Introduction: eHealth is described by the World Health Organization (WHO) as the use of information and communication technologies (ICT) for health. The use of eHealth closes the gaps in terms of geographical barriers, time constraints, lack of healthcare professionals in healthcare and service delivery. This study is important as it provides the current landscape and status of eHealth in the Philippines. Hence, policymakers, program implementors as well as other stakeholders, including the public, will be able to know which eHealth and telemedicine services and products are available in various sectors of society, either private or government, what are the existing gaps in eHealth, and the trajectory in the future based on the guide of the World Health Organization - International Telecommunication Union (WHO-ITU). Objectives: The objectives of the study are 1) to provide a landscape of eHealth in the Philippines since its start in the country; 2) to identify programs, services, and technology innovations implemented in the country on eHealth and telemedicine; and 3) to identify Philippine systems that correspond to the eHealth components laid out by WHO-ITU for a successful implementation of eHealth at a national level. Methods: We conducted an extensive review of the literature and key informant interviews with eHealth experts in the Philippines. The literature review covered research and studies, gray literature, peer-reviewed journals, databases, and government statistics. The years covered in this study span a total of 24 years from 1997, which is the beginning of the information management system as an institutional approach in the country, to 2020. The assessment tool was based on the framework provided by the WHO-ITU on the context for eHealth development. Results: The National Telehealth Center (NTHC) of the Philippines began with projects for 1) eLearning, 2) eMedicine, 3) eRecords, 4) eHealth Policy and Advocacy, and 5) eSurveillance. Telemedicine services are now being offered by hospitals in the country. This shows eHealth services, in general, and telemedicine are being utilized in not only targeting the poor, but also in giving faster, more efficient, and equally effective virtual health services to the general public, even the private-pay patients. Conclusion The sustainability of eHealth in the Philippines still depends on the national effort to institutionalize an eHealth structure and eHealth system where the various components are interrelated.
Telemedicine ; Health Services

Background: eHealth is the use of information and communication technologies (ICT) for health. It helps in improving the flow of information, through electronic means, in support of the delivery of health services, and the management of health systems. eHealth is used as the strategic context and tool in achieving population health, improved health system status, and socio-economic development goals. Objectives: This study is aimed at looking at the Philippine National eHealth Strategy, particularly the components of Terminology Standards and Interoperability concerning the eHealth strategy in the Philippines, and to assess the barriers and gaps in the integration of these two components. Methods: This study used secondary literature, internet search, Philippine laws, administrative orders, memorandum circulars, and grey literature to discourse terminology standards and interoperability in the Philippine eHealth system, and issues and gaps related to these components that may impede the delivery of Universal Health Coverage in the country. Results: The current Philippine National eHealth strategy includes the following sector governance, legislation, policy and compliance, eHealth solution (i.e., services and applications), strategy and investment, infrastructure (government), human resources, and standards and interoperability. Philippine Health Information Exchange (PHIE) is a software platform in the country that aims to connect many isolated electronic health systems. The proposed interoperability layer across health systems and services in the Philippines includes Patient’s Primary Healthcare Consultation at the Rural Health Unit, health research, legal information, patient healthcare at tertiary hospital, and health insurance claims. The study results showed that issues and gaps related to the interoperability of eHealth in the Philippines include technical issues such as lack of common semantics, lack of an institutional mechanism to regulate EMR, lack of incentives among eHealth providers and stakeholders to adopt standards for interoperability. Conclusion The effort of the Philippines to achieve interoperability and standards in eHealth goals can be characterized as a work in progress. The government, private sector, physician, patient, and other stakeholders are deemed to continuously develop a shared vision and interoperate under a standardized guide as eHealth is a complex endeavor that covers many aspects.
Telemedicine

Introduction: The Hearing for Life (HeLe) is a novel newborn hearing screening device initially designed according to specifications of clinicians of the Philippine National Ear Institute (PNEI). Unfortunately, targeted end-users, rural health workers, had difficulty using it. This research applied the user-centered design (UCD) methodology involving rural health workers in recommending design, content, and function requirements for HeLe. Objectives: This study aims to 1) describe how UCD was applied in a time-limited and resource-constrained environment, 2) assess the usability of the design prototypes, and 3) recommend design, content, and function requirements for HeLe. Methods: This research is a descriptive study using mixed methods. Six rural health units (RHU) involved in the HeLe research program were purposively selected for the study. There were 30 participants included, five health care workers per RHU. Applying the UCD method, the study had three phases: 1) user profiling (where participants accomplished a survey questionnaire, 2) inspiration phase (focus group discussions, workflow analysis, and interviews with a technical expert were conducted), and 3) ideation phase (designing and assessment of prototypes were done). Results: Participatory methods and structured procedures (i.e., card sorting, MoSCoW matrix prototyping, etc.) were applied to help determine and prioritize user requirements and elicit user feedback. These methods were chosen considering the time and resource constraints in the RHU. The prototype's System Usability Scale (SUS) score (81.94) was higher than the SUS score previously obtained (68) from the older version of the interface. Accuracy, durability, in-app instructions, feedback, and an easily understood interface were the most requested requirements for the telemedicine device. The need for the technology to be aligned with the RHU's workflow and available resources was highlighted in the focus group discussions. Conclusions The study documents practices and lessons learned in applying UCD methodology in design and development that have been demonstrated to improve usability of the device. The involvement of the users surfaced in the design, content, and functional requirements which can guide future iterations of HeLe and contribute to better understanding of ways to develop user-friendly telemedicine devices in the Philippines. This paper emphasizes that users should be involved in the entire process and not just recipients of the technology.
User-Centered Design ; Digital Technology ; Telemedicine

Introduction: There is increasing interest in innovation development and management in the Philippines, especially in the last decade. In the advocacy for universal hearing health, the HeLe, “Hearing for Life’’ Research Program was implemented. HeLe developed novel telehealth technologies and field tested a proof-of-concept service delivery model to improve provision of newborn hearing screening and intervention services in the Philippines. Objective: As the HeLe research period concludes, this appraisal was organized to document and assess the health information technology systems of the HeLe. Methods: The evaluation follows the elements of the Centers for Disease Control and Prevention (CDC) guidelines for evaluation of public health surveillance systems. It centers on the status of the eHealth-based components of the HeLe NHS interventions: HeLe NHS module in the Community Health Information Tracking System (CHITS) electronic medical records system, the Tele-Audiology module in National Telehealth System (NTS), and the HeLe NHS registry. The evaluation is based on interviews of key HeLe research staff and documentation review. Results: The HeLe system has a stable, SQL-Server-based architecture. It is a secure, web-based system with clean separation of back-end database and front-end Web, using Secure Socket Layer (SSL) technology. Standardization of data via mapping ensures reliable, comparable measures. HeLe demonstrates that NHS data collected by the HeLe NHS device can be sent to, stored in, and extracted from the CHITS electronic medical record system and exchanged across platforms. Where actual patient and NHS data were available, this HeLe system is validated to be efficacious to capture and seamlessly exchange data across various eHealth platforms. These eHealth technologies are described to be at Technology Readiness Level 5, “technologies are validated in a relevant environment”. The HeLe program, however, needs to address completeness in documentation as a standard practice, if only to ensure better management of risks introduced by novel eHealth systems in patient care. The CDC public health surveillance checklist used for this assessment is useful in identifying gaps in research management for the HeLe inventors. It is recommended to be incorporated to be standard and implemented early in the next iteration of the HeLe research. Conclusions Overall, the HeLe technologies, in this initial stage of research, have achieved the purpose for which they were developed. As a novel technologybased NHS system, HeLe is a potentially powerful tool to assist in monitoring newborn hearing disease caseloads by community-based primary care clinics, NHS facilities, and hospitals that provide definitive medical services. As other health systems strengthening reforms take root in the Philippines, secure exchange of data electronically across the country would depend on sound technologies, including those used in hearing health. This paper can be instructive to the emerging research community in the eHealth and biomedical development space especially in resource-challenged settings. Likewise, lessons can reinforce institutional support from research agencies, clinicians, and state/county or subnational health departments for policy and resource mobilization to better manage those identified with congenital hearing loss.
Telemedicine ; Electronic Health Records

Introduction: Access to appropriate and timely care underpins the Republic Act 9707 or the Universal Newborn Hearing Screening and Intervention Act of 2009. However, less than 10% of babies born every year have been screened for hearing loss. The Hearing for Life (HeLe) research program aims to increase the rate of newborn hearing screening (NHS) nationwide through the development and deployment of novel digital health or eHealth technologies in government rural primary care health centers (PCHC). The HeLe is also built on the global call for increased and systematic use of eHealth to strengthen health systems. Effectiveness of eHealth innovations requires acknowledgment of the product’s life cycle; one consideration is organizational readiness at this development stage of the HeLe. Objective: This study assessed readiness of the eight PCHC selected to use the HeLe technologies. Methods: This research utilized the Khoja-Durrani-Scott (KDS) eHealth evaluation tool to assess the PCHC’s readiness level prior to the implementation of HeLe. The KDS tool was distributed through a self-administered survey; data was analyzed using descriptive statistics. Readiness is measured in terms of seven dimensions or outcomes resulting from the use of the HeLe technologies. Results: The study revealed that the eight PCHC were most to least ready, in decreasing order, in the following areas: Ethical, Health, Technology, Social & Cultural, Readiness & Change Management, as well as Economic, and Policy outcomes. The study affirms the PCHCs’ value for equity in health care, i.e., providing accessible NHS services in the community setting closest to where the families and their newborns are. Likewise, results confirm the PCHC staff’s preparedness for another set of innovations, through agreement with statements on Technology, Social & Cultural as well as Readiness & Change Management parameters. Conclusions The results informed the training and technical support strategies to be implemented by the HeLe program proponents. However, even in this early development phase of the HeLe technologies, the PCHC are already concerned with how to sustain NHS services after the research. Fully aware that the HeLe ICT tools need to be maintained and upgraded, the PCHC views that economic and policy support should also be in place to ensure continuous delivery of the ICT-enabled NHS services. While results are illustrative, usefulness is limited by the small sample size and character of the study sites. Nevertheless, social dimensions still have to be carefully considered as innovative NHS tools are introduced to primary care health workers nationwide. Researchers have to be deliberate in working with broader health systems and policy advocacy efforts to allow novel NHS technologies to be smoothly introduced at the community level and frontlines of care.
Telemedicine ; Health ; Technology ; Change Management ; Policy ; Ethics ; Primary Health Care

Objectives: We present in this article the design and evaluation of a blended learning approach for training community healthcare providers in performing newborn hearing screening (NHS). Methods: We developed a blended learning course for training community healthcare providers on eHealth-enabled NHS, following Bloom’s revised taxonomy of educational objectives. The training involved three components: computer-based training (CBT), face-to-face (FTF) training, and on-site coaching. We used surveys and post-training interviews following Level 1 Kirkpatrick’s training evaluation model to get initial feedback on the training program. Results: Thirty-one community healthcare providers from five rural health units and a private hearing screening center, with a mean age of 42.2 ± 12.0 years, participated in the pilot. 93.5% of the participants agreed that the program content met stated objectives and was relevant to their practice. The length of the course was perceived to be adequate. Overall satisfaction with the program was rated at 8.5 ± 0.9 (with ten as the highest). The majority expressed that the CBT and FTF course were satisfactory at 93.5% and 100%, respectively. All participants agreed that the course enhanced their knowledge of newborn hearing screening and telehealth. Positive reviews were received from participants on the use of CBT to improve theoretical knowledge before FTF training. Participants declared that FTF training and on-site coaching helped improved NHS skills and implementation. Conclusion Competent community healthcare providers are critical to strengthening the performance of the health system, and advances in the education and technology sectors offer promising potential in upskilling local healthcare providers. The increasing access of Filipino healthcare providers to improved information and communications technology (ICT) is a significant catalyst for pedagogical innovation, like the use of blended learning in the continuous professional development of health practitioners. As ICTs gradually penetrate the health sector, the challenge we now face is not whether but how we can use innovations in education strategies to benefit healthcare providers.
Infant, Newborn ; Telemedicine

Objective: This pilot human trial demonstrates the ability of the investigational newborn hearing screening device to provide acoustic stimulation to produce evoked potentials, as well as its ability to capture and acquire auditory evoked potentials, especially the auditory brainstem response (ABR) wave V. This pilot study also demonstrates the ease of recognizing and identifying ABR waves in the graphical presentation of the evoked potentials over time. Methods: Fourteen normal-hearing adults or a total of twenty-eight (28) normal-hearing adult ears underwent auditory brainstem response testing using the investigational hearing screening device. A commercially available auditory brainstem response detection device was used to confirm that the acquired ABR waves of the investigational device are normal. The ABR waves displayed by the investigation device were also reviewed by the clinical audiologists to determine their recognizability and identifiability. Results: The pilot trial demonstrates the ability of the investigational newborn hearing screening device in providing acoustic stimulation to produce evoked potentials, and in acquiring and capturing ABR waves, specifically the wave V, among normal-hearing adult ears. The clinical audiologists recognized and identified the ABR wave V among the evoked potentials at 40dB, 60dB, and 80dB acoustic stimulation. About eighty-nine percent (89.2%) of all ears tested had identifiable and recognizable wave V upon acoustic stimulation at 40dB. Conclusion The investigational hearing screening device: (1) can provide acoustic stimulation to produce evoked potentials, (2) can accurately capture and acquire these evoked potentials, (3) can present these evoked potentials in a voltage per time graphical display which an audiologist and trained HCP can easily read and interpret (diagnostic ABR), and (4) can present wave V auditory brainstem potentials that can be easily identified by an audiologist and trained HCP (screening ABR).
Infant, Newborn ; Acoustics ; Pilot Projects

Objectives: This study explores the potential of the HeLe Service Delivery Model, a community-based newborn hearing screening (NHS) program supported by a web-based referral system, in improving provision of hearing care services. Methods: This prospective observational study evaluated the HeLe Service Delivery Model based on records review and user perspectives. We collected system usage logs from July to October 2018 and data on patient outcomes. Semi-structured interviews and review of field reports were conducted to identify implementation challenges and facilitating factors. Descriptive statistics and content analysis were used to analyze quantitative and qualitative data, respectively. Results: Six hundred ninety-two (692) babies were screened: 110 in the RHUs and 582 in the Category A NHS hospital. Mean age at screening was 1.4±1.05 months for those screened in the RHU and 0.46±0.74 month for those in the Category A site. 47.3% of babies screened at the RHU were ≤1 month old in contrast to 86.6% in the Category A hospital. A total of 10 babies (1.4%) received a positive NHS result. Eight of these ten patients were referred via the NHS Appointment and Referral System; seven were confirmed to have bilateral profound hearing loss, while one patient missed his confirmatory testing appointment. The average wait time between screening and confirmatory testing was 17.1±14.5 days. Facilitating factors for NHS implementation include the presence of champions, early technology adopters, legislations, and capacity-building programs. Challenges identified include perceived inconvenience in using information systems, cost concerns for the patients, costly hearing screening equipment, and unstable internet connectivity. The lack of nearby facilities providing NHS diagnostic and intervention services remains a major block in ensuring early diagnosis and management of hearing loss in the community. Conclusion The eHealth-enabled HeLe Service Delivery Model for NHS is promising. It addresses the challenges and needs of community-based NHS by establishing a healthcare provider network for NHS in the locale, providing a capacity-building program to train NHS screeners, and deploying health information systems that allows for documentation, web-based referral and tracking of NHS patients. The model has the potential to be implemented on a larger scale — a deliberate step towards universal hearing health for all Filipinos.
Neonatal Screening ; Hearing Loss ; Health Information Systems ; Community Health Services ; Delivery of Health Care

Background and Introduction. The RxBox is a telemedicine device that measures and transmits vital signs to remote experts. It has been deployed to primary care health centers (PCHC) in the Philippines serving disadvantaged populations, to decrease morbidity and mortality due to common diseases and poor access to care. Factors affecting its adoption by healthcare workers is unknown.

Materials and Methods. The study determined social and behavioral factors that affect adoption of a telemedicine device into the clinical workflow using the Unified Theory of Acceptance and Use of Technology (UTAUT) framework. This is a mixed methods research using review of records, survey and focused group discussions.

Results and Discussion. RxBox telemedicine devices were installed in 79 primary care health centers (PCHC) and were used a total of 15,705 times within the study period. An ordinary least squares regression analysis using the combined site and individual-level data showed that among the UTAUT parameters, only compatibility, facilitating conditions, and social factors have significant relationships with intent-to-use of the RxBox. The innovation assisted primary care health workers in their clinical responsibilities, improved the stature of their PCHC in the community, and helped in the care for patients. Training and technology support after deployment as well as encouragement by peer and champions (the PCHC physician, local government leaders) reinforced continuous use after training. Users described the experienced improvements in quality of services provided by the PCHC and the consequent benefits to their patients.

Conclusions. These factors should be accounted for in designing strategies to reinforce health workers' attitudes and enhance support towards acceptance and use of novel telemedicine devices into clinical routine in local health centers. Lessons are immediately useful for local leaders in low- and lower middle-income countries that suffer disproportionately from unnecessary maternal deaths and mortality due to non-communicable diseases. This contributes to the body of knowledge and should bolster national-level advocacy to institute an enabling policy on telehealth Information Communication Technology (ICT) and use of Filipino innovations towards health systems strengthening. Results can be used by implementers, evaluators, and regulators of health ICT, especially in resource-poor settings. Likewise, the study can encourage more research in the field to spur more dynamic local health ICT and biomedical device industries.

Objective: Newborn hearing screening (NHS) in the Philippines has been mandated by law since 2009. However, lack of awareness and knowledge about NHS remains a challenge, especially among healthcare providers. This paper describes the pilot implementation of a computer-based training (CBT) course on NHS and teleaudiology among primary healthcare providers (PHCPs) in rural Philippines. Methods: A four-module web-based training course on newborn hearing screening and teleaudiology in an online learning management system (LMS) was field-tested among PHCPs from eight rural communities in the Philippines. Participants were given four weeks to complete the course. Results: Forty-two PHCPs participated in the CBT. Thirty-four (81%) completed the whole course (mean attrition rate of 4.8% per module) at a mean duration of 10.2 days. Baseline data shows that participants had no NHS training, although the majority (83%) had information and communications technology (ICT) training. Comparison of preand post-test mean scores showed a 24.0% (p<0.001) significant increase in the post-test in all four modules. Passing rates (i.e., score ≥70%) from pre- to post-test increased by 54.6% (range: 38-80% increase). Usability of the CBT was rated high with a mean score of 4.32 out of 5 (range: 4.13 to 4.47), covering all eight parameters. Participants expressed general satisfaction and a positive attitude on CBT to improve knowledge on NHS and teleaudiology. Conclusion Even in low resource settings where gaps in ICT infrastructure exist, eLearning can be used as an alternative approach to increase awareness and support training of healthcare providers on newborn hearing screening.
Infant, Newborn ; Telemedicine