CHITS and ClinicSys: A Comparison

There are 6 parameters that has been set in evaluating the CHITS and ClinicSystem:

a.     Ease of Use

b.     Completeness

c.      Longitudinal tracking of patient

d.     Compatible with the DOH programs

e.     Generation of Reports

f.      Adherence to the WHO standards of a good data quality

Upon observation, the Healthworkers of Navotas City are confident and comfortable in using CHITS as their EMR even at the point of care. (Annex A) This study was made to check the completeness of data elements in ClinicSys to the data elements of CHITS, all data elements mainly on the demographics – are complete. With these elements present on CHITS, longitudinal tracking of the patient’s health may easily be monitored using CHITS.  Moreover, CHITS modules are compatible with the existing programs of the DOH, up until the reporting.  CHITS is being developed with WHO’s definition of good quality data: ¹

Accuracy and validity – of the original source data;

Reliability – data are consistent and information generated is understandable

Completeness – all required data are present

Legibility – data are readable

Currency and timeliness – data are recorded at the time of observation

Accessibility – data are available to authorized persons when and where needed;

Meaning or Usefulness – information is pertinent and useful

Confidentiality and Security – both important particularly to the patient and in legal matters

CHITS contain all the data elements seen in ClinicSystem. CHITS was designed to work in sync with the workflow of the RHU.  Moreover, it was designed to be used at the point of care. CHITS gives alerts on risks and reminds the health worker to ask all the pertinent question to the patient and the patients can be grouped under their family folders and data quality checking is definitely lessened – these are just some of the features of CHITS.  CHITS user interface follows the normal patient’s chart – for easy monitoring.

On the other hand, ClinicSystem can also be also be used at the point of care however in all steps from admission to the end of consult, the health worker needs to search over and over. When evaluating the patient’s clinical data, the health worker can view it through the “Health Record”, however updating it would take the health worker to access the modules. Reports can be generated on ClinicSys. Though health workers may need to check the quality of data due to service entries can be duplicated.

Data Element: CHITS	ClinicSystem	Comments
Patient Queue	Patient List	CHITS utilizes a queue, it lists down the patients who went to the RHU for their services for the day. On the other hand, the ClinicSystem is utilizing a list. It lists down all the clients in the database, it can be manageable to use the list if there are only a few patients on the list, but if the health facility caters to a community with thousands population and services atleast a hundred patients in a day, it may be difficult to manage the “Patient List”
Patient Search	Global Search	The PATIENT SEARCH on CHITS requires only 2 characters to search for the patients, that shortens the time to look for the health profile of the patient, as compared to the GLOBAL SEARCH of ClinicSystem, it requires the last name, first name, middle name and sex to search for patients’ health profiles. In all steps –from admission to ending the consult(Doctor’s order)health workers will have to search the list in the database.
ECCD	Childcare, Sick children, child immunization, child nutrition	All options under this module are complete from the ECCD program (immunization, delivery information, NBS, childcare remarks, patient info, service record - vit A, iron and deworming, dental services and breast feeding). Chart of weight for age, length for age and weight for length CHARTS is also available. While ClinicSytem divided it into - childcare, sick children, child immunization and child nutrition. In comparison, the ECCD module can show the whole status of the child from birth until the age of 6.   While ClinicSystem based it on the FHSIS requirements.  It is upon the researcher’s evaluation that the ClinicSystem’s modules are open for duplicate/multiple entry of a service. This will eventually require rigorous data quality check when the period of reporting comes.
General Consults	Vital Signs, Physical Exam, System Review, Doctors order, Consultation for follow-up. (Basic Services) Medical History	The General Consults Module shows the DOH programs that the patient is currently enrolled, the doctor can view the flow of the patients and which needs his attention, it shows the patient’s chart which includes the anthropometric measurements of the patient which can automatically computes the Body Mass Index of the patient. This can alert the Health worker if the patient needed to be taught on possible risks of improper BMI. Vital signs can be entered on this module, when the archive button is clicked the history of VS will be shown. Medical History, pertinent medical condition can be added through a tick box. The complaints and complaints note can be utilized when triaging the patients. ICD 10 can be search and selected automatically and under the complaint notes can be used as free text space where the HW can type in verbalized (subjective) complaints of the patient. History of present illness, Physical exam, diagnosis and treatment plan have a features a template that can be utilized by the health worker on head to toe, systems assessment, while the diagnosis and treatment plan templates are useful for the physician. The prescription and other instructions of the doctor can be updated on this module, this can be viewed by the pharmacy or the drug dispenser. Under the basic services of Clinicsys are the VS, PE System review, Doctor’s order and consultation follow up.  In comparison, the PE and the system review of clinicsys are of free text.  Under the Doctor’s order, the doctor can tick laboratory requests and imaging, the diagnosis can be searched using ICD 10 and the treatment plan is of free text. Scheduling of follow can be done under this module. The type of consult/service can be ticked (Required). On ClinicSystem, Medical History is a separate module (free text)
Dental Module	Dental	All the data elements in Clinicsys can be seen on CHITS. Data elements may be the same but clinicsys just show the presence Dental Caries Gingivitis/ Periodontal, Disease, Debris, Calculus. Abnormal Growth.Cleft Lip/ Palate and Others and numbers of Permanent Teeth Present No. of Decayed Teeth (D) Total DMF Teeth No. of Temporary Sound Teeth No. of Missing Teeth (f), it does not show dental condition of the patient according to the dental health module of the DOH.
Screening Report, Special Consult Forms, PIDSR Case Report forms	None	Under Forms module of CHITS – Screening Report, Special forms and PIDSR forms can be accessed and utilized for reporting. NCD monitoring form can be added on the patients health record, as well as the disability record, primary preventive services for health promotion and education services report can be updated when the patient joined these services. Risk assessment can be updated and be utilized by the health workers for preventive medicine.
Maternal Care Program	Postpartum and prenatal	All data elements on ClinicSystem is on CHITS.  CHITS user interface features the obstetric clinical picture of the patient in one page including all the pertinent services that a parturient patient needs. On the other hand ClinicSystem’s Prenatal and Postpartum module’s data elements only include dates, OB score, delivery, place of delivery, attendant and a free text remark. These data elements are included in CHITS.
National Leprosy Program Module	None	The leprosy module on CHITS includes the Drug Collection Chart, Household collection chart, PE, Med Hx and the Diagnostic and Treatment details for leprosy
Family planning Program Module	Family planning	The family planning module of ClinicSystem only includes – type of client, method, drop out and remarks – these data are all included in CHITS. CHITS features a full assessment pertinent to the enrollment of a patient to this program, when completed, the patient may be referred to the physician if risk factors are ticked and if the health worker assessment needed to be seen by the physician.
Laboratory Module	Laboratory (under doctors orders)	In the laboratory module of CHITS, request and results can be updated and viewed. While the laboratory module of ClinicSystem has tick boxes for blood chemistry, bacteriology, clinical chemistry, fecalysis, hematology, immunology, serology and urinalysis and updating for results can be done. These laboratory requests are all included in CHITS.
Dispense Drugs	None	CHITS Drug Dispense Module’s feature – it is shows the history of all prescribed, dispensed and administerd to the patient. It can be updated in the general consults page under the treatment and diagnosis. Though the treatment plan can used for these feature – it is of free text.
National TB Program Module	ITIS	All feature and data elements of ITIS.

Annex A

A focus group discussion(FGD) was organized for the end users of CHITS in Navotas City.  The focus group discussions were conducted in each health center of Navotas City Health Office.  The groups consist of the medical officers, the public health nurses and then registered midwives.

FGD are a form of group of interview that capitalizes on communication between research participants in order to generate data. FGD explicitly use group interaction as part of the method. Participants are then encouraged to talk to one another: asking questions, exchanging anecdotes, and commenting on each other’s experiences and points of view.  This method is useful in exploring people’s knowledge and experiences and can be used to examine not only what people think but how they think that way. ² The questions are designed to engage the participants and to explore the experiences of the health workers of Navotas City in using CHITS.

The Technology Acceptance Model (TAM) by Fred D. Davis was used as framework to assess the user acceptance to CHITS.

This FGD questions bases on TAM are to address the basic questions of why users accept or reject a system [CHITS] and how user acceptance is influenced by system characteristics.  From a practical standpoint, we are interested not only in explaining why a system is acceptable/unacceptable to a set of users, but also in understanding how to improve user acceptance through the design of the system. ⁴

A prospective user’s overall attitude toward using a given system is hypothesized to be a major determinant of whether or not he or she actually uses it. Attitude toward using, in turn, is function of two beliefs: perceived usefulness and perceived ease of use. Perceived ease of use has a causal effect on perceived usefulness. System design features directly influence perceived usefulness and perceived ease of use. System design features have an indirect effect on attitude toward using and actual usage behavior through their direct effect on perceived usefulness and perceived ease of use.

Figure 1 Technology Acceptance Model (Davis 1989)

The questions are rephrased in accordance to.  The strategy used to phrase the questions are: ³

            Use open-ended questions to allow the respondents to determine the directions of the response.

           

            Ask the patient to think back. The “think-back” questions ask participants to reflect on their personal experiences and then respond to a specific question.  People often give great examples of their experiences.

            Avoid asking why. The why questions has sharpness or pointedness to it that reminds one of interrogations.  The respondents tend to feel confronted and defensive.

            Keep questions simple.  The best focus questions are stated simply.

            Key questions should focus on the critical issues.

FGD Question: (English)	FGD Questions: (Filipino)	Construct Items
What are your challenges in serving the community?	Ano ang inyong mga pagsubok sa pagseserbisyo sa inyong communidad?	Actual Use
Which challenge/s do you think may be addressed by an EMR (CHITS or otherwise)?	Ano sa mga pagsubok na ito ang maaring masolusyonan ng isang EMR?	Behavioral intention to use
What can you say about CHITS?	Ano ang inyong masasabi sa CHITS?	Perceived ease of use
What do like about CHITS?	Ano ang inyong gusto sa CHITS?	Perceived usefullness
What do you not like about CHITS?	Ano ang inyong hindi gusto sa CHITS?	Perceived usefullness
In what way did CHITS help you in your work in the RHU?	Sa anong paraan nakatulong ang CHITS sa inyong trabaho sa RHU?	Behavioral intention to use

The FGDs were conducted at the most convenient time for the health workers, which falls after lunch time (1pm onwards).  The discussions were held in 9 health centers in Navotas City which by then participated by the heath workers which consist of the medical officer, the public health nurses and midwives. The total number of discussion participants is  ≥ 45 health workers.

The health workers of Navotas had a common and similar experiences in serving their communities. The most common theme in their answers on their challenges in serving their community are: they have security issues when they go to some areas, there is lack of resources (medical supply), the long waiting time on their PhilHealth capitation fund, the attitude of the patients and the reporting.

With all the challenges the health workers mentioned by the health workers, they were then asked with of the challenges they mentioned may addressed by using CHITS.  All groups answered that CHITS can help them in their recording and reporting. Majority of the participants agreed that CHITS is “maganda”, however they added that “mas maganda, pag palaging maayos”. Positive feedback on it is easy to use on reporting, easy to search patients, the inventory module and less paper work. Negative feedback on frequent error, problems with the hardware, LAN and Internet were presented. The issue on the there is no action to late action being done by the Navotas technical group (MIS) was also a common and similar theme.

Discussion and Conclusion:

Based on the themes drawn from the discussions, CHITS is easy to use.  The health workers mentioned that learning CHITS made them increased their proficiency in using the computer (sending and receiving eMail and for social networking, encoding and printing).  Majority of the health workers find CHITS as useful in their work, especially in recording and reporting.  Their attitude towards CHITS only became negative when CHITS was then affected by LAN and Internet issues as well as technical issues related to CHITS (improper shut down and database error)

Focus Group Discussion Tool

Instructions to the Interviewer:  The FGD process requires the facilitator to ensure that satisfactory answers are provided for each question with regards to the health worker's perspective in the use of the R4H application. Please ensure that the proper attitude is followed at all times.

1.     Before conducting the FGD, ensure that the interviewees are comfortable and at ease with you.   Having an atmosphere of camaraderie helps in eliciting candid and truthful answers from the participants.

2.     Inform the participants that the discussion will be recorded.  But ensure that privacy of information is also recognized

3.     Inform the participants the expected duration of the FGD. Encourage them to answer all the questions and openly voice out their thoughts.

4.     Have an attendance sheet ready for everyone to sign before beginning the discussion.

5.     Exercise your best effort to have all questions adequately answered.  If you feel that you cannot have the question answered adequately, please make sure you place annotations on why you feel this is so.

6.     RECORD the responses of the participants as accurately as possible.  Attribute the statements to the correct participant in your notes as much as possible, but especially for important remarks.  

7.     Your thoughts should also be written right away so that you may be able to easily recall the circumstances when collation of data in being done.  Your notes will also help the data collators to assess the situation when analyzing the answers.

8.     DO NOT SHOW your notes to the participants.

9.     If there are two or more facilitators, designate one person to take charge of the interview, and another to take down notes.  The head facilitator should always remember to provide the opportunity for the other members of the interviewing team to ask follow-up questions before moving on to the next.

10.  Avoid going into discussions that will elicit individual practices that are better left unsaid in a group discussion.  Always remember the question under discussion and ensure that the group focuses on the answering the question.  Do not allow the discussion to stray from the topic, as much as possible.

11.  After the FGD don’t forget to thank the participants and assure them that their answers will be looked into for the benefit of the NTSP.

FOCUS GROUP DISCUSSION QUESTIONNAIRE

Assure the interviewees that all information obtained from this interview will be kept confidential.  The objective of the interview is to provide a more comprehensive view of the environment and the factors that may affect the implementation of the program, hence truthfulness of thoughts and feelings of the intervievwee will be most appreciated.

What are your challenges in serving the community?

Which challenge/s do you think may be addressed by an EMR (CHITS or otherwise)?

What can you say about CHITS?

What do like about CHITS?

What do you not like about CHITS?

In what way did CHITS help you in your work in the RHU?

Any comments/suggestions regarding the CHITS?

These questions were translated into the Filipino language, as was used on the focus group discussion.

Ano ang inyong mga pagsubok sa pagseserbisyo sa inyong communidad?

Ano sa mga pagsubok na ito ang maaring masolusyonan ng isang EMR?

Ano ang inyong masasabi sa CHITS?

Ano ang inyong gusto sa CHITS?

Ano ang inyong hindi gusto sa CHITS?

Sa anong paraan nakatulong ang CHITS sa inyong trabaho sa RHU?

Mga komento at suhestyon?

Bibliographies

1.        Improving Data Quality: A Guide for Developing Countries

2.        Qualitative Research: Introducing Focus Groups by Jenny Kitzinger

3.        Krueger, Richard A. and Mary Anne Casey (2000). Focus Groups: A Practical Guide for Applied Research. 3rd Edition. Thousand Oaks, CA: Sage Publications.

4.        Davis, Fred D. (1991) User Acceptance of information technology:system characteristics, user perceptions and behavioral impacts.