Security Issues in Health Information System


Security and confidentiality are major issues in any Information System may it be in healthcare, transportation, banking or business and whether the system is electronic or paper-based.

This article lists all possible questions that should be answered in order to identify all possible risks of information and security breach.


  1. What is the flow of the system? What step/s in the system flow that protects data?
  2. What are the data/information being gathered? How sensitive are they?
  3. How are the information acquired?
  4. Who gives the information?
  5. Is the system closed to a group or open to all?
  6. How do you verify that the person who inputs the data is part of the group?
  7. Should I input any username and password in order to get inside the system?
  8. How are the data stored?
  9. How secure is the system?
  10. Is the website secured?
  11. Is the website encrypted?
  12. Are your security policies in line with the Data Privacy Act of 2012?
  13. Do you have Information Manager?
  14. In case of security breach, what are your next steps?
  15. In case of data theft or loss, what are your next steps?
  16. What is your plan to prevent data loss or theft?
  17. What is your data security plan?
  18. How do you monitor data breach or hacking?

These are some questions that anyone, who wants to implement a health information system, should answer to help identify security risk.


Implementation of Electronic Medical Record. Far from Ideal

In my previous blog article about electronic medical record last year entitled “Electronic Medical Record: The Now and Future of Healthcare Service”(1)

I summed up the barriers in the implementation of EMR into 5 factors:

  1. Acceptability or the lack of it of end-users most especially the doctors
  2. High cost of the system
  3. Heterogeneity of users
  4. Complexity of functionalities of EMRs
  5. Security and Confidentiality


One year after that article, my views on why electronic medical record is still far from full implementation in the country remain the same.

Barriers in the Implementation of EMRs

The Non-acceptance of doctors to use EMR is a mixture of factors that stem from the fact that EMR is a new technology.

  1. Time:

– Time to learn the system

– Time to enter data

– EMR eats up time supposedly for patients

– Time to convert records

In an article by Menachemi and Collum (2), EMR causes disruption of workflow of medical staff leading to temporary loss in productivity. Since EMR is a new technology, it requires time for users to get used to it. It needs training that requires time as well. A busy doctor does not have time to learn new system especially if the benefits of such new technology are not known to him. Like in any other system, the more you use the system, the faster you get to use it. Doctors are not willing sacrifice their time especially with their patients to learn new technology. Majority of doctors in the Philippines are still using paper-based medical record. With their numerous patients, it is difficult to know when and where to begin converting the paper-based database into electronic one. In addition, not only doctors but also nurses feel that EMR is taking their time with the patients. Kossman et al reported that nurses feel that EMR slows down their activities, interferes with their ability to efficiently manage time and decreases time with patients (4).


  1. Security and Confidentiality. With numerous news that reported online hacking of different international and local government agencies [e.g US Army Website Hacking (3), COMELEC Website Hacking (4)], people are very concerned with data cybersecurity. Security and Confidentiality has been a major reason for doctors not to start implementation of EMR. In every discussion about EMR, security and confidentiality has always been questioned.




3. Change Process. Healthcare providers have strong resistance to change (6), leading to non-implementation of EMRs. One of the reasons for this is that many healthcare providers are not aware of the benefits of EMRs. Another reason is the lack of political will, legislation, national policy to use of EMR. People are still not using EMR because they are not mandated to use it. At present, there is still no law or policy that requires all doctors to use EMR in their clinics.



  1. Electronic Medical Record: The Now and Future of Healthcare Service
  2. Menachemi, T. Collum. Benefits and drawbacks of electronic health record systems. Risk Management and Healthcare Policy. May 2011 DOI: 10.2147/RMHP.S12985)
  3. Kossman, S. Scheidenhelm. Nurses’ Perceptions of the Impact of Electronic Health Records on Work and Patient Outcomes. CIN: Computers, Informatics, Nursing 2008. Vol. 26, No. 2, 69–77
  6. Electonic Health Records. AManual for Developing countries. World Health Organization 2006

Consumer Adoption of Personal Health Record Systems: A Self-Determination Theory Perspective: a journal appraisal by AMagno

Authors: Vahid Assadi, PhD; Khaled Hassanein, PhD

(J Med Internet Res 2017;19(7):e270) doi:10.2196/jmir.7721

To quote ” A personal health record (PHR) system is an information system that comprises data as well as supporting tools and functionalities related to an individual’s health”.

It is also described by Markle Foundation as ““An electronic application through which individuals can access, manage, and share their health information, and that of others for whom they are authorized, in a private, secure, and confidential environment.”

the main objectives of this article are:

  1. develop and validate a model to understand how a person’s perceptions of
    one’s health (self-determination) would influence their intentions to adopt
    PHR systems, and
  2. (2) assess the impacts of the environmental factor of physician autonomy support and the behavioral factor of individuals’ autonomous causality orientation on their
    perceptions of being self-determined in their health management behavior.

Figure 1: Proposed Theoretical Model of the studySDT



Data collection was done through an online survey (cross-sectional survey) to gather measurement scales for the model factors as well as gather individual characteristics (eg, demographics, details of previous computer and Internet use) and control variables.

Subjects: Individuals with no experience using personal health record (PHR) system.

  • After the survey, all participants are shown a video clip of the PHR system, to provide participants with introductory information about PHR systems and to show them how a PHR system can be used through a few real-life scenarios.

Result: Number of subjects: 159

Perceived Usefulness and Complexity: key antecedents of behavioral intention to use such systems

Self-efficacy- important indicator of complexity

Key Points:

  1. the Self-Determination Theory can be used as a model to test consumer adoption of a new system or technology.
  2. Individuals with higher levels of ability to manage their own health (self-determination) are more likely to adopt PHR systems since they have more positive perceptions regarding the use of such systems.
  3. Self-determination is fueled by autonomy support from consumers’ physicians as well as the consumers’ personality trait of autonomy orientation.

Lesson’s learned:

The SDT model can be used to test consumer adoption of a new system or technology. There points in the SDT model that trigger other points (example: Perceived usefulness and complexity contributes to the intention to use of the consumers.

How can this relate to the local setting in the Philippines?

Personal Health Record System is a new technology in the Philippines. It is even a newer system them the electronic medical record. But the impact and scope of this system can be huge especially in a field or condition where patients’ and/ or their relatives’ active participation are very important (eg cancer, diabetes mellitus, pregnancy).

In fact this will be the basis or topic of my possible thesis for this Masteral degree. Personal Health Records among pregnant women and their health care providers.



Final Blog for HI201: Health Informatics at a glance!

My impression of Health Informatics as a Master’s degree was very shallow before I start with this course. I thought it was about the use of computer in healthcare. But there are more to it than just that. After 4 months of Introduction to Health Informatics, I have learned some many things from this class. It is an eye opener for the future work I am going to embark.

That was 14 weeks of reading articles, blogging and discussions. Fourteen driving questions that have to be answered by a blog. I have enjoyed each and every activity we did in the class.

Here is the summary of my learning per week with a link to each blog I made.

Week 1. Health Informatics, eHealth and Global Health: what’s the relevance?

Health Informatics is very much related to ehealth, global health and public health in a way that technology and health informatics is necessary to achieve population-wide healthcare service.


Week 2. Advancing Health Informatics in the Philippines

advancing HI in the Phils

There are many issues to address in order to advance health informatics in the Philippines. With every technology, acceptance at first is slow, but progress is inevitable. Open-mindedness is an important trait to acquire.


Week 3. Sustainable Health Information System: How to obtain in developing countries

sustainable HIS

Health Information System is mixture of human resources, infrastructure, financing and system design.


Week 4. Governance and Management of Health Informatics

Proper governance and management leads healthcare system to success.


Week 5. Philippine Health Information Exchange: A Healthcare service must!


In Public Health perspective, with Philippine Health Information Exchange, movement of health information will be easier and faster.


Week 6. Building a health information system: Enterprise Architecture

Enterprise Architecture is the blueprint of any healthcare system.


Week 7. Electronic Medical Record. The Now and Future of Healthcare Service


Shifting from paper-based to electronic medical record, healthcare service will become more efficient, safe, and accessible everywhere anytime.



Week 8. Empowering Patients through Personal Health Record

Providing Personal Health Record, patients can access their heath information any where, anytime.


Week 9. Interoperability: Bridging all systems together


To make health information exchange between systems possible, interoperability and standards must be in place.


Week 10. Clinical Decision Support System: Healthcare providers’ personal and clinical assistant:


CDSS is an important part of electronic medical record that acts as an assistant that helps in clinical decision.


Week 11. Knowledgement: Knowledge Management for Healthcare and Research


Transforming data to information to knowledge to wisdom. The process that we need in doing research in healthcare.


Week 12. Confidentiality, Security and Trust: the blood that runs through Medical Profession:


Health information is very sensitive that requires utmost confidentiality, security and trust.


Week 13. Telehealth: Universal Health for the islands of the Philippines


Healthcare for the remote areas in different islands of the Philippines.


Week 14. Mobile Health (MHealth): Healthcare on the go!

The use of mobile applications in phone and gadgets to provide healthcare services.




Mobile Health (MHealth): the healthcare on the go!

The traditional healthcare picture is like this, a patient consulting a clinic or a hospital for a chief complaint. The patient is interviewed for a complete history and thoroughly examined. Laboratory examination is then requested to aid in the diagnosis and in management. Traditional medicine revolves primarily in a medical facility where patient and doctor meet and communicate. However, in some settings, particularly in remote areas, going to health facilities like a hospital is not possible. Thus, technology plays a big role in this situation. Like telehealth, Mobile health or MHealth is medicine and technology combined.

In a study in the Philippine communication, there are 119 million mobile connections and 41 millions active mobile social users. This proves that Filipinos are well connected in the Internet. This should be taken advantage of by the Department of Health and Department of Science and Technology, to use mobile phones as an arm of medical practice. At present, there are a huge number of mobile applications in different medical and paramedical specialties but I believe, their potentials are not realized. Majority of these applications are US-based and the number of applications developed for Filipino users is lesser. Personally, I have 8 health related mobile applications installed in my mobile phone, excluding Google and its sub-applications. Many legitimate medical institutions have there on applications like Mayo Clinic and Harvard Medicine, and even journal publications like JAMA, ACOG etc…

So how can mobile applications be useful in healthcare? These are some benefits of mobile applications:

  1. can be used as point-of-care devices
  2. function in remote locations
  3. carried and used at any time
  4. a platform for collecting and communicating information via short message service (SMS) (
  5. it can be used as victim locator in calamities for rescues
  6. it empowers and educates patients and relatives suffering from different conditions. (Mayo Clinic, CDC Guidelines)
  7. electronic medical records and personal medical records
  8. Patient reminders during disease management (e.g hypertension, weight and Diabetes management)

These are just some of benefits of mobile applications in healthcare. Although, MHealth has fast evolved in the practice of medicine, I cannot emphasize enough that these are just an adjunct to the traditional medicine. These can only be used after a physician has done proper assessment of the patient’s condition.






An idea of mobile application, that I think will be my future thesis for this Master’s degree is a doctor locator, entitled, DOKTOR KO HANAP KO!. A GPS-enabled doctor locator that primarily helps patients locate a specialist nearest to him/her. The application has different modules depending on subspecialities. The application only includes all doctors that are board certified by specialty and subspecialty societies. As a specialist (gynecologic oncologist), I see cancer patients from different parts of the country in my clinic operated by a non-trained doctor. These patients most of the time is not aware of such subspecialty. Cancer management is particularly tricky in a sense that error in management has a big impact on patient’s survival. It has been proven in studies that cancer patients managed by oncologists from the start of treatment have better prognosis than that of patients initially managed by a non-oncologists. Other services of this application is generalist to specialist referral system, disease information for patients’ education and messaging system for better communication between doctor and patient.









Telehealth: Universal Health for the islands of the Philippines


In 2012, during the 15th Congress, then Congressman Joseph Emilio Abaya introduced the House Bill No. 6336 or the Telehealth Act of 2012. It is an act promulgating a comprehensive policy for National System for Telehealth Service in the Philippines. The aim of this bill is to protect and promote the right to health of the people, especially for those in medically unserved and underserved areas.

In 2014 during the 16th Congress, Congressman Rogelio Espina introduced the House Bill No. 4199, also known as the Telehealth Act of 2014, which is an act promulgating a comprehensive policy for a National Telehealth System with the use of advanced communications technology in the Philippines.

As stated in the latest Telehealth bill, it is the intent of the Legislature to recognize the practice of telehealth as a legitimate means by which an individual may receive health care services from a health care provider without in-person contact with health provider. The National Telehealth System shall create a parity of telehealth with other health care delivery modes, to actively promote telehealth as a tool to advance stakeholders’ goal regarding health status and health system improvement and to create opportunities and flexibility for telehealth to be used in a new models of care and system improvement.

I will give two sections (one each) in these bills and comment. In the 2012 version of the bill section 5, it is stated, “the delivery of health care via telehealth is recognized and encourage as a safe, practical and necessary practice in the Philippines. All health care providers shall be encouraged to participate in telehealth pursuant to the Telehealth Act. In using telehealth procedures, health care providers shall comply with all applicable State guidelines and shall follow established State rules that are consistent with accepted safe clinical norms, as security, confidentiality and privacy protections for health information”. Telehealth is a form of consultation from 2 different locations. Telehealth is ideal particularly in the Philippines having more than 7,000 islands with many areas still not being reached with medical services. This answers the question “How can telehealth support healthcare in the Philippines?” and it also addresses the lack of medical practitioners particularly medical doctors in many remote areas in the country. I agree that I can be safe and definitely very practical in the part of the patients. In ideal setting, it mirrors the traditional consultation. A trained paramedical staff in a remote health facility like barangay health center can do the physical examination. All medical practitioners should be encouraged to participate on this to achieve “Pangkalahatang Pangkalusugan” or universal healthcare. With proper training and communication, telehealth system can be successful. An obstacle in this type of practice is the poor and slow Internet infrastructure in the Philippines that will lead to slower and poor communication between the remote areas and the specialists.

In the 2014 version of the bill, section 7 determines the role of the National Telehealth Board, which is to ensure the implementation of this Act and to serve as an executive body of the National Telehealth System. The Board comprises of the DOH secretary (chair), and its members: DOST Secretary, DILG undersecretary, a representative from the League of Provinces in the Philippines, a representative from the League of Municipalities, a representative of Philippine Health Insurance Corp (Philhealth), a representative of Association of Municipal Health Officers and a representative from the Philippine Medical Association. In the old version of 2012, aside from these representatives, the board is also comprise of the Executive Director of the National Institutes of Health, Executive Director of the National Telehealth Reference Center, and 2 community representatives of underserved areas. The telehealth program should be a national program and the board as stated in the 2012 version is the more appropriate. The local government heavily represents the board in the 2014 version. My concern with this board is the political will of each local government to make sure this program will work properly. Based on our experience, many projects that are devolved to the local government are discontinued once there is a change in the local leaders.

In general, Telehealth is a very good alternative to the traditional health care, particularly in our country. People from remote areas do not need to go to Manila or other urban areas to seek consult. Proper training and technology and strong political will are essential for a smooth implementation of this program. I hope this bill will be passed into a law as soon as possible.



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Confidentiality, Security and Trust: the blood that runs through Medical Profession



The medical profession deals heavily on patient-doctor trust. Without this trust, medicine is nothing. And to ensure patient’s trust towards the doctor, privacy and confidentiality should be given utmost importance.

There are several laws or policies in the Philippines protecting people (and as patients) of data privacy and confidentiality. Here are some of these laws/ policies:

  1. Philippine Constitution: The privacy of communication and correspondence shall be inviolable except upon lawful order of the court or whne the public safety or order requires otherwise.
  1. Republic Act 10173 or the Data Privacy of 2012:

An act protecting individual personal information in Information Communications Systems in the government and private sector creating for this purpose. It aims to protect the fundamental human right of privacy of communication while ensuring free flow of information to promote innovation and growth.

  1. Magna Carta of Patient’s Rights and Obligation:

Under this law: Right to Privacy and Confidentiality: The privacy of the patients must assured at all stages of treatment. The patient has the right to be free from unwarranted public exposure except: 1. When his mental or physical condition is in controversy and an appropriate court requires him to submit physical or mental examination by a physician, 2. When the public health and safety so demand and 3. When the patient waives his right in writing.

Right to Medical Records: The healthcare institution shall safeguard the confidentiality of the medical records and to ensure the integrity and authenticity of the medical records.

  1. Code of Ethics of Philippine Medical Association: Under this code, physicians should hold as sacred and highly confidential whatever maybe discovered or learned pertinent to the patient even after death except when required in the promotion of justice, safety and public health.
  1. Civil Code (Republic Act No. 386): Every person shall respect the dignity, personality, privacy and peace of mind of another
  1. Revised Penal Code (Act No. 3185): it criminalizes “Revelation of Secrets” by providing provision to protect the secrets of any person particularly from hospital employees who have direct hand on patients’ medical records.
  1. Rape Victim Assistance and Protection Act of 1998 (Republic Act No. 8505): Protects the privacy of rape victims
  1. Juvenile Justice and Welfare Act of 2006 (R.A No. 9344): Protects the privacy of minors.
  1. Philippine AIDS Prevention and Control Act (Republic Act No. 8504): orders all health professionals, and other personnels who have knowledge of an HIV patient’s status to strictly observe confidentiality in the handling of all medical information, particularly the identity and status of persons with HIV

House Bills:

House Bill no. 4199 (16th Congress)/ House Bill 6336 (15th Congress) (the Telehealth Act of 2014): Under this bill, it aims to provide a policy framework and establish a National Telehealth System that will govern the practice of and development of telehealth in the country. Any medical records generated, including records maintained via video, audio, electronic or other means due to telehealth examination, consultation or monitoring must conform to laws regarding confidentiality of healthcare information of the patient, his/her rights to medical information and record keeping requirements.

In one of the hospitals I am affiliated with, I reviewed the resident’s manual. It is stated in this manual that 1. all cases should be kept confidential at all times; 2. Only the attending physician is allowed to update his private patient any new information except if he orders the resident to do so. It is also stated in this manual that it is considered a serious offense if a resident posts a patient’s picture or video (without the patient’s consent) or any hospital related articles in the Internet.

I also inquired regarding a document or standard operating procedure regarding privacy and confidentiality in the medical record section. The hospital is already partially implementing electronic medical record (imaging and laboratory results can be viewed through EMR) but medical histories, and doctor’s orders are still manual or paper-based. The process of getting documents from the medical record of a patient previously admitted in the hospital depends on 1) who personally request or get the document and 2) the purpose of getting the document. In case the patient is the one getting the medical document, he/ she should show 1 valid identification card showing he/she is really the patient previously admitted. No letter of request for the document is needed. In case a relative is the one getting the document, I was told that the relative has to prove he/she is a relative of the patient, either by showing the ID of the patient or an authorization letter from the patient. It would be easier if the person getting the document has the same family name of the patient, which somehow proves their consanguinity. The process seems lax but the medical record employee said it also depends on the purpose the document will be used. They require a letter of request or authorization (in case the patient is not the one getting the document) addressed to the head of the Medical Record Unit if the document will be used for medico-legal purpose, but if only to ask for financial assistance, such letter is not needed. It also depends which part of the medical record is being asked for. If the discharge summary or medical certificate or operative technique, it would be easier to get a copy of these documents but it the whole or part of doctors’ order or more sensitive document, again they have to write a letter to the head of the unit indicating the purpose of getting such document.

Majority of hospital staff, including medical students, are not aware of the many policies and laws in the Philippines regarding patients’ privacy, however many are aware that medical information are confidential, which should be treated with privacy. The hospital itself has many stories of students taking pictures during an operation and post in social media without the patient’s consent. It is also difficult to stop gossips between medical staff about patients especially if the patient is a high profile patient. Data privacy is still an issue in a paper-based medical record/ information system; much more if everything is electronic-based.






Knowledgement: Knowledge Management for Healthcare and Research


Health informatics deals with a vast number of data from a lot of sources with the use of technology to increase healthcare efficiency. Aside from efficiency, data can be transformed into a valuable knowledge. Data are organized into information then put into context to form knowledge then interpreted into wisdom. These processes are included in knowledge management or what I call “KNOWLEDGEMENT”. The goal of knowledge management is to bring the right information to the right person at the right time and place1. Knowledge when shared to others will bring more knowledge. The effect of Knowledge management depends on different factors, which include 1. The quality of the source of data; 2. the data itself; 3. The quality of the process of data transformation; and 4. person who process and interpret the data (culture, training experiences). Knowledge is divided into 2 categories: 1. Explicit, which comes from tangible information like written, spoken or electronic information and 2. Tacit knowledge, which are from a person’s insights or ideas.


How can knowledge management improve access to healthcare research?

As I have mentioned, knowledge management transforms raw data into a valuable information and knowledge. Through several layers of transformation, data become accessible to health care research. A research itself is a form of knowledge management. A researcher gathers raw data from patients, medical records etc, and other information from other researches to form knowledge. Knowledge management makes researches easier by combining pertinent data together to form statistics.

At present, there is no integrated gynecologic cancer statistics/ reporting system in the country. I know this for the fact because I had the training in gynecologic oncology in the Philippine General Hospital, and most of my consultants, who give lectures in different venues, cite PGH Gynecologic Oncology Annual report. This can be bothersome because it does not reflect the true status of the gynecologic cancer in the Philippines considering there are many islands in the country and many gynecologic oncologists are practicing outside the metro area. I believe DOH has their own statistics but I know it also is not reflective of the status of the gynecologic cancer in the Philippines. This is a dilemma of the Society of the Gynecologic Oncologists of the Philippines because, as the main organization for this type of cancers, it should have its own reporting system.

For this dilemma, knowledge management is very important. There are many data being gathered everyday from different patients, by different specialists from different locations in the country. It would be a very important program if the society, in collaboration with DOH and maybe DOST and an IT company, will come up with knowledge management system to transform these data into knowledge, that truly reflect the condition of gynecologic cancer in the Philippines.

Possible e-Health projects:

  1. A Web-based Tumor registry- a web-based tumor registry will transform patients’ data into statistics and reports necessary for researches and clinical practice
  2. Integrated EMR for gynecologic oncologists with Clinical Decision Support System (CDSS) and Personal Health Record (PHR) for the patient- if there is only one medical record all gynecologic cancer specialists use, it would be easy to communicate and refer patients among ourselves, which will translate into efficient healthcare system. CDSS and PMR will help doctors and patients in cancer management.
  3. A mobile application to locate gynecologic cancer specialist nearest to the patient’s location- this will provide the patient access to proper cancer management with proper facilities. This will prevent patients being maltreated from different doctors without proper training in the management of gynecologic cancer.
  4. An electronic infographic of different gynecologic cancers (Primary, Secondary, Tertiary prevention and management) to empower and educate cancer patients and their relatives about these types of cancer.

These projects possibly help doctors in their clinical practice, patients in their cancer management and researchers in creating local studies.



  1. Straus et al. Knowledge translation is the use of knowledge in healthcare decision making. J Clinical Epidemiology 2011;64:6-10.
  2. Grimshaw JM et al. Knowledge translation of research. Implementation Science 2012,7:50.
  3. Knowledge Management for Public Health Professionals. Association of State and Territorial Health Officials, 2005.

Clinical Decision Support System: Healthcare providers’ personal clinical assistant

More common in the United States and other developed countries, Primary care is a major part of the healthcare system. It deals with all patients with signs and symptoms to come up with a sound diagnosis and management. Primary physicians, after a complete history and physical examination, order a set of laboratory and imaging studies to help in the diagnosis. If the case is more complicated, the patient is then referred to specialist. In this system, primary care serves as a triage; hence, more cases are seen in primary care than a specialty clinic. With a vast possible clinical scenario, clinical decision support system comes in handy.

Clinical Decision Support System (CDSS) is an electronic system, usually embedded in electronic medical record that helps physicians in diagnosis and management of patients. According to Robert Hayward of the Center for Health Evidence, “CDSS link health observations with health knowledge to influence health choices by clinicians for improved health care”.

In one systematic review, CDSS improves process of care in 63%, however in another study, it did not reduce death. CDSS eliminates human errors caused by many human factors. These factors include limited time of consult, stressed physicians, clinical experience of physicians, and incomplete data from the patient. With CDSS, signs and symptoms gathered from consults are lumped together and all possible differential diagnoses will be available to the physician for further review. Another benefit of CDSS in healthcare is that It can avoid adverse drug reaction and medication prescription errors by prompting nurses or physician of incompatible medications that cannot be mixed together.

As a clinician myself, my clinical decision may be based on different factors. 1. Based on my clinical training. I had my 4-yr residency training and 3-yr fellowship training in the Philippine General Hospital, a premier referral center in the country. All these years, I’ve seen many cases enough to build a database of cases. 2. Local and International literature. With the shift to evidence-based medicine, many decisions and recommendations are now based on available quality literature. 3. Patient’s factors like financial, emotional and social factors. Clinical decision will also be based on what is acceptable to the patient. A particular management maybe applicable or available to a patient but he or she may not afford it, then the next possible less expensive management is the more appropriate treatment.

Community Health Information Tracking System (formerly called Child Health Injury Tracking System) or CHITS is an electronic medical record system developed by the National TeleHealth Center (NTHC) to improve health information management at the Regional Health Unit (RHU) level. It is develoed to gather data and generate reports that can be used by the RHU to improve healthcare in the area.



Clinical scenario:

A 36 years old female consulted the regional health unit due to blooding vaginal discharge of 4 days duration, right lower quadrant pain and post-prandial vomiting.

Physical Examination:

BP: 140/90  HR: 90  Temp: 38.9

On abdominal examination:

The abdomen is tender at the right lower quadrant only. No palpable mass

On internal examination:

The external genitalia is normal, the vagina is smooth, cervix is smooth but tender on movement, the uterus is small, there is tenderness in the right adnexal area. There is a 6×6 cm tender mass at the right lower quadrant/ adnexal area.

Using CHITS, the complete history and physical examination is recorded.

Using the CDSS:

These clinical data are entered in the CDSS embedded in the CHITS. The pertinent data include bloody discharge, RLQ pain and vomiting with physical findings of fever, RLQ tenderness and right adnexal tenderness are entered. The CDSS gave differential diagnoses, which included, Ectopic pregnancy, acute appendicitis and Pelvic Inflammatory Disease. It suggested the following laboratory and imaging studies:

Pregnancy test: negative

AP CT Scan: 6 x 4 cm tubular mass with fluid collection within. No gestational sac noted within the tubular mass. Ovarian in origin cannot be ruled out. Uterus is small. endometrium is thin.

Based on these tests, Ectopic pregnancy was ruled out

Because of the fluid collection inside the tubular mass was noted in CT Scan, the physician interpreted it as pus collection, thus diagnostic laparoscopy was contemplated. After loading of antibiotic with polymicrobial coverage, the patient underwent diagnostic laparoscopy, which later showed the definitive diagnosis of Tuboovarian abscess. Appendix was noted to be normal.



Bates DW et al. Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality. J Am Med Inform Assoc 2003;10:523-530.

Jaspers MW et al. Effects of clinical decision-support systems on practitioner performance and patient outcomes: a synthesis of high-quality systematic review findings. J Am Med Inform Assoc 2011;18:327-334.

Souza NM. Computerized clinical decision support systems for primary preventive care: a decision-maker-researcher partnership systematic review of effects on process of care and patient outcomes. Implementation Science 2011:6:87

Ash JS et al. Recommended practices for computerized clinical decision support and knowledge management in community settings: a qualitative study. BMC Medical Informatics and Decision Making 2012;12:6