Dube, Mandy
Greetings all!
Internet usage for health related programs has grown tremendously as evidenced through publications, reports and occurrences within public health programs. The exponential growth in the use of the internet is self-evident. Many mHealth projects have been developed not only to leverage the availability of the internet but also mobile phones as well. The BID Initiative hopes to harness the use of phones and the internet to develop a robust immunization registry that will allow health care providers to access immunization data at the click of a button or two! However, the use of internet comes with a cost and Governments may not be in a position to reimburse this cost to the health care provider.
We are wondering how health care providers can be encouraged to use internet services provided at their cost to record and report immunization data. This would reduce reliance on government’s ability to provide money for internet connectivity.
If anyone has any experience on health care provider driven internet use for work, please do share with us.
Best wishes,
Mandy
DZENOWAGIS, Joan Helen
Mandy,
Despite the worthiness of the goal regarding immunization data, there are very serious problems with this scenario. Data ownership, reliability and controls; access and security, sustainability to name a few. Resource constraints may sometimes force the use of insecure platforms and services for communications and storage, which already presents a problem. But fundamentally a government’s inability to pay local internet access charges cannot be used as justification for exchanging data via private internet accounts paid for by individual workers. Once governments decide they need the data then there is normally a way found to pay for gathering, transmitting and analyzing it, and for securing it properly. This is part of prioritizing health services and systems improvements. It is a core part of national eHealth strategies/ plans to specify the infrastructure and other components and the budget required to meet information and communication needs for programs, geographies or populations. The problem has to be solved at the national or regional level if these are government registries you are trying to build. If health workers are government employees they must operate within those bounds, and you shouldn’t propose otherwise.
Joan Dzenowagis
Dr Joan Dzenowagis
eHealth Unit
World Health Organization
20 Ave Appia, CH-1211
Geneva 27, Switzerland
tel. +41 (22) 791-2504
cell +41 (79) 217-3469
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Dube, Mandy
Dr. Dzenowagis,
Thank you so much for your input. The BID Initiative will be working with the government to provide devices on which the data will be collected, stored and transmitted via the immunization registry system. However, the issue of transmission outside of the system (for example if someonewants to submit a report via email) might indeed pose a challenge because to the best of my knowledge government workers skill do not have official government email accounts. (I suspect this may be remedied when the e-governance project is rolled out)
So the understanding am getting from your guidance is that such data should only be transmitted over an internet connectivity pathway that is paid for and secured by government and that even if a government employee was using an official email account, they cannot transmit that data at an internet café or by using a personal mobile data device. Is this an accurate understanding? Any further policy and practice guidance in this regard will be highly appreciated.
Best wishes,
Mandy
Hozumi, Dai
Thank for the interesting discussion topic.
For me, in order to think further on this issue, I would like to look at the issue from several different angles; legal, ethical, technical, and economical perspectives come to mind.
Legal: What kind of legal framework can a country/ministry of health use to ask the donation of private assets for the transmission of government or public data? Demanding that all health workers consistently transmit the data using their private time/connection is basically same as reduced salary (even though the amount might be small). If mandating the use of private connection is not legally prohibitive, then the system needs to rely on the goodwill of health workers to voluntary contribute their network time. In this case, what kind of legal protection will you provide to health workers when health workers are blamed for privacy violation or misuse of the data? Or how will you punish them?
Ethical: Will the use of private network connection expose patients to possible privacy concerns? Or do you limit the type of data to be transmitted through the privately contributed network use? What about the storage of transmitted data? We have numerous reports on the government computers hacked and confidential information is breached. Use of private devices to transmit the data is probably discouraged to handle sensitive information such as health data.
Technical: how mush consistency and regularity the ministry can demand on health workers to report data when relying on private network use? Online surveys, even if some financial incentive is given, usually have very low response rate and similar level of reporting rate can be expected from health workers and it is likely that the reporting rate declines overtime. Is that OK with routine reporting? It might make more sense to rely on use of private network connection for episodic data (such as reporting of an outbreak of flu) that can be established as emergency among all health workers?
Economical: when a single purchaser negotiate the bulk purchase price of network time, it is likely that the ministry might be able to negotiate for favorable pricing from service providers (unless there is corruption or other technical reason). It will be very informative if someone can provide a cost analysis showing the percentage of network transmission cost among the total cost of ownership of digital health information system. It will also be informative to learn what are price negotiation strategies that the ministries of health have taken. It might be that the discounted internet connection by the government to offer to health workers for their public and private use might be cost economical depending on the perceived benefits of such services among health workers and the actual cost.
Dai
Dai Hozumi
Director, Public Health Strategy and Analytics
PATH
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Peloso, Liz
Thank you all for the interesting discussion.
First I want to clarify that it is not the position of the BID Initiative to have health workers bear the cost burden of activities required for their work. So for example, we would not expect them to send their reports at their own costs.
Despite this, there are some interesting “grey” areas which bear further discussion. Things are often not as simple as they seem.
As with all emerging technologies and significant changes, often the technology becomes available before there are adequate government policy and legislation to provide guidance.
We need to ensure we differentiate the transmission of aggregate data and that of personal health information (PHI). Regarding the transmission of personal health information (that is anything with names and identifiers associated with the health data- for example the result of a lab test, or even the Baby X is overdue for Measles) our approach at the BID Initiative is that this data must be protected according to the laws or policy of the country. In the absence of any law or policy (which is the case in many developing countries) we will develop to a very high bar- one that would meet the general guidance or legislation in countries where it does exist (so for example HIPPA in the US). These restrictions in general would prohibit any solution that had a nurse transmitting data from an internet café or even using their own device as it is too difficult to secure properly.
Some of the grey area regarding data transmission is around the submission of aggregate reports. In some areas, the government does not reimburse the health care workers for the travel to submit their reports. While we are not condoning that, if I were a health worker sending that report via email (even if I pay for it myself) would save me both time and money. Seems tempting. If we provide the means to do this- does that make the broader problem worse (as now the pressure on the government is lower to address compensating the health workers to deliver the reports). Do you allow that? Or does this encourage the government to pay for the electronic transmission as a faster and more cost effective alternative they may be able to afford?
One thing we are doing at the BID Initiative is encouraging several cost effective means of accessing peer support and encouraging the dissemination of good ideas and practices. One way that has been successful to date is through the use of WhatsApp. Nurses can sign up to a WhatsApp group of other immunization nurses in their area. This allows them to exchange ideas or comments, and has even proven valuable in helping to address situations such as stock shortages. Participation is entirely voluntary, and we do not reimburse them for their internet usage to send the messages (most of them are already using the application in their daily lives and have internet bundles, plus it would be virtually impossible to administer any simple repayment scheme). Again, is this a slippery slope? Will this grow into a mandatory step in a process for addressing a clinic issue? Is it any different than expecting the nurse to call from their own phone? Few health facilities in rural areas have a dedicated clinic phone.
As things such as our WhatsApp groups continue to flourish and possibly expand, it will be interesting to hear if others have experience in this already and to see what direction it may go.
Liz Peloso
Better Immunization Data Initiative- Global Director
Street:Trinity Place Alick Nhkata Rd | Lusaka | Zambia
Tel: +260 974 607 136 (Zambia) | +255 782 933 682 (Tanzania) | Skype: liz.peloso
Web:www.path.org | http://bidinitiative.org/
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From: bidini...@googlegroups.com [mailto:bidini...@googlegroups.com]
On Behalf Of Dube, Mandy
Sent: Thursday, July 02, 2015 4:05 PM
To: DZENOWAGIS, Joan Helen; bidini...@googlegroups.com
Subject: RE: Encouraging health workers to use internet for work at own cost
Dr. Dzenowagis,
Thank you so much for your input. The BID Initiative will be working with the government to provide devices on which the data will be collected, stored and transmitted via the immunization registry system. However, the issue of transmission outside of the system (for example if someone wants to submit a report via email) might indeed pose a challenge because to the best of my knowledge government workers skill do not have official government email accounts. (I suspect this may be remedied when the e-governance project is rolled out)
So the understanding am getting from your guidance is that such data should only be transmitted over an internet connectivity pathway that is paid for and secured by government and that even if a government employee was using an official email account, they cannot transmit that data at an internet café or by using a personal mobile data device. Is this an accurate understanding? Any further policy and practice guidance in this regard will be highly appreciated.
Best wishes,
Mandy
From: DZENOWAGIS, Joan Helen [mailto:dzeno...@who.int]
Sent: Thursday, July 02, 2015 12:09 PM
To: Dube, Mandy; bidini...@googlegroups.com
Subject: RE: Encouraging health workers to use internet for work at own cost
Mandy,
Despite the worthiness of the goal regarding immunization data, there are very serious problems with this scenario. Data ownership, reliability and controls; access and security, sustainability to name a few. Resource constraints may sometimes force the use of insecure platforms and services for communications and storage, which already presents a problem. But fundamentally a government’s inability to pay local internet access charges cannot be used as justification for exchanging data via private internet accounts paid for by individual workers. Once governments decide they need the data then there is normally a way found to pay for gathering, transmitting and analysing it, and for securing it properly. This is part of prioritizing health services and systems improvements. It is a core part of national eHealth strategies/ plans to specify the infrastructure and other components and the budget required to meet information and communication needs for programs, geographies or populations. The problem has to be solved at the national or regional level if these are government registries you are trying to build. If health workers are government employees they must operate within those bounds, and you shouldn’t propose otherwise.
.
To view this discussion on the web visit https://groups.google.com/d/msgid/bidinitiative/BN3PR0701MB17199ACBEC67BFB2D531CDB7D8970%40BN3PR0701MB1719.namprd07.prod.outlook.com.
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