time was spent collecting requirements, performing usability tests
on doctors, and doing groundwork for a pilot study on Moca in the Batanes Province. I
heard many stories of how new technologies were used but then abandoned in the
health facilities because the equipment broke, the staff wasn’t properly trained, or there
was no technical support. I learned that in order to introduce a technology that would
successfully address a healthcare problem, the system must be customized and
integrated with the existing workflow. I realized which features would be useful,
uncovered software bugs, and received feedback on which parts of Moca were easy or
difficult to use. I collected the paper forms from their existing workflow and converted
them into an electronic teleradiology procedure loaded onto Moca for more accurate
usability testing.
Figure 2. Workflow in Batanes with paper x-rays that need to be

sent to radiologist in Manila for diagnosis of TB, turnaround time is about a couple weeks
Figure 3. Current workflow in Basco with email tele-referrals to radiologist in Manila through the National Telehealth
Center, No internet in Rural Health Unit so turnaround time is 1 week
Figure 4. Expected teleradiology workflow in Batanes with Moca, turnaround time is at most 24 hours
Because I would only be in the country for a short time, it was essential to train local
people on the software and hardware involved in Moca: Google Android platform,
OpenMRS electronic medical record system, G1 phone, and Moca Dispatch Server. I
delivered a presentation to the telehealth team at the NThC on OpenMRS the electronic
medical record system, its use in existing pilots across the developing world, and its
potential for a range of medical applications. This helped them begin to see how
OpenMRS could fit into their healthcare system at the hospital level of care across the
country, and this is a technology they are strongly interested in pursuing. I also worked
closely with Randy Fernandez, a research assistant in the National Telehealth Center,
to deploy a new instance of the Moca server in the Philippines and debugged the
system to upload images from the G1 phones to the server properly. One of the key
challenges we ran into was that the local telecom companies did not support Android
phones at the time, so we had to find workarounds in order to get Moca on the GPRS
network and to send large image files across the network. Out in Batanes, where the
phone would be left with the doctors, we realized that we would need local technical
support to help the doctors in case of problems with the phone. Hence, I trained the
network administrator at the provincial health officer to be our point person in case of
technical difficulties. He had no prior programming experience, so we walked through
how to download the code onto the phone, send error log reports, and debug Moca. As
a result, I came up with a technical support manual on Moca to help new users in the
future (see appendix).
Recruiting Local Developers to Work on Moca

In addition to providing technical support for the existing system, it will be also crucial to
have developers working on new features and customization of Moca going into the
future. Hence, I delivered Moca recruiting talks at the University of Philippines Manila
campus as well at the Diliman campus to over 60 students. I spoke to classrooms of 4th
year computer science students interested in finding a project for their senior thesis.
Each student filled out and submitted an interest form, and I will be going through and
contacting them to figure out a work plan.
Figure 5. Moca recruiting talks at UP Manila (left) and UP Diliman (right)
Figure 6. Examples of some projects the students could get involved with in Moca
There is also a pair of Ateneo University students working on a windows version of

Moca, so we also had joint meetings to introduce them to the NThC researchers and
also align them with the work/progress of the US-based Moca team.
Figure 7. Collaborating on the Windows Mobile version of Moca at Ateneo University
Ensuring Sustainability in Adoption of Telemedicine

At the beginning of my project, I performed an extensive literature review of research
papers to find out how telemedicine was being incorporated in other countries by their
governments and insurance companies (with a particular focus on Southeast Asian
countries). There were many examples of pilot studies done across the world in places
like Taiwan, Malaysia, US, Canada, Peru, Japan, Peru, and so on. However, there
weren’t many countries that had telemedicine completely integrated into their healthcare
system with full reimbursements for such services. It seemed that many countries had
difficulty getting all the important stakeholders to work together and agree upon a
standard framework for telemedicine practice and to invest properly in such
infrastructure.
Figure 8. Key stakeholders

Hence, from the start, we knew that we had to engage all the stakeholders in the
adoption of telemedicine. We spoke with health service providers and health
professionals, and feedback was immensely positive. They explained the drawbacks
of the healthcare system and welcomed the potential of quality care that eRecords,
eLearning, and eMedicine could provide them. We also worked with universities as
mentioned above, as the pipeline of developers who would be supporting the
localization of the system. Since healthcare delivery and management has been
devolved to the jurisdiction of local government units (LGUs) in the Philippines, we
worked with government officials such as the Governor of Batanes to ensure that he
saw the value in putting financial resources towards this type of infrastructure. We
began to engage the telecom companies (Globe and Smart) as well because they
would be providing the cellular 3G/GPRS and internet connectivity in remote regions
like the Batanes, so their buy-in would be important. Last but not least, the support of
the insurance organizations is paramount to making it accessible by the poor, and this is
further discussed in the next section.
Figure 9. Talking about Moca in a Department of Figure 10. Presenting Moca at Research Triangle
Science and Technology (DOST) Telemedicine Institute meeting with NThC and people from
Meeting with UP Manila National Telehealth Tarlac Province
Center and UP Diliman
Figure 11. Presenting Moca and business plan for Figure 12. Presenting Moca at MIT Alumni Club
venture-backed corporation for telemedicine to of the Philippines lunch at Enderun College with
University of Philippines Manila Dean of the Ted Chan
College of Medicine with NThC and Moca team
member Ted Chan
Convincing PhilHealth to Prioritize and Invest in eHealth

I worked extensively with PhilHealth, the national social insurance corporation, in the
Philippines. Although they are intended to provide everyone in the country with health
insurance, only 80% of the population is covered leaving about 18 million uninsured. For
their members they create benefit packages for diseases like malaria, TB, H1N1 and
cover fixed amounts on inpatient hospitalization. However, they come up with these
numbers without knowledge of what the actual cost of care to patients is, what services
patients need the most, benefit utilization rates of members, and other health status
information on patients (see Analysis of Philippine Healthcare System in Appendix).
There is a disconnect between what is happening on the ground and what those needs
are compared to the policies being made in the PhilHealth headquarters. Hence, there
is a tremendous need for electronic documentation of care to ensure quality care.
We wanted to emphasize how their interests and goals (PhilHealth Medium Term Plan,
universal coverage by 2010, Millennium Development Goals, and disease control) were
strictly aligned with those of eHealth and the National Telehealth Center. With
eRecords, PhilHealth would be able to figure out what services were being used by
members, measure health indicators such as maternal mortality, perform disease
surveillance, ensure continuous drug supplies to health facilities, reduce fraud, and
obtain accurate reports for policy making. With eLearning, PhilHealth would be able to
ensure accredited health professionals received continued education to provide the
highest quality of care to the members of their community. eMedicine would help
PhilHealth reach its target of universal coverage because it would provide access to
specialist care for the most remote individuals.
I started off with the connections that Dr. Marcelo introduced me to at PhilHealth (Ms.
Gitch Diaz of the CorPlan Department), and from there I was referred to other
individuals in other departments who could help me. What worked well for me was to
stop by people’s offices, do informational interviews, ask for more references, and
repeat the same process. In this manner, I was able to speak with members from all the
departments integral in incorporating eHealth into PhilHealth: accreditation, health
informatics, standards and monitoring, benefit development, corporate planning, fraud,
IT, and legal. Through these meetings I was able to organize presentations where I
educated department heads and executive officers in PhilHealth on the value of
eHealth. Throughout the whole process, Dr. Marcelo and the team at the NThC
provided very valuable insight along the way on how I could communicate and engage
the interests of those who work at PhilHealth most effectively.
Individual Meetings
Ms. Gitch Diaz (CorPlan)

Ms. Jennifer Enriquez (CorPlan)
Dr. Israel Pargas (Accreditation)
Dr. Rizza Herrera (Accreditation)
Dr. Art Alcantara (Health Informatics)
Mr. Arnold Quijano (Health Informatics)
Dr. Giovanni Roan (Benefits Development)
Dr. Ceferino Banaga (FFIED Fraud)
Dr. Neri Santiago (Actuary)
Attorney Pineda (Legal)
Mr. Mario Matanguihan (IT)
Mr. Rommel Isaac (ITRMD)
Ms. Ann Marie San Andres (Physical Resources and Infra.)
Presentations
7/8 Presentation with Chief Operating Officer and Operations Grp

Improving Access to Healthcare for PhilHealth Members
Dr. Marcelo introduced the National Telehealth Center and its initiatives in
eHealth throughout the country. Then I presented my research on how eHealth
could be integrated into PhilHealth through their initiatives P4P, Capitation, and
Contracting. I had a matrix that explained the spectrum of involvement in
supporting telemedicine from just written policies (no cost) to continuous financial
investment in building telehealth infrastructure in their facilities.
7/20 Presentation with Senior Vice President and her Quality Assurance Group
Extracting P4P from an RHU-Based Electronic Health Record
At this meeting, I presented how electronic medical record systems could directly
make an impact on their quality assurance of care delivered in PhilHealth
accredited facilities. Then Alison Perez, lead developer/implementer of CHITS for
the NThC, did a live demo of CHITS and answered specific capability questions.
7/22 Follow-up Presentation with COO and Operations Grp

Operations Perspective on Using eHealth for Capacity Building in PhilHealth
In this presentation, I updated the COO on her concerns and requests for more
in-depth research on legal issues, policy proposals, and IT initiatives. I also
emphasized how eRecords in RHUs are a good fit for the PhilHealth framework
using reasons from Figure 14.
7/22 Presentation with President and Chief Executive Officer

Strategic Perspective on Using eHealth for Capacity Building in PhilHealth
With Dr. Marcelo and Ms. Gitch Diaz from CorPlan Dept, we presented an
overview of the NThC and eHealth services to the CEO. Then I recapped the
work I had done in his organization for the past 6 weeks, highlighted how eHealth
fit well with PhilHealth’s operations of quality assurance monitoring, generating
reports for decision making, and benefit development. Then we discussed the
future actions he could take to utilize eHealth to help his members to the fullest.
7/23 Presentation with Sector on Out-Patient Benefit Package

OPB Monitoring using an RHU-Based Electronic Health Record
The group went over their new out-patient benefit guidelines, which included
specific policies allowing RHUs to spend their funding on technology
infrastructure. I presented how eRecords and CHITS could be specifically
tailored to fit their information needs on monitoring the outpatient benefits’ usage.
This is already an existing initiative, and the need for eRecords is very apparent,
so this was the most concrete discussion with realistic short term goals among all
my presentations.
By speaking with so many individuals on their role in the corporation and obstacles
faced by their department, I found many ways that eHealth would build capacity for the
corporation. Each presentation was tailored for the target audience and focused on how
eHealth could specifically integrate with existing initiatives in PhilHealth and serve to
streamline efficiency in the company.
First I researched about 3 new initiatives in PhilHealth and identified areas for
integration:
Capitation is the money that PhilHealth provides to accredited rural health units (RHUs)
(as reimbursements on the premiums paid) to run their operations and upgrade their
facilities. Each RHU receives 300 pesos per household that is an indigent sponsored
family in their community (the poorest level in society meaning the government pays for
their health insurance). Hence for 1000 indigent families, an RHU may receive 300,000
pesos to operate their facility. This money is allocated towards bonus compensation for
health workers, administrative expenses, equipment, drugs and supplies, and facility
upgrades.
In a policy proposal (see appendix) I wrote, we recommended that the RHUs be allowed
to spend their capitation on telehealth infrastructure (computers, Internet connectivity,
and web conferencing equipment). We also recommended stricter requirements for the
release of funds including documentation on how the capitation funds were spent in the
past and electronic reporting of what services were delivered to patients. This
information reported to PhilHealth would be more accurate than the current paper forms
that people fill out to the minimum extent so that they can receive funds. With electronic
reporting and CHITS (community health information tracking system created by the
NThC for RHUs), PhilHealth would be able to directly receive real-time data on the
actual patients visiting the center and which services were provided - valuable
information to base benefit package policies on.
Pay for performance (P4P) is a new initiative aimed at using incentives to promote
certain behavioral practices in healthcare by service providers, health professionals,
and patients. These incentives can come in the form of money, transportation vouchers,
faster claims processing time, earlier release of funds, and etc... PhilHealth is doing a
baseline study in several provinces in preparation for a P4P pilot on maternal care.
They want to reward mothers when they comply with their 4 required prenatal visits,
postpartum visits, and delivery of the child at a health facility instead of at home.
eRecords can make a big impact in reducing maternal mortality by tracking mothers
throughout the pregnancy process, figuring out baseline statistics on maternal care
(exact statistics on maternal mortality are ambiguous and different between PhilHealth
and the Department of Health), and monitoring for improvement in these health
indicators. CHITS the RHU-based electronic medical record system already has a
maternity module to keep track of a woman's health record throughout her pregnancy:
risk factors, date of visits, trimester dates, vital signs, position and size of fetus, blood
pressure, FPAL, GP, vaccines/services rendered, and postpartum visits (date of
delivery, outcome of pregnancy, facility where mother gave birth, nutrition of child,
breastfeeding) as well. Because the program rewards good performance, accurate
monitoring of the patients and of the service providers is important otherwise it gives
people an easy way to report false behavior to earn incentives.
Contracting is another initiative still undergoing negotiations. This is a method for

contracting with certain facilities for certain health services at a standard quality, price,
and performance. (Currently, health facilities and doctors can charge whatever price for
a service and PhilHealth will only reimburse a fixed amount). This moves towards zero
out of pocket expenses for poor patients on certain outpatient diagnostic services.
eRecords also plays a big role here in monitoring the health providers to ensure they
are following the contract. In return, the facility will receive faster claims processing,
which PhilHealth can deliver much more easily if the claims are submitted electronically.
PhilHealth Fraud Department does random checks on hospitals and claims by

tracking down the patient and verifying the service was performed. To increase
operational efficiency, they are interested in a way for the hospital log book to be
electronic. In real time, they could see which patients are being served and send a
representative to check the hospital to ask the patient immediately about the services.
PhilHealth Legal Department says that there are no legal limitations in using
PhilHealth field offices as a place for teleconsultations or sending teleradiology referrals
because of the existing computer infrastructure and Internet connectivity already setup.
There are concerns about malpractice or lawsuits, but this can be addressed by (1)
requiring patients to sign an informed consent form waiving liability of the doctor, and (2)
amending PhilHealth’s warranties of accreditation for doctors and health facilities.
PhilHealth Health Informatics Department currently encodes the paper reports from
the RHUs into the computer. It’s a tedious process and they are about 7 months behind
on entering data. They are in charge of the analysis and summaries of claims data, so
they are already telling management that they need integrated analytics software
systems to make their job easier. They are also involved in new initiatives dealing with
interpretation of data (geographic information system GIS, profiling of health facilities,
and information auditing), where interfacing with CHITS at the RHU level would be
valuable.
PhilHealth Accreditation Department is in charge of accrediting health facilities and

professionals (and coming up with the guidelines for it). We would work with them to
define what type of accreditation or certification professionals would need to be able to
perform telemedicine services. They are also involved new initiatives like contracting
with service providers.
PhilHealth Benefit Development Department determines the amount of coverage in

benefits for members such as through benefit packages (maternity, H1N1, malaria,
etc...) They have the new guidelines for what diagnostic services PhilHealth will cover
for outpatient procedures. We would work with them for determining coverage of
telemedicine services (which AMA codes would map to PhilHealth case codes).
PhilHealth IT Department will be important in determining whether the corporation

could handle electronic communication and data storage needs of the health facilities.
IT capacity must be developed to support electronic billing, medical records, and
reporting. The department is also currently working on some business intelligence
systems for computing analytics to present to upper management.
Figure 14. Excerpts from the PowerPoint presentations made for PhilHealth that highlight
how PhilHealth can benefit from eHealth services
Community Impact
In the Philippines, the National Telehealth Center has already made good headway on
research and development of eHealth and telemedicine systems. However, their largest
need was to figure out how to scale these solutions across the country in a sustainable
manner. My work helped open many doors in PhilHealth as a source for telehealth
policy decisions and funding. I was able to identify for the NThC and PhilHealth where
the possible departments and programs could collaborate for mutual gains (see
PowerPoint slides in Figure 14).
The biggest thing holding PhilHealth back from promoting and practicing telemedicine
was being unaware about what telemedicine is. To make the conversations more
concrete with action steps, I researched the implementation details of what would be
feasible in terms of PhilHealth’s support of eHealth – benefit development,
accreditation, legal issues, IT capabilities, and health informatics systems – and
summarized these findings in presentations. Through 5 formal presentations as well as
countless one-on-one meetings with the department heads, I was able to educate over
15 key PhilHealth leaders (including the COO and CEO) about eHealth and seek
tangible ways to move the effort forward.
Figure 16. Meeting with PhilHealth Head of the Figure 17. Presentation to the PhilHealth COO
Corporate Planning Department and Operations Working Group
Figure 17. Presentation for the Senior Vice Figure 18. Follow-up Presentation for the COO
President and her Quality Assurance Group and Operations Working Group
Figure 19. Presentation for the Sector on Out Figure 20. Presentation for the President and
Patient Benefit Package Monitoring CEO of PhilHealth and the Head of the Corporate
Planning Dept
The response was very positive. The Head of the Corporate Planning Department was
eager to support us through continual feedback on the best way to navigate the
corporation, as well as access to internal documents and help setup meetings for us
with top executives. The COO and operations group also were very enthusiastic about
the potential applications of eHealth and came up with many ideas we could explore –
using service offices for teleconsultations and having PhilHealth donate old computers
to the RHUs. The COO said that they could not afford to go further without moving
forward with eHealth because they currently made decisions by looking up at the sky
(there is no data to go off of). The Senior VP of the QA group assured us that the group
realized the value of electronic documentation and would be committed to working
towards ensuring IT systems were in health facilities. The Sector on OPB already
issued new guidelines to allow RHUs to use their money from PhilHealth for technology
infrastructure. In their meeting, they came to a point where they needed to discuss
monitoring of the usage of the benefits and they saw CHITS (community health
information tracking system designed by NThC) as something with much potential.
Because 6 weeks was a short period of time to create huge changes to a big
corporation, I identified 3 major action items that the NThC could work on to carry on
collaboration with PhilHealth. I transitioned the NThC team members as well with all my
information and introduced them to the correct points of contact at PhilHealth to begin
the work immediately.
1. Introduce people from Pasay City (site with 5 years experience of using an
electronic medical record system in an RHU setting) to PhilHealth OPB team to
answer questions about usage of CHITS
2. Analysis of CHITS data for PhilHealth Actuary Study with VP, Deputy Chief
Actuary office to study how PhilHealth can utilize the information from the rural
health unit level:
• Profiling of patients (disease, gender, age)
• Utilization rate of benefits in OPB package
• % of RHU patients not covered by PhilHealth
• Services of those who are not PhilHealth members
• Most popular services for all members
• Most popular services for non PhilHealth members
3. Integration of CHITS with PhilHealth

National Telehealth Center to enhance the PhilHealth module in CHITS to keep
track of health indicators needed for reports/decision making by PhilHealth.
Ideally, PhilHealth would like the following to be tracked by CHITS:
• OPB Labs/services
• Drugs prescribed, drugs dispensed
• Referrals (where referred, why, how) ...another module maybe?
• Targets from PhilHealth

To quantify the people/organizations influenced, we can look at the number of health
service providers that PhilHealth accredits. From the actuary study on CHITS, if
PhilHealth realizes how valuable the information from the health facilities is and will start
requiring electronic health record systems, 1,531+ hospitals and 1,217+ rural health
units will be affected (in addition to the other types of clinics, see below). These systems
will affect the 21,143 professionals working in these facilities, so that they become
technology literate to be able to use these telecommunication technologies. In addition,
in the future if PhilHealth incorporates telemedicine services into their outpatient benefit
package, then their members, approximately 80 million Filipinos, would experience
tremendous improvements in healthcare delivery.
Figure 15. Number of PhilHealth accredited facilities from PhilHealth’s

Annual Report 2007: Bridges, Reaching out for Universal Healthcare
I made sure to transition others on the project to take over my work after I left. Dr.
Marcelo will primarily be taking over my work at PhilHealth. He will work as a consultant
for PhilHealth for 4 months, so he will interact closely with the teams I
presented/discussed eHealth with in order to ensure that they have the necessary
information and policies to make smart decisions on expansion of membership and
benefits in the future. I also had another teammate from Moca also go to the Philippines
with me this summer. Ted Chan, who is a 2009 graduate from MIT Sloan, worked in
parallel on a business plan for a venture-backed corporation aimed at implementing and
scaling telehealth in the Philippines. The corporation would provide the infrastructure to
scale telemedicine services across the country and the work at PhilHealth would
hopefully move towards paying for such services.
Overall, with valuable help from many local people especially at the National Telehealth
Center, I was able to educate many people about eHealth and telemedicine both on a
policy level at PhilHealth and also at a technical/implementation level at the universities
to begin a base of local developers working on Moca for the potential to influence
millions of people’s access to healthcare in the Philippines.
Personal Impact
Being in the Philippines was more different than I ever imagined. The trip definitely
changed my perspective on things and was one of the most amazing experiences of my
life. My trip was continually filled with unexpected adventures, new friendships, and
amazing people. I found the Filipino culture to be incredibly inspiring. The people have
faced many difficult times including the long struggle for democracy in their country and
it’s frustrating to hear about all the corruption entrenched in the political system. I
walked through the streets of Manila every day to get to work. I saw poverty that I had
never witnessed firsthand before. Small children would rush up to me and walk beside
me with their hands open begging for money or food. They would be knocking on your
window in the taxi cab or coming into the restaurant and wait next to your table. It was
heartbreaking. I could feel it in the air – a heavy feeling in the atmosphere that life was
hard. Even for the people that had full-time working positions, it was a struggle to
provide a living for them and their family. I remember seeing squatters for the first time
and was floored by the idea of how many people would live in such small quarters.
Yet despite it all, the people are extremely resilient - proud of their country and culture
for what is has become. I found them to have certain fervor for life, something that
Americans do not always have. Children in the streets played with joy and the people in
general laughed with friends and had a good time. Being fully immersed in the Filipino
culture, I was able to see their strong sense of values rooted in family and religion. They
love having large, happy families and remain close-knit with the children living at home
until they get married. Even for people not related to them, Filipinos have an undeniably
warm sense of hospitality to welcome any and all guests.
I had a chance to go to the Batanes for work and it was a paradise there. The views we
saw, hills we trekked, waters we swam, and beaches we rested on were absolutely
breathtaking. Every photograph I was able to take was so picturesque. I loved visiting
the provinces. There, life was simple and peaceful. It was mostly rural, where small
homes lined the one main road that passed through the entire city. People planted their
own food for eating, fished in the sea, raised chickens, or owned a small store to make
a humble living. They would gather in small groups and sit by the main road, watch their
kids play, or just talk. They helped neighbors out as if they were family with tasks like
building a house or delivering a baby. It’s quite eye-opening when I contrasted the
province lifestyle with the one in America filled with material and superficial concerns. It
felt like a different world out there in Batanes, an escape from reality where you could
just sit and reflect on life.
Last semester, I worked for months on Moca but had very broad and vague ideas about
who the technology would actually help. As a result, being able to meet the healthcare
workers and patients on the ground was motivating and unforgettable. This entire
experience solidified my interest in working for technology solutions for healthcare. Had
I not gone to the Philippines to work on this project, I think I would’ve settled for any old
software job sitting in an office 40 hours a week. Now that I’m starting to look for a
career, I know that there are jobs out there like this that are engaging, rewarding, and
multidisciplinary and I’m determined to find them!
Donor Recognition
Thank you so much for the opportunity to travel to the Philippines to perform this work.
This trip has opened my eyes to the harsh realities people must face in developing
countries. It gave me a concrete reason to work hard every day to do any small part that
would help make the lives of the people I saw every day better (those on the sides of
the street, those in the hospital wards, and etc…). I feel that I’ve been sheltered for
much of my life in America, but this experience (going to the Philippines, speaking to the
locals, understanding what their needs were) confirmed my choice for a career path. I
want to pursue mobile healthcare applications for developing countries and get very
involved on the policy side of these issues. These issues need as many people working
on them as possible, and I am excited to learn more about how I can take part of this in
the future!
Acknowledgements
Much of my work couldn’t have been made possible without the counsel and
opportunities provided by the team at the National Telehealth Center – Dr. Alvin
Marcelo my supervisor, Dr. Alex Gavino, Dr. Raymond Sarmiento, Alison Perez, Xandra
Bernal, Randy Fernandez, and Coy Caballes. The Moca team, especially Ted Chan, Dr.
Leo Celi, and Gari Clifford, also provided me with great guidance along the journey in
terms of the focus of my work in the Philippines as well as professional growth. Thank
you all so much for everything!
Appendix: Analysis of Philippine Healthcare System
University of Philippines Manila, National Telehealth Center - July 8, 2009

Written by Katherine Kuan, Moca
QUALITY OF CARE
Current System Ideal System Proposed Solution Methodology
Epidemics (H1N1, malaria, Disease tracking and Health facilities register the eRecords
dengue) spread rapidly, immediate management of diagnoses of patients so
Policies are created after epidemics, Anticipate that those with certain
the spread has occurred health events and define diseases can be
protocol before anything geographically pinpointed
happens and quarantined
Health facilities sitting Continued supply of drugs Electronic management of eRecords

without anymore at health facilities without supplies/drug logistics,
supplies/drugs for the requiring patients to buy Track drug usage at each
quarter, Heavy influx of drugs outside, Forecast facility over time
patients when drugs are drugs required and ship
delivered but rapid drop-off them to health facilities to
when they run out arrive on time when
needed
Expensive prescription Doctors should prescribe Ensure doctors are eRecords
drugs with high mark-up generic drugs and promote prescribing generic (not
price community pharmacies branded) drugs, Electronic
record keeping of
prescriptions
Patients forgo visits to Preventive medicine, Affordable access to eMedicine
doctor because of diagnosing sickness before specialists in a timely
cost/distance until they it becomes a major health manner
become sick and require problem
hospitalization (i.e. if not
treated, TB can spread to
10 other people each year)
Long latencies in diagnosis Immediate turn-around- Teleconsultations with eMedicine
when patient data is time in diagnosis and specialists through email,
physically mailed to patient referrals, immediate audio/video conferencing,
specialist start of treatment, improved mobile phones
health outcome of patient
Possible misdiagnosis by Immediate access to IT infrastructure to link eLearning,
general practitioners in second opinion from health facilities through eMedicine
remote areas when network of specialists, Internet or cellular network
patients don’t have access DTTBs learn from their
to specialists mistakes for future cases
when specialists correct
them
18 million Filipinos not Hit 2010 target of achieving Increase service offerings eMedicine
covered by PhilHealth universal coverage (85%) with telemedicine to
of the nation’s population provide healthcare access
for the poor in rural areas
REPORTING AND MONITORING

Unsure how capitation PhilHealth can view Strict requirements for eRecords
funding is spent breakdown of how an LGU allocation of funds, Strict
spent its capitation and monitoring of how the
ensure it was wisely spent funds were spent
on long-term improvements
in healthcare
Lack of effective methods PhilHealth can influence Method to monitor the eRecords
for PhilHealth to enforce behavior changes through actual performance of
requirements on health pay-for-performance and members & service
facilities because control of verify such performance providers without room for
health facilities devolved to with tangible evidence fraud
LGUs before distributing rewards
Handwritten reports with Automatically calculated Electronic medical record eRecords
calculation or data entry reports and statistics system customized to
errors (1 error per midwife available at any time output health statistics and
x 44,000 barangays= official reports as defined
44,000 total errors for that by the DOH
month)
Some facilities use Secure centralized Open-source electronic eRecords
spreadsheets (Excel) to database of patient medical medical record system with
keep patient records records with workflow software development of
(insecure place to store customized to fit the needs features custom to
data without back-up, high of the different levels of workflow
potential for error in hospitals, Fast retrieval of
spreadsheet formulas) patient files
Quotas are much higher Quotas/performance Keep up-to-date records of eRecords
than the actual # of people indicators calculated based demographic makeup and
eligible for that on local characteristics of health status of a local
vaccine/service in a the region population
province
Report false information to Accurate reports for Eliminate manually written eRecords
meet quotas feedback on how to target reports, Require computer
improvements in PhilHealth generated reports (from
services, and for medical record system) on
nationwide policy decision actual number of services
making provided
POLICY AND DECISION MAKING

Most recent available No need to wait for reports Electronic medical record eRecords
FHSIS/DOH health data to trickle from the bottom system customized to
from 2006, decision up (from barangay to output reports/statistics to
makers can’t make health district hospitals to regional DOH
policies based on data from and provincial hospitals),
2-3 years ago Auto-generated reports
available at any time
Unsure about utilization Track which benefits are Make patient data eRecords
rate of member benefits being used by which anonymous, Perform data
patients, identify successful mining on database for
programs and create more program feedback
targeted ones for the future
Unsure about cost of care Contract standard rates Electronic billing eRecords
(cost of procedure to with service providers, No
patient, salary of doctors) out-of-pocket expenses for
because power is patients
delegated to LGUs, Difficult
to set price points for
packages
ADMINISTRATIVE LOGISTICS
Wait for up to 6 months for Reduced overhead in Electronic billing to eRecords
reimbursement claim to be processing transactions, automatically generate
processed More efficient process to claims and incorporate
verify member eligibility checks for data validity
and benefits’ status
Each health facility has Integrated medical record Electronic medical record eRecords
own medical records, filing systems where patient can system accessible from
system, and ID numbers visit any accredited any health facility to make
for patients (redundant PhilHealth facility and their patient transfers easier
databases w/ related info unique medical file will be
and waste of multiple ID easily retrieved for
cards) continuity of care
Hospital or PhilHealth Doctor, who actually Data validity checks on eRecords
manually encodes the interacts with patient, patient visit, requires doctor
diagnosis of the patient, writes diagnosis and to assign a code before
allows room for errors in assigns ICD10 code moving on
misunderstanding written immediately
notes of doctors
HEALTH PERSONNEL
Training of medical Continued medical training Training sessions eLearning
professionals limited to on up-to-date practices and conducted through
what they learned in school latest technologies, webcasts and video
years ago specialty training outside conferencing, IT
the formal classroom (i.e. infrastructure in remote
x-ray reading) locations to receive training
Reliance of rural health Access to online repository IT infrastructure in remote eLearning
professionals on books that of latest information and locations to receive this
are expensive, out-dated, medical advances, training
and with limited information discussion forums and
communities to share
information and help each
other on cases
Appendix: Summary of eHealth Services of NThC

University of Philippines National Telehealth Center
Written by Katherine Kuan
Obstacles to Quality Healthcare in the Philippines
• Shortage of trained medical professionals, recruiting/retaining qualified staff

• Shortage of quality health facilities, urban areas have more and better facilities
than rural areas
• Limited transportation accessibility and infrastructure
• High cost of medicine compared to other countries
• Barriers of distance, isolation of rural health practitioners
• Lack of data standards for health records
• Lack of unique national ID system
“ONeHEALTH is the flagship program of the University of Philippines’ National

Telehealth Center developed to address such obstacles. ONeHEALTH stands for “One
Network on eHEALTH.” With advanced new technologies comes much potential to
deliver quality health services to remote areas of the country.” - NThC
eRecords: electronic health records essential for quality management of patient and
treatment information, for use at all levels of health system (existing services: CHITS,
BuddyWorks, ISIS)
• Collect and integrate patient data from many remote sites, enable smooth patient
transfers
• Monitor patients over long period of time, especially for those with chronic
diseases
• Minimize information loss/error (i.e. from regional language differences in
symptom/treatment terminology), improve data quality with guidelines/alerts if
wrong data entered
• Bridge communication gaps among levels of health system
• Reduce costs with proper drug prediction, ensure uninterrupted supply of drugs
• Enable disease surveillance and rapid response (i.e. for the H1N1 virus)
• Auto-generate standard reports at any time
• Track which PhilHealth benefits are utilized by members
• Drive policy making process with systematic information and evidence
eLearning: a form of education/support for health workers - doctors, nurses, midwives

and health volunteers - through online content on community healthcare (existing
services: videos for Stroke, Avian Influenza, Basic Management of Childhood

Poisoning, TB)
• Provide opportunities for barangay healthcare workers (BHWs) to acquire and

utilize new knowledge
• Increase local capacity for proper patient care, decreased hospitalization time
and faster recovery
• Create collaborative social network of health facilities and universities
• Empower healthcare workers through demonstrated improvements in
competence, confidence, and morale
• Promote discussion and sharing of ideas among staff on site
eMedicine: draw on expertise of medical specialists far away using telecommunications

technology, telereferral services for general medicine, pediatrics, surgery, radiology,
dermatology, ophthalmology, psychiatry (existing services: BuddyWorks, SMS, MMS,
email telemedicine)
• Provide critical clinical decision support for BHWs

• Increase access to specialized care for rural citizens
• Reduce need for patient transfers, decreased travel time and cost
• Decrease cost to patients and hospitals with improved accuracy of diagnosis and
quicker recovery time
Appendix: Matrix of PhilHealth Initiatives with eHealth

Appendix: Policy Proposal for PhilHealth

Policy Proposal on Improving PhilHealth Services
Through eHealth Infrastructure
Katherine Kuan, UP Manila National Telehealth Center
1 Executive Summary
At no cost to PhilHealth, the Corporation can provide increased quality of healthcare to its members by
supporting the practice of eHealth services in its accredited facilities:
• eRecords: electronic medical records

• eLearning: continued education of medical professionals through online content
• eMedicine: draw on medical expertise far away using telecommunication technology
The first steps to integrate eHealth services into PhilHealth are outlined in this paper:
• Amend policy on capitation:

o Allow RHUs to spend their capitation on eHealth infrastructure
o Require RHUs to submit accurate electronic documentation/reports for full payment
• Incorporate eRecords into P4P monitoring
o Select an existing CHITS (Community Health Information Tracking) site for the P4P pilot
site
o Use CHITS data on site for baseline analysis and for progress tracking
Electronic documentation of care will vastly improve the ability of PhilHealth to track progress on its
programs and create more targeted initiatives to improve specific health indicators.
By streamlining claims processing, tracking package utilization, ensuring Bench Book standards are
followed, reducing fraud, improving drug delivery, and also providing detailed reports about health
outcomes and benefit utilization, PhilHealth will soon be able to reach its short and long-term goals
(universal coverage, Millennium Development Goals, and disease control).
2 Introduction
PhilHealth membership has been successfully increasing, but access to quality healthcare still remains a
challenge for millions of Filipinos. To figure out whether 300 pesos per indigent family is enough for
capitation, it’s important to examine how LGUs are spending their funds. In addition, questions still remain
such as: What is the utilization rate of the OPB? Does it cover the services that are really needed in
communities?
To ensure quality outpatient care is provided to PhilHealth members, there needs to be documentation on
what services were provided and what the outcome was. Electronic medical record systems (i.e. CHITS)
are the solution to a number of challenges facing PhilHealth today:
• Unsure how capitation funding is being spent, if it’s sufficient to support RHU operations
• Unsure about utilization rate of PhilHealth member benefits
• Need method to monitor performance for programs like P4P, contracting
• Fraud and calculation errors from handwritten reports
• Tedious data collection process, FHSIS/DOH reports come out 2+ yrs later
• Claims reimbursement process can take long time
Instead of relying on information from claim forms, PhilHealth will be able to use electronic medical record
systems to monitor and manage the type of care being delivered on the ground. CHITS is an electronic
medical record system designed specifically to adapt to the workflow of RHUs in the Philippine healthcare
system. Implemented in 20 sites across the country over 5 years, the system is highly recommended for
obtaining electronically documented care at PhilHealth accredited facilities. As a result, PhilHealth
management will be able to base decisions on real-time data, in order to create targeted programs that hit
performance targets on health indicators for the country.
By encouraging RHUs to utilize capitation to invest in CHITS and other eHealth infrastructure (computers,
Internet connectivity, video conferencing), their capacity to provide quality care at the local level will
rapidly increase.
In summary, eHealth and telemedicine have the potential to help the Corporation in the following ways:
• Increase access to quality care (i.e. telemedicine to reach specialists) for members
• Allow service providers to submit claims electronically for faster processing
• Allow facilities to track their patients over long time, quantitatively measure performance
improvements
• Allow system to monitor supply & demand, gather empirical data for health system performance
analysis
3.1 Policy Recommendations Regarding Capitation

1 Modify disposition of PhilHealth Capitation Fund (PCF)
Current Policy Proposed Policy
80% Drugs, medical supplies/equipment, 65% Operational expenses

referral fees, site improvement Drugs
Medical equipment/supplies
20% Administrative expenses (50% for Referral fees
physicians, 50% for personnel in OPB Site improvement
services)
20% Administrative expenses
Health personnel salaries
Training for workers (eLearning sessions
through video conferencing or online
resources)
10% Technological Infrastructure

Computers
Internet Connectivity
Electronic medical record system (CHITS)
Camera, video conferencing equipment
5% Telehealth services payable to National Telehealth

Center, subscription for fixed # telemedicine
referrals to specialists
2 Create stricter requirements on release of PCF funds in article 2.3 PhilHealth capitation fund
Capitation amt released with following Capitation amt released with following conditions:
conditions:
Required electronic submission of Monthly OPB
Initial release within first 2 weeks of Report Form (if paper report submitted, deduct 10%
applicable year, RHU accreditation and of capitation in successive quarters)
payment of premiums required
Required budget proposal on how capitation from last
Successive releases on third week of first quarter was spent (proposal subject to auditing)
month of quarter, reports and payment of
premiums required Random audits by PhilHealth on the validity of
reports, phone calls to the patient, visit RHU, flag
fraudulent cases
Initial release within first 2 weeks of

applicable year, RHU accreditation and
payment of premiums required
Successive releases on third week of first

month of quarter, reports and payment of premiums
required
3 Specify details on reporting/monitoring mechanisms required at RHUs, modify article 3.1

of Reporting, Monitoring, and Evaluation
RHU required to submit Monthly Report For information systems management, the Corporation
Form, Transmittal Form, Patient Treatment strongly recommends the RHU to install the CHITS
Summary, Tally Sheet for OPB Services electronic medical record system (to monitor OPB
Rendered services delivered by RHU for PhilHealth)
Health Finance Policy and Services Sector, RHU required to submit electronic Monthly Report Form,
Benefits Development Office, Accreditation Transmittal Form, Patient Treatment Summary, Tally
Dept, Quality Assurance Unit monitor and Sheet for OPB Services Rendered
evaluate the package
Health Finance Policy and Services Sector, Benefits
Development Office, Accreditation Dept, Quality
Assurance Unit monitor and evaluate the package
4 Modify referral system to include teleradiology referrals and teleconsultations in article 2.4
Referral System
In case of inability to take x-ray, RHU can In case of inability to take x-ray, RHU can refer patient to
refer patient to another facility, paid by another facility, paid by capitation fund
capitation fund
In case of specialist care (including radiologist), refer to

In case of specialist care or higher level of specialist (without travel) using telemedicine
care, refer to PhilHealth accredited hospital
(hospitalization qualifies for in-patient If telemedicine can’t resolve the case, refer to PhilHealth
coverage) accredited hospital
5 Extend outpatient benefits for indigent program members to include telemedicine

services in article 2.1 of OPB Guidelines
Primary consultations with GPs Primary consultations with GPs
Lab fees: chest x-ray, complete fecal blood Tele-consultation with specialist (with GP referral) **
count, fecalysis, urinalysis, sputum
microscopy Lab fees: x-rays for teleradiology referrals, chest x-rays,
complete fecal blood count, fecalysis, urinalysis, sputum
Preventive services: cervical cancer microscopy
screening, BP measurement, rectal exam,
body measurements, breast exam, smoking Preventive services: cervical cancer screening, BP
counseling, lifestyle change counseling measurement, rectal exam, body measurements, breast
exam, smoking counseling, lifestyle change counseling
** Must be at telemedicine certified facility, Can be out-

of-pocket expense for patient (at first) but later to be
included in standard outpatient benefit package
3.2 Pay-for-Performance Pilot Study Recommendations

3.2.1 Select a CHITS site as a P4P pilot site to facilitate monitoring of
performance in order to distribute incentives. Choose from 20 existing sites:
Lagrosa Health Center, Pasay City Pagsanjan Rural Health Unit, Laguna
Malibay Health Center, Pasay City Mendez Rural Health Unit, Cavite
Marikina Heights, Marikina City Alfonso Rural Health Unit, Cavite
Sto Nino Health Center, Marikina City Orion Rural Health Unit, Bataan
Taniong Health Center, Marikina City Real Rural Health Unit, Quezon Province
Quezon Rural Health Unit, Quezon Province
Child Hope Foundation Inc.
Sigma Rural Health Unit, Capiz Labuan Rural Health Unit, Zamboanga del Sur
Cuartero Rural Health Unit, Capiz One municipality in Zamboanga Sibugay
Tapaz Rural Health Unit, Capiz Batanes PHO , Basco, Batanes
Dumalag Rural Health Unit, Capiz
Uyugan Rural Health Unit, Batanes
3.2.2 Require performance at pilot site to be reported using electronic medical record
system to:
• Prevent fraudulent data that says performance target achieved

• Track progress of pilot sites as feedback loop on whether
P4P incentives are effective
• Utilize data for statistical analysis on maternal care to provide to
management for decision making
3.2.3 Perform baseline analysis on the P4P site by using previous years of CHITS data
for that site, will be able to show quantitative improvement directly as a result
of the P4P program
3.3 Recommendations for Using PhilHealth Service Offices for

Telemedicine
PhilHealth service offices, which are widely established across the country, already have existing
telecommunication infrastructure such as computers, Internet, and perhaps video conferencing.
3.3.1 Draft up a Memorandum of Agreement between PhilHealth and LGUs
• Teleconsulation: Allow local health professionals to refer patients to

specialists using teleconsultations, to be held in the PhilHealth field office
• Store-And-Forward Telemedicine: Allow local health professionals to send
images, audio, video of the patient to a specialist for diagnosis, using
PhilHealth field office Internet connectivity
3.3.2 Draft up a Memorandum of Agreement between PhilHealth and UP Manila National

Telehealth Center (NThC), allow NThC to coordinate telereferrals and teleconsultations
between patients and appropriate specialist
3.3.3 Require all patients utilizing telemedicine services to sign an informed consent form to
waive liability from PhilHealth
3.3.4 Amend Warranties of Accreditation for Health Professionals, certify specialists to answer
telemedicine referrals
4 Roadmap on Providing eHealth Services for PhilHealth Members

Appendix: Sample Referral Forms for Workflow

Appendix: Usability Testing of Moca
Batanes Provincial Office and General Hospital

Directions for Users
1. Turn on G1 phone using red button

2. Hit the gray arrow to unveil the list of applications
3. Select the Moca application by using your pointer finger to touch it on the screen
4. Perform a "Radiology examination" procedure using Moca
5. Use the patient with
ID number: 22222
First Name: Peter
Last Name: Smith
Birthdate: 01/03/1985
6. Perform a "Surgery follow-up"
Directions for Moderator
1. What is your goal in referring a patient?

2. Can you tell me what your usual procedure for seeing a patient and taking an x-ray is?
3. What problems come up with this type of workflow?
4. From scale of 1-10, Easy to use?
Batanes Provincial Health Office
Goal
• Increase quality of x-rays compared to previous status

• Clients have access to affordable, quick reading of their x-rays
• Better management of patients
Existing Workflow
• Patient comes in, received by nurse at registration area

• Interviewed for general data: name, birthdate, occupation, where they live
• Nurse interviews them for chief complaint, basic symptoms, history of illness, vital signs (bp,
heart, BMI, heart rate), past family history, OBGYN history, others (alcohol use, exercise)
• Doctor asks them for history of present illness, physical exam, do other lab tests
• Give x-ray request form, go to BGH, come back
• Take picture of x-ray and send to Manila
• Take contact number, while awaiting the x-ray results
• Administer drugs, final instructions
• Signs/symptoms for immediate follow-up
• For teleradiology, don’t write a lot, just important details
• Save all replies in email
• Not yet protocol to write the reply of the email down in the patient record
• Can take up to half a day for 1-2 images to be uploaded
• Hard to use own email to store data, need to find a way to store data
• Use digital camera 3MB
Usability
• Not too hard to get used to, looks daunting, lots of tabs
• “After I went through the process of filling out data, it was quite easy. Much easier than sitting
in front of the internet and typing it all.”
• “Very user friendly for people to use this technology”
• Okay with leaving it on the table to wait for it to upload
• Doctor in Batanes also wants to learn how to read x-rays for emergency cases when can’t
wait for the image to be uploaded for a diagnosis
o Will look for old x-rays to see similar cases
o Library to compare x-rays, teaches them what to look for
o WHO donated book of expert labeled x-ray images
o See where in the x-ray are the densities/haziness
o Learning tool for the doctors in Batanes
Difficulties
• Easier if had a pen for the touch screen

• Keyboard small but okay
• Taught them to use tip of finger, not fingernail
Issues
• Not all patients have medical ID number, usually list them alphabetically based on household
head
• Slash character for birthdate should be automatic
• Verbal notes
o Clarify what the verbal notes are, who records them (patient or physician)
o Didn’t need to record a verbal note, but can leave it in
o Not all doctors used to recording their notes, more comfortable typing them
• Written comments
o Daunting to see little space, think they can’t write a lot, will have to scroll down a lot
to read all the data, can only read one line at a time
o Make ½ or ¾ of the screen filled with the text box
• Didn’t really need to use the GPS coordinates
• Hard to hold it and tap it, kind of hard to use, right handed, hold it on top of the camera
• Telehealth format has chief complaint, quick history of illness, rundown of physical exam
findings, purpose of referral, what has been done to the patient, signs/symptoms
• “Why do I have to go back?” to review the pages
• Don’t have fixed number of options for the diagnosis, have a free text entry box for diagnosis
• Took about 5 mins to learn and talk through the workflow
• Send back SMS or PDF file, whichever is faster (priority is speed)
• PDF radiology report of patient for clearances, to see actual reading (most patients don’t
care)
• Will likely be sending 2 or 3 images at a time
• Personal data
o Barangay
o Municipality
o Middle name/initial (many similar first/last names)
o Date
o Gender
o Chief complaint
o Short history of present illness (1 or 2 lines) “Include all data significant to case at
hand, OBGYN, alcohol, smoking, medication taken”
o Physical findings (empty text box)
o Diagnosis (large empty text box)
Batanes General Hospital
Existing Workflow
• See patient, ask why they came, symptoms, physical exam, lab exam
• If need more diagnostic exam, may refer to telehealth
• Send to Manila
o Send x-ray plates through relatives or someone they know, just drop it off at airport to
give to radiologist (turn around time 1+ week)
o Radiologist will write findings, sometimes send back official report, relatives relay
information back
Usability
• Willing to enter data using the phone

• Cannot carry around big computers
• With computers, have to login to the net
• “It’s nice, much better than just ordinary paper” (faster)
• Prefer phone over writing it down
• Could use it to take picture of ECG print out, video recording of ultrasound, OB/GYN (Cervical
cancer), external eye exam
Issues
• Couldn’t select the option “female” for gender

• Click next/prev goes too fast
• Force close during camera app
• X-ray procedure
o
o Part to be x-rayed: upper extremities, lower extremities, chest, skull, neck, cervical, back
Upper extremities: arm, forearm, hand, shoulder, elbow, wrist
• Choose side: right or left
o Choose view: antero-posterior, lateral, postero-anterior, oblique
Lower extremities: hip, thigh, knee, leg, ankle, foot
• Choose side: right or left
o Choose view: antero-posterior, lateral, postero-anterior, oblique
Back: thoracic, lumbar, thoracolumbar, sacrum, coccyx

Appendix: Usability Testing OpenMRS Media Viewer
Philippine General Hospital, National Telehealth Center, Batanes General Hospital

Radiologist
Usability test done on radiology oncologist (for radiation therapy for cancer patients) at Philippine General
Hospital (PGH). He is a consultant with the radiology department at PGH and teaches residents. He
voluntarily answers all teleradiology referrals for the National Telehealth Center by email.
Existing Workflow
• Uses Mac image viewer called “Preview”

• Uses Preview to modify darkness/brightness, white balance
• “Eventually we want it like this (the OpenMRS image viewer). What we do now is difficult
because I open the email, read it, etc..”
• Receive only a few films by email, 10 per week
• Willing to read up to 100 plates per day
• Problems w/ x-rays (patient is breathing), radiology technician not properly trained
• Send notification to cell phone to check the web
• Will check email when get home, 1x per day, sometimes 2x

• Each takes on average 1 minute to diagnose, chest x-ray 2 mins, max 5 mins
• Slow internet at hospital
• Doing telehealth referrals for pro bono now
• 1 patient per email so don’t mix up names with images
• Takes 1 min to download the image, 2-3 minutes to diagnose
Take proper chest x-ray image (to retrain radiology technician)
• Angulated by 15 degrees
• See apex
• Top part of chest should take up 50% of the x-ray
• Female patient should remove bra
Features Needed
• Zoom magnification
• Vary contrast and brightness
• Just save original image (not modified version)
• Panel of information: symptoms, clinical diagnosis, clinical history
• View past x-rays (2 side by side, previous and latest)
• Access to older films (zoom and brightness capabilities on those images too)
• Radiologists need box for “findings/interpretation” and for “notes”
• Clinicians should be able to write diagnosis, treatment, notes (some fields can be blank)
• No drop down box for diagnosis, no fixed reading (except for “normal chest”)
• No cancel button needed, will read it then
• If not sure of diagnosis, will leave it blank or refer to someone else put case on “hold”,
assign it to another doctor, allow both doctors to be on the case
• Output an official report, type report next to image, then go directly to an editable version
of the official report (auto populate the official report and then make it editable, preview +
edit report)
• Don’t need to annotate image, maybe a circle/arrow/pointer if clinician wants to see
lesion (dermatology cases may require annotations)
• List of on-call doctors, typically on-call all day from 7am-11pm, diff person per day, a
doctor is on-call 2-3 times per week
• Could charge 30-50 pesos per x-ray plate reading
• If bad image, disappear from queue until need it again, don’t need the bad pics
• Personal digital signature
Nurse
Difficulties
• Double click to annotate
Workflow
• Clinician needs to incorporate the radiologist reading with other data from patient (ECGs,
other labs)
• Once sure about interpretation, don’t need to go back and save, only compare, won’t
return to edit it
• Clinician rad tech radiologist clinician
• Time diagnosis 48 hrs
• Use Windows default image viewer
Features Needed
• Make the image DICOM compliant (Open binary file, first part is text (key value pairs in
header), parse into fields, latter part is image
• Embed in file the doctor who interpreted the data
• Click on annotation to edit again
• Zoom (enlarge it so one lung is screen width, 3-5 MP)
• Don’t need to rotate it
• Label it as “user” or “patient”
• Add doctor’s name as the one interpreting the data
• Annotation box can be fixed to a corner of the screen
• Don’t need other info from medical record of patient besides the summary
• Compare with previous x-ray films, click to see previous plates, side by side comparison
• If not sure, need to refer to another doctor (residents may be unsure about diagnosis)
• Clinician needs diagnosis, treatment, other notes box
• Clinician may not need to annotate image
• Can have another system for clinician, pull out radiology image for same visit of patient
• Change brightness, contrast, sometimes can see shadows
• Date is fine, don’t need timestamp
• Bad image quality -> comment why bad image, want another view
• Retake shot (i.e. top of chest)
• Save original ones with new images
• Drag image around, zoom to click, scroll image like Google maps
Doctors in Batanes
• Need annotations for clinicians and radiologists

• Blank spot for clinical diagnosis
• Blank spot for radiologist (i.e. there were no densities, diaphragm is intact, heart is not
enlarged)
Doctor in Manila
• Spell checking for the boxes

• Findings, diagnosis boxes
• Make sure it’s embedded in the workflow (see surgery system by National Telehealth
Center)
• Separate screen for diagnosis of patient, not in the image viewer
Appendix: Technical Support Manual for Moca
Batanes Provincial Health Office - July 1, 2009

1 Setup Basic Tools

1.1 Download Eclipse
From USB key, Copy Eclipse folder into Program Files folder on computer
Launch eclipse.exe
Hit the icon that says “Go to workbench”
Install plug-ins by going to Help > Install New Software > Click “Add…” Button
SVN plug-in
Help > Install New Software > Add… to add site

Name: http://subclipse.tigris.org/update_1.4.x
Location: http://subclipse.tigris.org/update_1.4.x
Click OK
Click Next, I agree to terms and conditions, Finish
Android SDK plug-in
Help > Install New Software > Add… to add site

Name: http://dl-ssl.google.com/android/eclipse/
Location: http://dl-ssl.google.com/android/eclipse/
Click OK
Click Next, I agree to terms and conditions, Finish
1.2 Setup the Android SDK
From USB key, copy Android folder into My Downloads folder

My Computer > Right click > Properties > Advanced Settings > Environment Variables
Under system variables, find “Path” > Edit > Add semicolon
Find system path location of the android SDK TOOLS folder
Copy this path into the Path variable
1.3 Install the Android phone device onto computer

Click “No not this time” for Windows Auto Installer

Driver located in Android folder directory under usb_driver, x86 folder
Under Eclipse, Click Windows > Preferences > Android > Browse for the Android SDK
location (select the folder that has the tools folder located inside it)
2. Download Moca Code into Eclipse
2.1 Import the Moca project into Eclipse from the server
Right click in the left hand side panel (Package Explorer) > Import
Click on SVN folder > Checkout project from SVN
Create new repository location
Location: http://dagny.mit.edu/svn/moca/trunk/clients/moca, Click OK
You’ll see the folders show up under http://dagny...
Click http://dagny.mit.edu/svn/moca/trunk/clients/moca
Click Next, Next, Finish
2.2 Undo changes in Eclipse and get the version from the server
Right click the file or folder > Replace with > Latest from Repository
2.3 Save changes onto the server (only commit changes that are applicable to all
deployment sites)
Right click the file or folder > Team > Commit
2.4 Back up your data
Go to C:\Doc and Settings\PHO Main\workspace

Copy the project folders onto hard drive or something else
2.5 Update Code in Eclipse for MoCa
Right click on MoCa > Team > Update to Head
2.6 Create new procedure for the phone
Under the code branch, MoCa > res > raw

Right click raw > New > File
Create new xml file (ex: radiology.xml)
To rename, Right click the file > Refactor > Rename
Copy surgery.xml and create pages according to the doctor’s wishes
(http://www.mocamobile.org/development/index.php?title=How_to_Define_Your_Own_Procedures)
Add this procedure to the list of procedures by going to MoCa > src > org.moca.util >
MocaUtil.java
2.7 Open Logs for Android
Window > Open Perspective > DDMS (android icon next to it), Find logcat window
3 Setup Moca on Android Phone
3.1 Install Moca application
In Eclipse, Right click the folder > Run > Android Application
On Phone, Hit Menu > Reload Database

Menu > Settings
Moca Dispatch Server URL: http://moca.mit.edu/mds-dev
Initial Packet Size: 1 kb
Username: admin
Password: moca!mobile
Enable Upload Hack
3.2 Uninstall Moca application
Home > Settings > Applications > Manage Applications > Moca
Uninstall > OK
3.3 Change APN settings on Android Phone for GPRS to work in Philippines
Go to Home > Settings > Wireless Controls > Mobile Networks > Access Point Names >
Smart WAP
Correct Settings (starts automatically using your minutes):
APN: internet
Proxy: 10.102.61.46
Port: 8080
Incorrect Settings (to save minutes):
APN: internetq
Proxy: 10.102.61.46q
Port: 8080
3.4 General Tips
Always need to enter an ID number (no dashes allowed)
If it crashes, hit close, and then launch the application again > Saved Procedures >
continue and try to upload again
If you hit upload to server and it doesn’t go back to the main Moca home screen, then it
didn’t upload. Try to upload again
4 Login to OpenMRS to Check Uploads
Access OpenMRS Electronic Medical Record System
Go to URL http://moca.media.mit.edu:8080/openmrs/
Username: admin
Password: ********
Click Administration > Moca > Moca Queue
Appendix: Summary of Workflow in Batanes
For Singapore Lien i3 Challenge Application

The governor of Batanes was very enthusiastic about Moca and said it was “very, very
applicable.” He said it was easy to use and clear to follow. He said that there are only
general practitioners in Batanes and no specialists available, so telemedicine would
provide access to specialists and quality healthcare for his community. He said that cost
wasn’t really an issue and that they want to make the investment. Also, local technical
support wasn’t an issue. He said that “Filipinos are fast learners” and that they would
work it out. In general, he is proud of the culture and heritage of the province (especially
since Batanes Day celebrations just happened) and proud to have such a healthy
community. They have KSK a local social health insurance program, and I believe all
citizens in Batanes are covered by insurance (either just PhilHealth or PhilHealth plus
KSK).
From my impression, the people in Batanes were very peaceful and hospitable. They
lead simple lives, some live in huts by the beach, and they help each other out a lot. For
example, if someone is building a house, there are no construction workers around to
hire, so they ask their neighbors to help them out. During Batanes Day celebrations you
can just walk into people’s homes when they have a party and they will feed you even if
you are a stranger. We met the governor by going to his house one night because he
had a party for his wife’s birthday, and all the neighbors, family, and friends were
invited.
Rural Health Units
For some health services, some people pay. RHU services are free for people who live
in that municipality. If you’re from outside, depending on your income class, you can pay
from 25 pesos to 100 pesos for the consultation with the doctor. At the RHU they
perform minor surgeries, a dentist comes in once a week, and other primary care
consultations. Sometimes they ask if they can pay later (sometimes they do, sometimes
they don’t). Sometimes Dr. Lariosa (municipal health officer) gets paid for services with
a chicken, fish, other food or homemade goods. That’s the culture there because the
neighbors help each other out (i.e. you can always get eggs from your neighbor if they
have chickens).
Teleradiology
When doctors don’t know how to diagnose the patient from the x-ray, they either send
the plate to Manila or sometimes refer the patient to Dr. Lariosa or Dr. Thea. This is a
problem because Dr. Thea at the provincial health office isn’t really supposed to be
receiving many patients anyways. They say that the doctors (like at the Batanes
General Hospital) and staff are a little hesitant to use telereferrals. They’ve been trained
already multiple times, but they really aren’t motivated to use telemedicine. It’s mostly
Dr. Lariosa or Dr. Thea who do the telereferrals. Even with telereferrals through email, it
can be slow. In the provincial health office, internet connectivity is really slow.
Sometimes it can take up to half a day to upload an image to an email, so Dr. Thea is
definitely willing to wait until it finishes uploading (half an hour to half a day) via GPRS
with Moca. It’s not urgent that she does it right after each other, since it’s just the x-ray
plate, she can just upload one, set the phone down, and wait till it finished uploading.
Then come back later. Sometimes the x-rays are sent to Cagayuan (sp?) but it takes 1-
2 weeks before they get a reading.
Dr. Thea says that they only received basic training on radiology, but just to be sure,
they like to send the x-ray to Manila to make sure they’re reading it correctly. It’s also
practice for them because then they can see whether they read the x-ray correctly and
learn from their mistakes. Sometimes if a similar case comes up again, she will go back
and find the email from the previous case. It’s disorganized though because she has to
search her email. Once they receive the diagnosis from PGH, they just tell the patient. I
don’t think it’s officially recorded anywhere, they don’t require an official report to be
printed out. She thinks that a revenue opportunity would be if the official report was sent
by PGH so that they could charge the patient money if they want a copy.
eLearning
There’s definitely a good case for a database of expert-labeled images here to be used
as training material for them. They have some books donated by WHO (see attached
image) where they can see examples of what sample chest x-rays are and how they
were diagnosed. Books are expensive and limited in the number of examples they
provide. It’s necessary to develop this capacity at the local level because in the case of
an emergency if the patient can’t wait for a teleradiology referral or for the snail mail
way, the general practitioner has to make the call. At that time they can only use what
they know from experience and the examples of past telereferral cases to try to find a
similar image.
Insurance
In terms of insurance, there is insurance from PhilHealth, where it is mandatory for them
to pay 100 pesos per month. For the formally employed sector, they pay 100 pesos per
month for coverage of the whole family. They can avail of inpatient services, but if they
come to the clinic they cannot reimburse services/medicine. Even for inpatient services
though, PhilHealth will cover maybe 50-70% (don’t quote us on this number) of the bill
depending on what the hospital charges. Basically hospitals can charge whatever they
want and PhilHealth will always reimburse up to a flat amount according to what
service/case it is. With telemedicine though, people will be able to pay less out-of-
pocket expenses for even better care.
There is an informally employed (or self-employed group). They are not mandated to be
enrolled because there is no employer giving them a salary. They are the most
vulnerable group in terms of not having insurance coverage.
The indigent program in PhilHealth is where people with income class < 14,000 pesos
per month for a family of 6 receive free healthcare coverage. Indigents receive inpatient
and outpatient benefits. For inpatient benefits, they don’t have to pay. The facility can
submit the claim straight to PhilHealth, but they can wait up to half a year to be
reimbursed. This is where eRecords can come into play and automate billing for faster
turnaround time from PhilHealth (latencies in verification of member benefits can be
done faster electronically). The money to provide indigents with PhilHealth insurance
comes from governors, mayors, congressmen, or the province itself.
There is also KSK, a local social health insurance (community-based). It’s not
mandatory, so they have to work on marketing for people to buy it. There are about
1000 households enrolled in KSK out of 3000 in Batanes. Reimbursements are quicker
because it’s only run by a couple of people in the provincial health office. KSK was
setup by a German NGO partner. The NGO did a survey to see how much people can
afford for healthcare. I think they found about 50 pesos per month to be affordable.
Another consultant pegged it at 90 pesos per month. For KSK, members pay 92 pesos
per month for coverage. They receive 5000 pesos for hospitalization per family per year,
and 500 pesos for outpatient services.
Benefits of Telemedicine
For telemedicine, we can save the amount of money it costs someone from Batanes
traveling to Manila. It’s about 16,000 pesos for airfare, 1,000 pesos per day for
board/lodging, so it comes out to be 18,000 for 1 person but usually they travel with
more than one person. If someone does actually fly out to Manila, if the illness is not an
emergency, PGH will send the patient back home and ask them to follow up in 6 months
for a surgery later. Even if the person needs an operation, they may have to come back
after 6 months to actually have the operation. Basically they have to fly in first for
advice/consultation/diagnosis and then later come for the operation. This initial
consultation can be done through teleconsultation and save lots of money!
Teleconsultations are also valuable in cases where rehab is needed or surgery follow-
up.
In terms of volume, there are about 20-30 x-rays taken per day for the 3 health facilities
in Batanes. For the provincial health office, the max they requested was 4-5 x-rays per
day, but not all of these are referred to a specialist.
An officer in the Provincial Health Office in Batanes says that it’s hard to compute the
health statistics manually from all the provinces. If data looks incorrect, they have to go
track down the RHU to figure out where the error came from (simple calculation error or
misread handwriting). Hence, they made an Excel spreadsheet with formulas (but these
are also prone to error). Everything is compiled into 1 spreadsheet (where each sheet
has all the statistics for a different city/municipality – see attached picture). So one file
has statistics for each month of the year for each city/municipality and I’m not sure if it’s
backed up regularly or in a secure place (anyone can access the files if they go on that
person’s computer in the office). They really want software that can generate these
reports easily, to save time and minimize errors.

Deliver of Ehealth &amp Telemedicine Services To The Philippines by Katheine Kuan

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mobile care: scalable imaging and

diagnosis for the developing world

Delivery of eHealth and Telemedicine Services to the

City of Manila and Batanes Province

In Partnership with University of Philippines Manila,

Written By Katherine Kuan

“Catastrophic illness or ill health in general is

Laying Groundwork for a Moca Deployment in the Batanes Province

Figure 2. Workflow in Batanes with paper x-rays that need to be

Recruiting Local Developers to Work on Moca

Figure 5. Moca recruiting talks at UP Manila (left) and UP Diliman (right)

There is also a pair of Ateneo University students working on a windows version of

Figure 7. Collaborating on the Windows Mobile version of Moca at Ateneo University

Ensuring Sustainability in Adoption of Telemedicine

Figure 8. Key stakeholders

Convincing PhilHealth to Prioritize and Invest in eHealth

Ms. Gitch Diaz (CorPlan)

7/8 Presentation with Chief Operating Officer and Operations Grp

Improving Access to Healthcare for PhilHealth Members

7/22 Follow-up Presentation with COO and Operations Grp

7/22 Presentation with President and Chief Executive Officer

7/23 Presentation with Sector on Out-Patient Benefit Package

Contracting is another initiative still undergoing negotiations. This is a method for

PhilHealth Fraud Department does random checks on hospitals and claims by

PhilHealth Accreditation Department is in charge of accrediting health facilities and

PhilHealth Benefit Development Department determines the amount of coverage in

PhilHealth IT Department will be important in determining whether the corporation

3. Integration of CHITS with PhilHealth

• Targets from PhilHealth

Figure 15. Number of PhilHealth accredited facilities from PhilHealth’s

Appendix: Analysis of Philippine Healthcare System

University of Philippines Manila, National Telehealth Center - July 8, 2009

Health facilities sitting Continued supply of drugs Electronic management of eRecords

REPORTING AND MONITORING

POLICY AND DECISION MAKING

Appendix: Summary of eHealth Services of NThC

Obstacles to Quality Healthcare in the Philippines

• Shortage of trained medical professionals, recruiting/retaining qualified staff

“ONeHEALTH is the flagship program of the University of Philippines’ National

eLearning: a form of education/support for health workers - doctors, nurses, midwives

services: videos for Stroke, Avian Influenza, Basic Management of Childhood

• Provide opportunities for barangay healthcare workers (BHWs) to acquire and

eMedicine: draw on expertise of medical specialists far away using telecommunications

• Provide critical clinical decision support for BHWs

Appendix: Matrix of PhilHealth Initiatives with eHealth

Appendix: Policy Proposal for PhilHealth

• eRecords: electronic medical records

• Amend policy on capitation:

3.1 Policy Recommendations Regarding Capitation

Current Policy Proposed Policy

80% Drugs, medical supplies/equipment, 65% Operational expenses

10% Technological Infrastructure

5% Telehealth services payable to National Telehealth

Current Policy Proposed Policy

Initial release within first 2 weeks of

Successive releases on third week of first

3 Specify details on reporting/monitoring mechanisms required at RHUs, modify article 3.1

Current Policy Proposed Policy

Current Policy Proposed Policy

In case of specialist care (including radiologist), refer to

5 Extend outpatient benefits for indigent program members to include telemedicine

Current Policy Proposed Policy

Primary consultations with GPs Primary consultations with GPs