I also changed the bottom toolbar to have the sliders stacked on top of each other so that it would be less wide on the screen when added next to the Moca panel. There are 2 new buttons to the toolbar - revert to default image and full screen mode.

Even though I used a pre-made Pan/Zoom component from Adobe Developer Connection, I had to read through the library to understand how to modify it for OpenMRS’ purposes. I added support for each Generic File in this encounter to save the image processing and zoom settings added so that if the user moved to the next thumbnail, the settings would still be saved when the user returned. However, these settings are not permanently saved to the OpenMRS server. According to my usability tests, the specialist wants to manipulate the image but doesn’t need to save the modified version. Another problem was that the image was animated to stick to one of the four corners of the content rectangle. This caused the image to fly to unexpected positions and the mouse would lose the image underneath it (see below). I wanted the ability to pan and drag the image anywhere, so I removed many of their animations and edge boundary restrictions.

With my modifications, the panning is much more controlled and the image stays under the mouse.

Here is the final version of the media viewer! (Although more modifications are coming soon..) Within the Moca module in OpenMRS, the doctor will access a list of pending cases from healthcare workers.

When a doctor clicks on an item, the media viewer will appear.

The doctor can browse through all the media files associated with this patient’s encounter and then fill in diagnosis and treatment recommendations on the left hand side. When the doctor hits the “send” button, it will get uploaded to the OpenMRS server and modify the encounter. The encounter viewer already built into OpenMRS shows the objects already associated with that encounter.

You can see that a new Obs was added to the list for this encounter of concept type “Diagnosis.” The value of the Obs is the text that we entered in the Moca panel above. This view also shows that Dr. Mark Johnson (the user account currently logged into OpenMRS) made this diagnosis on August 25. Different doctors are allowed to make a diagnosis for an encounter and a single doctor can also make multiple diagnoses if they change their mind.

Here are more examples of how the media viewer can be used in other applications. For this tele-oral case, you can add a summary below the image.

Or pop out the summary to move it around and allow you to zoom in on the image closer.

For teleradiology cases, many patients will have multiple x-ray views taken to help the doctor with the diagnosis. These can all be viewed together easily in the workflow. The 4 x-rays for this patient are displayed in preview thumbnails along the bottom.

You can turn off the toolbar on the bottom for a bigger view of the image. (Use the options menu in the upper right corner).

If you try to fix the image (brightness, contrast, sharpness, zoom) but don’t think the settings improve the image, you can always revert to the original image with this button on the toolbar.

The original image is back!

If the encounter contains an audio file, simply click on the audio thumbnail along the bottom toolbar and the file will begin playing. You can play/pause at any time, mute/unmute, change the volume, and skip track position. The audio player also displays the current time out of the total time length of the file, which provides the doctor with a cue point in annotating the file.

Here is an example of video playing in the media viewer. This is a video taken by the G1 phone in the MIT media lab. It was converted to FLV format using the Adobe Media Encoder. You can play/pause, mute/unmute, change the volume, skip to any position in the video, and change to full screen mode.

Example of ultrasound video being played in the media viewer.

Video full screen mode!

That’s it! Next features to come: drop down boxes for diagnosis/intepretation fields (for data mining purposes), upload a file to the encounter viewer, and download all files.

Specs for what Flex supports:

I captured some sample videos on the Android G1 phone to see if it could be embedded in my Flash application, but the video didn’t play properly. It turns out the problem was because the video was in .3gp format and using H.263 encoding. You can find encoding information using Ctl + I when viewing the video in Quicktime (there are no menu options for this).

I double-checked the Android documentation and found this page to confirm that audio and video files created by the Android G1 phone are NOT in MP3 or H.264 format. (Source: http://developer.android.com/guide/topics/media/index.html)

After discussing this format support problem in Flex with other computer science students at MIT, I came up with two design options: 1) Find an open source video player that supported crucial formats (i.e. AVI, MP4) and embed that using HTML/Javascript in my Flash application, or 2) Convert all files uploaded to OpenMRS into MP3 and FLV format to be played by the Flash media viewer. I tried looking for a media player written in Flex so that it could be easily integrated with my application. I found various players, but the FlowPlayer (http://flowplayer.org/demos/installation/index.html) looked the most promising. However, after testing it with my sample MP4 files, sometimes the audio would play without the video portion. I also had difficulty importing the player into FlexBuilder because it required Adobe CS4 Professional.

After much more research and experimenting, I decided to go with the second option of requiring the format to be MP3 or FLV. This was a better idea because raw video files can take over a hundred MB and would provide variable output quality/size. Meanwhile, storing the videos in FLV format would only take up 10-15MB of space and would stream much faster when the doctor loaded the page. (Youtube.com also converts all uploaded videos into FLV format for streaming).

Hence, I looked into ready-made programs that would perform video transcoding for me. There are a lot of options on the Internet but many charged money for the solution or had a GUI interface (so integrating it to run automatically would be difficult). A command-line option that looked most promising was FFMPEG (http://ffmpeg.org/). FFMPEG is an open source cross platform solution to streaming and converting both audio and video. It worked on converting many of my MP4 test files into proper FLV files, but it didn’t support conversion of 3gp files form the phone. If you’re interested in using this tool for your project, this tutorial is very easy to follow and understand.

FLV Converter - A Layman’s Guide to Flash Video Conversion

http://worldtv.com/blog/guides_tutorials/flv_converter.php

Then I looked into Adobe solutions and found the Adobe Media Encoder. As I mentioned above, Adobe CS4 Professional requires a license, but I decided to just use the trial version since it includes the Adobe Media Encoder. It worked very well and converted all my files to  FLV format, including my 3gp test file. There’s also a command-line interface for the media encoder (http://help.adobe.com/en_US/FlashMedia-Encoder/2/help.html?content=get_started_11.html), so it can be integrated with the Moca module on OpenMRS. However, the only problem left is that we would need a license for the software. I decided to assume that transcoding would be an issue that we would deal with later, at the very least, the user could convert the file using a free converter from the Internet. I moved onto spend time on developing the audio and video player for my media viewer.

Flex doesn’t have any pre-built media players for easy integration into projects, so I had to browse online for ones made by other developers. After much searching, I didn’t find any players that suited the needs of the OpenMRS media viewer. For example, the audio players were too simple (just play and mute buttons), too complex (with filters and audio synthesis tools), or didn’t have open source licenses. As for video players, I found ones like Flow Player (described above), but then realized that there is an FLVPlayback component in CS4. I imported the SWC from CS4 into FlexBuilder and used this pre-made component for my media viewer.

Using the Flash FLVPlayback control in Flex

http://blog.flexexamples.com/2008/12/11/using-the-flash-flvplayback-control-in-flex/

Building Web Video Players

http://www.adobe.com/devnet/video/customization.html

FLVPlayback Directly in Flex

http://yourpalmark.com/2008/04/30/flvplayback-directly-in-flex/

I modified the version from this tutorial to a different skin with more control options, docked the control bar below the video (no fading), made audio/video play simultaneously, and changed my Flex application HTML file to enable full screen mode. Pictures of the finished FLV player will be in an upcoming post.

Since the FLV Playback component didn’t play MP3 files, I had to come up with an audio player that somewhat visually matched the video player. There were many tutorials on how to use the Sound and SoundChannel classes in Flex, so I decided to create my own audio player.

Creating an audio player turned out to be a challenging task even though there were pre-built Sound classes.  Some difficult parts were figuring out to update the time and slider as the audio played, allowing the user to skip to a different position in the track, switching the play icon to a pause icon (as well as mute/unmute icons), linking the volume control slider with volume changes in the sound channe.

Foundation Actionscript 3.0 with Flash CS3 and Flex

http://books.google.com/books?id=B4aB0hJsNMoC&pg=RA1-PA319&lpg=RA1-PA319&dq=track+sound+position+flex&source=bl&ots=t-W4JrGLqK&sig=ikrulCJ6pcQ0LoE3RU6w1Bu9o2c&hl=en&ei=dCCSSsnwFpSnlAe29pmiDA&sa=X&oi=book_result&ct=result&resnum=1#v=onepage&q=&f=false

Working with Sound

http://livedocs.adobe.com/flex/3/html/help.html?content=Working_with_Sound_12.html

Loading External .mp3 File and Retrieving ID3 Information

http://manewc.com/2008/02/07/as-3-loading-external-mp3-file-and-retrieving-id3-information/

Create a Simple and Attractive MP3 Player

http://flash.tutsplus.com/tutorials/actionscript/create-a-simple-and-attractive-mp3-player/

Coming up with the button skins and look-and-feel of the audio player took some time. Here are some design iterations:

]]> http://mocamobile.org/blog/?feed=rss2&p=172 http://mocamobile.org/blog/?p=163 http://mocamobile.org/blog/?p=163#comments Tue, 25 Aug 2009 21:49:23 +0000 katherine http://mocamobile.org/blog/?p=163 The goal is to embed the OpenMRS media viewer for encounters into the Moca module. Hence, when healthcare workers upload patient symptoms, images, audio, and video, the doctor can login to OpenMRS and view all this information within one screen for a smooth workflow.

Moca consists of a queue of pending cases from healthcare workers, and when the doctor clicks on one item, he/she will be brought to a page that contains a panel of patient symptoms and diagnosis options (on the left side) and the Flash media viewer (on the right side).

To make this panel for Moca in OpenMRS, I used HTML, CSS, and JSP. It displays the patient name and links to his/her patient dashboard in case the doctor wants to look up information on past patient visits. Then it lists question/answer response pairs according to the procedure defined by the doctor and downloaded to the G1 Android phone. These questions include “What is the size of the lesion?” or “Does anyone else in the family have this condition?” Although it would be easier to display the entire list on the screen at one time, I decided to use a scrolling box for scability because some of the procedures can get very long.

For the section where the doctor can write a diagnosis, I originally had it set up as the following (see below). This panel was designed using feedback from the doctors in the Batanes (in the Philippines). The radiologist said that he only provided findings/interpretation and other comments for an x-ray. He didn’t assign a diagnosis or treatment (that was the clinician’s role). However, for the teledermatology cases in Africa with Click Diagnostics, the specialists would provide a diagnosis and treatment. Because each pilot would involve different specialists with different medical applications, with the help of my team, I decided to instead make this panel customizable for each workgroup or pilot. Hence, radiologists in Manila would require 2 fields (findings/intepretation and other notes), while doctors in Africa for dermatology and opthamology would use 3 fields (diagnosis, treatment, and other notes).  I’m working on this custom interface, and will write about this soon.

The other parts of this interface came from my usability tests on doctors in the Philippines. For example, they wanted to see the name of the doctor writing the diagnosis to ensure proper identification of who made the diagnosis. Other options they wanted were to send a reply to the healthcare worker asking for a retake of the image and the ability to leave the case pending or to refer it to another specialist.

Taking all of these workflow requirements into account, I came up with an updated version of the Moca panel. I utilized tutorials on HTML forms and JSP servlets to learn how to post data from the HTML text fields to the OpenMRS server. This data is stored as a new Observation within the current Encounter for this particular patient in OpenMRS.

JSP Tutorial

http://www.jsptut.com/Forms.jsp

Invoking Servlets and JSP files within HTML forms

http://publib.boulder.ibm.com/infocenter/wasinfo/v4r0/index.jsp?topic=/com.ibm.websphere.v35.doc/wass_content/040204040102.html

Handling Form Data

http://www.apl.jhu.edu/~hall/java/Servlet-Tutorial/Servlet-Tutorial-Form-Data.html

More details on how this panel integrates with the media viewer will come in my next post.

We had a very productive 6 weeks there including software testing of Moca, usability testing, training local developers, recruiting new students to work on the project, and understanding the existing workflow at different levels of the healthcare system in the Philippines. We shared Moca through presentations with many groups such as University of Philippines Dean of the College of Medicine, PhilHealth Insurance Corporation President and CEO, Former President of Globe Telecommunications, Director of Strategy at Ayala, MIT Alumni Club of the Philippines, SMART telecommunications company business strategy team, Department of Science and Technology Joint Telemedicine Project Team, RTI, Tarlac State University, as well as countless doctors, nurses, and staff along the way.

Ted focused on developing a business plan for a venture-backed corporation to devlier and scale eHealth services in the country, while I focused on working with PhilHealth to push for reimbursement of telehealth services for all members (about 80% of the population).

Below is the summary of my experience in the Philippines that I wrote for the MIT Public Service Center.

http://web.mit.edu/kkuan87/Public/katherinekuan_report.pdf

Table of Contents:

1. Introduction
2. Project Summary
3. Community Impact
4. Personal Impact
5. Donor Recognition
6. Appendix
   Analysis of Philippine Healthcare System
   Summary of eHealth Services of the National Telehealth Center
   Matrix of eHealth and PhilHealth initiatives
   Policy Proposal for PhilHealth
   Sample Referral Forms for Workflow
   Usability Testing of Moca
   Usability Testing of OpenMRS Media Viewer
   Technical Support Manual for Moca
   Summary of Workflow in Batanes

This is a brief summary of the issues I ran into in developing this feature and what references I consulted to solve them.

In order for the image to be displayed and manipulated in the Flash application, it had to be retrieved from OpenMRS. I created an Encounter Servlet that would HTTP get the images from OpenMRS for a given unique encounter ID. The media viewer module page in OpenMRS loads the viewer by sending the Flash SWF file the ID number of the encounter it wants to be displayed. Then Flash does HTTP GET to the Encounter servlet to retrieve all images, creates internal classes to hold the images and then displays them. In order to load an image from a URL, I used the solution posted here.

Three Ways to Load an Image in Flex

http://ntt.cc/2008/03/09/tips-three-ways-to-load-an-image-file-in-flex.html

When I mentioned that I created internal classes, I essentially created an encounter class in Actionscript with generic file classes. A generic file class would hold metadata and the actual image/audio/video object. In order to build instances of these classes with the correct information, the Encounter Servlet on OpenMRS would send XML summarizing the encounter information and the obs ID numbers of the images/audio/video files in OpenMRS. I had trouble with XML parsing and being able to retrieve the fields, but solved it using the example provided here. The key part was realizing that you could access data in a tag heading using the @ symbol: e = new Encounter(xmlStr.@patientFirst,xmlStr.@patientLast,xmlStr.@patientID);

Adobe Flex Documentation on XML Class

http://livedocs.adobe.com/flex/2/langref/XML.html

I researched many sites to find a good image processing library for image manipulation in this viewer. There were some with licensing issues, but in general there were good options with just using the built-in libraries. Hence, I decided to go with these libraries, but if we find that the resolution isn’t good enough for medical diagnosis, replacing the zoom, brightness, contrast, and sharpness methods with another library would be pretty straightforward since the code is modular.

Here are the resources that I used to develop the OpenMRS media viewer.

Flex Interface Guide (FIG): The Pan | Zoom Component from the Adobe Developer Connection

http://www.adobe.com/devnet/flex/samples/fig_panzoom/

Image Manipulation in Flex by Andrew Alderson

http://www.insideria.com/2008/03/image-manipulation-in-flex.html

BitmapUtil for Changing Image Contrast and Brightness in Actionscript by Stan Reshetnyk

http://flashcrafter.org.ua/content/bitmaputil-changing-image-contrast-brightness-actionscript

Okay! Below are the screenshots of the media viewer Flash application, which is embedded in the OpenMRS media viewer module.

What you see when the application launches. You can see the toolbar at the bottom with sliders where you can zoom, change sharpness, change contrast, and change brightness of the image. You can also zoom or pan by using the mouse directly over the image like in Google Maps (use the mouse scroll button to zoom in/out).

You can also use the options menu to hide the bottom toolbar to allow more screen space for the image. Even without the toolbar you can still zoom/pan with the mouse.

Zooming way in to the upper part of the chest.

This is an example of teledermatology and how you can play with the contrast slider. Original picture:

After changing the contrast:

Example of teleradiology and you can manipulate brightness. Original picture:

Making it darker. The original of this particular image was already pretty good, but if it was too bright, this would be useful!

Making it brighter.

Example of opthamology and manipulating sharpness level. Original picture: (From http://www.mymedicalcareer.com.au/specialties/ophthalmology/)

After picture. Looks sharp right?!

Coming up: Proper thumbnail downscaling for the preview strip in the bottom toolbar, Moca panel on the left for patient symptoms to go along with the image

I will blog more about the trip in the coming posts, but I wanted to write about the extremely valuable input I received on the OpenMRS image viewer from the doctors and health professionals who I worked with. Below is a summary of the feedback I received when doing usability tests on them. I tried to gather research on the specific workflow that the media viewer would be used in so that I could tailor the system to integrate well with that workflow.

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

Sponsored by an MIT Public Service Center summer fellowship and Google Summer of Code with OpenMRS, I will be working on 3 main deliverables while in the Philippines:

- Test/Deploy Moca on the ground in the Philippines
- Business Proposal on telemedicine services for PhilHealth Insurance Corporation and the Philippines Department of Health
- Media viewer for images, audio, video in the OpenMRS electronic medical record system (see earlier blog posts)

It’s been quite an adventure and time just zooms by, so here goes my update!

PROMOTING LOCAL AWARENESS AND UTILIZATION OF OPENMRS

Soon after I arrived in Manila, I was able to pass on my knowledge of OpenMRS to the National Telehealth Center (NThC) team to help them to assess whether it would fit the needs of the Philippines healthcare system. Previously they weren’t familiar with the system at all, aside from what was mentioned in the Moca demo video. Hence, I delivered a powerpoint presentation to 3 doctors, 3 research assistants, and 1 nurse at the Telehealth Center about OpenMRS, its design architecture and data model, customization capabilities, and case studies of successful implementation sites. They received the information very well and are interested in learning more about how to create forms targeted for clinical health scenarios like dermatology and radiology. A possibility they are exploring is to deploy OpenMRS in the hospitals in the Philippines integrated with CHITS (a University-of-Philippines-designed electronic medical record system for midwives in local health clinics).

I spent the first two weeks or so working with Randy Fernandez, one of the research assistants, on installing OpenMRS onto the linux box in the center. Ultimately we were successful, so now the Telehealth Center has its own instance of OpenMRS! Yay! Hopefully Randy can now be the local expert who can help deploy OpenMRS in other sites in the country, or at least other research sites for now (like Ateneo University).

LEARN ABOUT LOCAL TELEHEALTH INITIATIVES

The Telehealth Center has many great initiatives going on. I will post a summary of them in my next blog entry, but I was able to learn about them through several key meetings during my first week in Manila. The first was at a joint meeting with University of Philippines Diliman (sister campus to UP Manila). It was an amazingly long meeting that took almost the whole workday but there was free lunch so it was all good! We discussed practically all the new telehealth projects in development by the programmers at NthC and UP Diliman: RxBox (suitcase-like box that contains ECG, tape measure, and other tools for basic biometric measurements and transmits it to a specialist via GPRS), nurse triage system (to receive/assign telemedicine referrals to specialists), optics projects, and knowledge base project. The team was enormous - about 26 people attended the meeting, but it still felt like we needed 15 more full-time developers! It takes quite an army to produce good software/hardware for telemedicine.

Another day, I attended the RTI meeting about CHITS (local electronic health record system for community health centers). It was another day-long event that involved people from the provincs of Tarlac interested in deploying CHIT in their province. I met Ramon Duremdes, a businessman from the SMART telco; Mike McKay from RTI who had traveled and worked with Baobab in Malawi as well as other projects in Africa; plus Joel Zapanta, the assistant to the governor of the Cavite province (I hope I got all their names/titles correct..). Alison Perez, the last man standing on CHITS (there used to be many programmers on CHITS but now there is only one left to support everything!), presented the in-depth technical details and demo of CHITS.

PROMOTING LOCAL AWARENESS OF MOCA

At the RTI meeting, I also presented Moca in a short talk to the attendees (about 20 people perhaps). I emphasized that our goal was to transmit medical data (images, video, audio) included information on the key strong points of Moca: seamless integration with OpenMRS the electronic medical record system, fully customizable procedures downloadable onto the phone, and connectivity even in remote areas with synchronization and packetization. I also covered use cases like cervical cancer screening, radiology, surgery follow-up, and prenatal ultrasound screening.

The other day, I went with Xands Bernal (Telehealth nurse) and Raymond Sarmiento (Telehealth doctor) to visit the radiology department in PGH (Philippines General Hopsital). We met with the radiologist Dr. Edilberto Joaquin Fragante, who has already been reading x-ray plates through telerefferal emails from Batanes (remote island without a radiologist, hundreds of km away). Basically instead of mailing the paper x-rays to Manila and waiting for a diagnosis by mail (which takes 2+ weeks), we can use teleradiology so that the radiology technician in Batanes can just take a snapshot of the paper xray and send it as an attached image of an email to the telehealth center to route to the radiologist. With Moca, we envision

RESEARCH FOR BUSINESS PROPOSAL FOR PHILHEALTH

To prep for my meeting my Ms. Gitch Diaz, Head of the Corporate Planning Department at PhilHealth, I did an extensive literature review of telemedicine practices in other countries. I must have read 40 or so articles. By referencing documents written by Dr. Alex Gavino and consulting with Alison Perez and Dr. Alvin Marcelo from the National Telehealth Center team, I compiled a 1-page summary of eHealth services from the NThC and how PhilHealth could benefit from them.

University of Philippines National Telehealth Center

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.

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 and support for healthworkers - doctors, nurses, midwives and health volunteers - through interactive 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: BuddyWork, 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

APN Settings for Phone using Globe SIM Card:
Name: Globe Internet (doesn’t matter)
APN: internet.globe.com.ph
Proxy: 203.177.042.214
Port: 8080
(No values for other fields)

APN Settings for Phone using SMART SIM Card:
APN: smart1
Proxy: 10.102.61.46
Port: 8080

APN Settings for Phone using SMART SIM Card:
APN: internet
Proxy: 10.102.61.46
Port: 8080

APN Settings for Phone using Sun SIM card:

APN: wap
Proxy: 202.138.159.78
Port: 8080

I also worked on creating a VM image of the Moca server to bring to the Philippines. I downloaded VMware Workstation, installed Ubuntu 9.04 on top of it, and am currently in the process of installing OpenMRS. After this, I will have to load in the Moca module into OpenMRS and then install the Moca Dispatch Server on it. I’m creating a document that will track this process step-by-step and will post it here when I’m done!

In addition, I’m leaving for the Philippines in 3 days, so I’m also doing some last-minute research on telemedicine, eHealth, EMRs, and eLearning. I plan to summarize the research I perform into executive summaries that can be presented to the stakeholders of a telemedicine business proposal for the country - PhilHealth Insurance Coproration and Department of Health to name a few. Below are some papers that I’ll be reading:

An information system and medical record to support HIV treatment in rural Haiti. Fraser HSF, Jazayeri D, Nevil P, Karacaoglu Y, Farmer PE, Lyon E Smith-Fawzi MK, Leandre F, Choi S, Mukherjee JS. British Medical Journal, 2004

Diagnostic Accuracy of Chest X-rays Acquired Using a Digital Camera for Low-Cost Teleradiology. Szot A, Jacobson F, Munn S, Jazayeri D, Nardell E, Harrison D Drosten R, Ohno-Machado L, Smeaton LM, Fraser HSF. . Int. J. Med. Inform., 2004

A web-based laboratory information system to improve quality of care of tuberculosis patients in Peru: functional requirements, implementation and usage statistics. Joaquin A Blaya , Sonya S Shin , Martin JA Yagui , Gloria Yale, Carmen Z Suarez , Luis L Asencios , J Peter Cegielski  and Hamish S Fraser. BMC Medical Informatics and Decision Making 2007

Medical information systems: A foundation for healthcare technologies in developing countries. Gari D Clifford, Joaquin A Blaya, Rachel Hall-Clifford, Hamish SF Fraser, BioMedical Engineering OnLin,  2008

Design of Health Care Technologies for the Developing World. Robert A. Malkin,  Annu. Rev. Biomed. Eng. 2007

The day opened with an introduction of OpenMRS and its vision by co-founder Hamish Fraser. (See slides posted here: http://www.slideshare.net/hamishfraser/openmrs-meeting-boston-introduction). We also had presentations on the current capabilities of OpenMRS as well as deployments (in Kenya, Rwanda, South Africa, Zimbabwe, and Mozambique). In the afternoon, we had breakout sessions about OpenMRS deployment in the field, OpenMRS API and module development, standards/integration of OpenMRS, and clinical decision support. Overall, the meeting was very productive and many sources of collaboration were identified among all the people involved. For example, for myself, I was able to meet many OpenMRS developers for help on my GSOC project, as well as experienced implementers of OpenMRS (for help on research with my research fellowship in the Philippines this summer).

To prepare for my trip to the Philippines in a couple of weeks, I also had a conference call with the University of Philippines team about technical requirements for the pilot and the workflow of the pilot. In addition, I also worked on learning how to setup/install OpenMRS, Tomcat, MySQL so that I would be able to help get the technical team in the Philippines get Moca up and running.

As for my GSOC project, this week I worked on integrating my Flash application with OpenMRS. I made an encounter servlet in OpenMRS to pass encounter information (patient name, ID, image/audio/video obs IDs, and dates) to the Flash application. It didn’t quite work though, so i backed up and tried something simplier. I managed to get successful HTTP get/post requests of text data from Flex to OpenMRS working. From my understanding, passing a Java object into Flex to be converted into an AS3 object is done with Flash remoting, which is a proprietary package. After examining the problem further, it seems that we don’t need the full object to be passed into Flex and text would work just as well. Hence I created an XML schema with a parser for passing encounter data between Flash and Java:

<?xml version=”1.0″ encoding=”utf-8″?>
<encounter patientID=”1010″ patientFirst=”John” patientLast=”Smith”>
<genericFile type=”image” obsID=”39″ summary=”This x-ray is abnormal. Patient could have TB.”>
<annotation text=”This appears abnormal” x=”10″ y=”10″/>
<annotation text=”This also is abnormal” x=”20″ y=”20″/>
<annotation text=”This could be TB” x=”30″ y=”30″/>
</genericFile>
<genericFile type=”audio” obsID=”45″ summary=”The x-ray appears normal.”>
<annotation text=”This is normal” x=”10″ y=”10″/>
</genericFile>
</encounter>