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Designing Health IT: From Health Systems Design to User Interfaces

Posted: 25 May, 2015   Recommendations: 28   Replies: 92

There is significant evidence and many examples of how design can stimulate healthy behavior and improve overall health. We see this at many different levels, from the design of cities, individual buildings or workspaces, down to the information systems used (Handy 2002). The physical environment has been shown to have an impact on the prevention of obesity and its associated adverse health consequences (NTFPTO, 2000) and though there are many studies about the impact of health IT, the field of design in health IT is still nascent.

Many organizations have created guides such as AHRQ's Designing Consumer Health IT: A Guide for Developers and Systems Designers (link below), but our field has struggled to apply these practices.

To discuss design and its impact, we are fortunate to have an exceptional group of panelists joining us for this virtual Expert Panel from June 1-5:

     • Joseph Cafazzo, PhD PEng, Lead for the Centre for Global eHealth Innovation, University Health Network, and Senior Director of UHN Healthcare Human Factors
     • Amy Cueva, Founder and Chief Experience Officer, Mad*Pow, founder of Mad*Pow’s Health Experience Design Conference, HxRefactored
     • Zach Landis-Lewis, PhD, MLIS, Postdoctoral Scholar, Department of Biomedical Informatics, University of Pittsburgh
     • Alvin Marcelo, MD, Associate Professor of Surgery and Health Informatics, University of the Philippines Manila and Chair, Asia eHealth Information Network
     • Anjali Sastry, PhD, Senior Lecturer, System Dynamics, MIT Sloan School of Management, and Lecturer, Department of Global Health and Social Medicine, Harvard Medical School

During the discussion, panelists will share their thoughts on the following questions:
     • When does the design of a project end, and how do you know if it's successful?
     • How will you know if you've designed it right?
     • How do you incorporate design to try and make your implementation more likely to succeed?
     • How do you get people to buy in to the fact that this is important and should be funded?

This panel is part of our US Communities Initiative, which is supported by the Agency for Healthcare Research and Quality (AHRQ), and aims to foster discussions between health care professionals on evidence-based practices, and translating these practices across disparate settings, to improve healthcare delivery in underserved populations in the US.

In an effort to understand the impact of our Expert Panels, we have created a short (4 question) survey. Your responses are greatly appreciated—please take the survey before the discussion begins:

As with all GHDonline panel discussions, we hope you’ll chime in with questions, comments and descriptions of your own work. We look forward to a rich discussion!



Paul Nelson Replied at 9:19 AM, 25 May 2015

Collective action at its best. Hopefully!

Madhuri Gandikota Replied at 9:56 AM, 25 May 2015

Dear Joaqin,

Thanks so much for this information and invite. This is such an impactful topic.
I certainly look forward to learn about all expert thoughts.

I also take an opportunity to share about an exciting event Health DataPalooza 2015 .
Please find the attached information about Health DataPalooza 2015, being held in Washington DC between May 31 to June 3rd, 2015.
I share the following mail, with the GHDonline community.


Attached resource:

Yudha Saputra Replied at 10:25 AM, 25 May 2015

Dear Joaquin,

Thank you very much for the invitation.
In my own practice, not a lot of people understand about health IT, yet. Its usefulness, impact, function, and how can it reduce the number of disease and health problems in their daily life. Developing country is really something. Sometimes infrastructure and capabilities cannot get along with motivation. Really need a strong, undoubtable reason first before we can continue to strive to the next step. But monitoring and evaluating, is a great challenge. Will it improve or banished, it depends on how well it work so far.

Hope this discussion can deeper our understanding about health IT and may lightened our future to improve the quality of it.

Once again, thank you

Let's the fun begin!

Warm Regards,

Marie Connelly Replied at 10:28 AM, 25 May 2015

We're looking forward to an excellent discussion next week! Below, please find a few of the resources Joaquin mentions. Please feel free to share additional resources on this important topic, as well as any questions you'd like to see our panelists address next week.

Attached resources:

Luis Azpurua Replied at 11:17 AM, 25 May 2015

Dear Joaquin,

Thanks for the invitation.

As you may know in Latin America we are in differents levels of health IT planning or implementation.

How do we get into this GDH online panel discussion?

Gurpal Bindra Replied at 2:11 PM, 25 May 2015

Great ideas with great researchers are an essential part of this
From theoretical to practical and from pilot to scale are where challenges
lie. The landscape is littered with gr8 ideas successful pilots but failed
scalable outcome.
Would encourage all interested to look at a wonderful analysis by kentaro
toyamas . His book GEEK HERESY is a must read for novices and experts.

arnab paul Replied at 2:03 AM, 27 May 2015

As you may know in India we are in different levels of health IT planning or implementation. Most of the healthcare providers and entities are working in silos, it would be interesting to see how it pans out once we have a National E health authority ( nEHA ) in india.
I am looking forward to a rewarding experience here at GHD.

Rajendra Pratap Gupta Replied at 2:30 AM, 27 May 2015

Also, it will be great to see the setting up of the IHIN - India Health Information Network by the Government of India - this will serve as a discussion and networking forum for HCIT stakeholders. More update after 30th May

Rajendra Pratap Gupta Replied at 2:48 AM, 27 May 2015

We recently released the M2M standards document on Remote Health Monitoring


Dr. Suresh Munuswamy Replied at 2:50 AM, 27 May 2015

dear mr gupta,
thank you for the update on NEHA and IHIN and your untiring efforts for
health informatics in India.

Dr. Suresh Munuswamy Replied at 3:15 AM, 27 May 2015

dear mr.gupta,
thank you for the link. last week I met dr.Sarbadhikari and he too
mentioned the same and that you were part of the release team.

Olajide Adebola Replied at 4:29 AM, 27 May 2015

Dear Joaquin,

Thanks for the invitation. The topic for discussion is very important. Designing for change and human centered design is key. I will participate.

Many thanks,

Dr Olajide Adebola

Alvin Marcelo, MD Replied at 5:49 AM, 27 May 2015

Thank you for the invitation, Marie. I hope to be able to share our experience in the Philippines (national) and the Asia eHealth Information Network ( for the region. Gurpal Bindra hits it on the head that the eHealth landscape is full of pilot projects with only a few going to scale. At AeHIN, we are promoting the alignment of national eHealth strategies with governance -> architecture -> standards -> program management -> IT operations. The WHO-ITU National eHealth Strategy Toolkit has helped with how to start but the journey is long and hard for many developing countries. At AeHIN, we aim to bring the travelers together and share their experiences. This thread by GHDOnline is one good way of sharing those experiences...


Joaquin Blaya, PhD Replied at 7:32 AM, 27 May 2015

Thank you all for this wonderful feedback and comments, it's wonderful to
see this much excitement around this panel which will start next week.

There have been a couple of questions raised that we'd like to answer.

First, if you're receiving these emails, then you are signed up for the
panel and will see it.

Also, the invitation was from me, however when you reply it goes to the
community so that we can ensure you're signed up for the panel. So if
you're emailing a response please keep in mind that all of the community
will see it.

Looking forward to the panel,

Rodrigo Cargua Rivadeneira Replied at 10:06 AM, 27 May 2015

morning I have in whatmay help the orders in my country ( Ecuador ) we are in
the implementation of a comprehensive health system for the Ecuadorian state.

Paul Nelson Replied at 12:24 AM, 28 May 2015

Am I correct? Did Australia just scrap their nation's electronic medical record? Does anyone know why? I am also aware that Great Britain did the same thing several years ago. I am also aware that when I attend my patients at the hospital, my work productivity is 50% less than when I used the paper record. And, today the IRS (of our USA) said they had been hacked and that several million citizen records were accessed. As a Primary Physician for nearly 40 years, reducing hospital days by 25% for employer or medicare-eligible groups is knowable and reproducible. The current iteration of EMRs sold for primary health care are woefully inadequate.

Wouldn't it be appropriate to initiate an intense study of what it takes for a justly efficient and reliably effective Primary Physician to manage the level of uncertainty that characterizes Primary Health Care? Maybe its been done, but I don't see any system yet that would substantially improve "through-put" in my office with a system that would perform at a sigma 6 level of down-time, like my paper record has for the last 40 years. Wouldn't it be better to design a core emr with licensed public access by developers through a cloud community for specific projects, the first being security?

A/Prof. Terry HANNAN Replied at 1:39 AM, 28 May 2015

Paul, I am travelling in Europe until next week so I will try and formulate a considered response to your Australian question and our PCEHR. There may be others on this site from Oz who could comment before I do.
You may try and read postings on a Dr David More's blog in Australia

A/Prof. Terry HANNAN Replied at 1:51 AM, 28 May 2015

Paul, here is the blog addresss. Terry

David Grayson Replied at 6:30 AM, 28 May 2015

Paul check this link
I work in New Zealand healthcare where our primary care is 100% digital. You are welcome to visit Middle Earth and see the future anytime. Regards David

Timothy Simard Replied at 8:55 AM, 28 May 2015

Hi David,
I would appreciate the opportunity to learn more at your convenience. You can reach me best at <mailto:>

I'm the CEO of Anthurium Solutions (ASI) based at University of Massachusetts Boston. ASI is a mission driven HIT company that over the past 4 years has developed a Platform-as-a-Service (PaaS) architecture - which offers a Patient Care and Medication Management enterprise solution. Our global mission is to deliver technology and solutions to help patients holistically and change the way people will work in the 21st Century.

Patrick Crisp Replied at 2:59 PM, 28 May 2015

Hello Paul

I work as a family doctor in New Zealand and I have 'written' an electronic health record. 2 comments:
1. I think that the reason the primary care in New Zealand has such a high uptake of EHRs is that the main EHR used is basically an electronic version of a paper health record but with benefits. The EHR does not try to change how the primary care doctor works. You get the advantages of easy accessibility to your patients' data, electronic referrals, drug-drug interactions, electronic lab test ordering and viewing of results etc. Having said that, the coding systems used in New Zealand are totally inadequate, so there is a lot of room for improvement.
2. What has always surprised me about those doctors/clinics who use my software: they only use a small subset of the program. Almost all just use the part that is the electronic version of a paper health record.

Thanks for this discussion
Patrick Crisp

Marc Koehn Replied at 3:14 PM, 28 May 2015

Patrick's point that access to specific tools (e.g. online lab results) is one of the drivers for EMR adoption is echoed in this analysis by Dennis Protti (Professor Emeritus at UVIC). For me the key point here is that in addition to interfaces which enhance rather than stand in the way of care processes, EMR tools have to provide access to new health data (e.g. lab or discharge summaries) and capabilities (e.g. ePrescribing) in better or faster ways. The fact that, in practice, some of the features are not used is an interesting issue. Are they poorly implemented or designed? Do they fail to sufficiently enhance the care process?

David Grayson Replied at 5:22 PM, 28 May 2015

Thanks Marc - note we have good uptake of EMR in PRIMARY care here and variable adoption of partial EMR in hospitals but NO EHR yet.
I am in Northern region of NZ (4 DHBs and over half of national population) and we are about to embark on an implementation planning study for possible adoption of an EHR.
Does anyone know of good organization readiness assessment template for EHR implementation? Thanks David

Rodrigo Cargua Rivadeneira Replied at 5:45 PM, 28 May 2015

Buenas tardes David
claro que si tengo algunos lineamientos escríbeme por interno.

Rodrigo Cargua

David Grayson Replied at 6:01 PM, 28 May 2015

Gracias Rodrigo
Mis disculpas, yo no hablo a español pero a usar MS traductor.
Gracias por su respuesta. ¿Cuál es tu correo electrónico?
Mi hija está viajando a Eqcuador el año que viene así que también me gustaría averiguar sobre proyectos de salud pública que podría ser voluntario para ayudar con. Gracias.

Rodrigo Cargua Rivadeneira Replied at 7:19 PM, 28 May 2015

Disculpas David
mi correo es
con gusto me pongo en contacto con tu hija
y a las ordenes en lo que pueda ayudar.

Rodrigo Cargua

Joseph Cafazzo Replied at 12:14 PM, 1 Jun 2015

Hello everyone. Nice to meet you virtually! So glad to be participating as a panelist.

I'm lead the Centre for Global eHealth Innovation at Toronto General Hospital. We are 70 researchers and staff that are passionate about getting the technology right for patients and providers. Within the team is Healthcare Human Factors, a specialized group of 30 people that scrutinize health technologies through the lens of human factors engineering, cognitive psychology, and design excellence.

I look forward to conversation this week!


Attached resources:

Jossy Onwude, MD Replied at 12:59 PM, 1 Jun 2015

This is exciting. I would like to know more on how health IT can be used to tackle Diabetes. It is estimated to have more cases around the world by 2020 and am wondering how health IT can help reduce it.


Marie Connelly Replied at 4:58 PM, 1 Jun 2015

Very excited to hear from our panelists this week—such an important topic! As we get started today, I wonder if our panel and community might share some initial thoughts on the current challenges in designing health technologies?

Joaquin mentioned that design in this space is still in its nascent stages, so I'd be eager to hear from colleagues here about why that's the case, and how we might begin to move things forward. Looking forward to hearing your thoughts!

A/Prof. Terry HANNAN Replied at 6:57 PM, 1 Jun 2015

To Paul Nelson, Paul I am just back from Prague and I am posting this in response to your earlier question re the Australian PCEHR. Here are 2 links to some recent discussions on this topic (including a comment from myself).
Please let me know if they are accessible or of any use (of course they may not be) :)
I believe the core message re this project can be summarised under the NFI Syndrome [No Flaming Idea].
1.From Pulse+IT
2. From Dr David More’s blog

A/Prof. Terry HANNAN Replied at 7:12 PM, 1 Jun 2015

To Jossy Onwude-your enquiry is very relevant in this era of the obesity epidemic. As a physician who has worked in a diabetic clinic and tried to monitor some of the HIT implementations in this area there is a question that continues to be asked. "We have some excellent eHealth projects in the field of diabetes management so why is the desired improvement NOT seen?" I believe this is a political-social problem not solely a technical one. The technology devices are here but the tsunami of fast-food outlets (associated with government revenues [sine que non tobacco]) overrides the powerful educational and CDS tools we can provide to patients at the present time-DISCUSS!
In support of these views I am posting some interesting data that I have accumulated over the years.

1. Indian presents AdEx India Analysis
Fast food outlets advt. on TV registers 22% rise (8 February, 2005)
Key Findings:
 Fast Food Outlets Advertising up 22 per cent on television in 2004 compared to 2003
 Summer seasons see heated food Advertising Expenditures rise
 Fast Food Outlets advertising shows a rise from 2000 on TV
 McDonald’s ‘Happy Price Menu’ tops Chart in 2004

2. Fast food comes to Iraq: SMH. April 21 2003
Basra: Fastfood giants Pizza Hut and Burger King have set up their first franchises inside war-torn Iraq, even as many aid convoys waited on the borders for the war to officially end. The arrival of the two restaurants - sited inside giant trailers on a British military base near Basra - won a rapturous welcome from soldiers, whose limited range of rations lost their appeal many weeks ago. But some officers were less keen on the new arrivals, which are due to start selling food tomorrow. "I would prefer we got decent showers and toilets sorted out first," muttered one high-ranking officer.

3. Fast Food Nation: The Dark Side of the All-American Meal
By Eric Schlosser (Houghton Mifflin) NYT Book Review 21 Jan 2001
“The Golden Arches,” Schlosser says, “are now more widely recognized than the Christian cross.” Of course, McDonald's isn't alone. “The whole experience of buying fast food,” he writes, “has become so routine, so thoroughly unexceptional and mundane, that it is now taken for granted, like brushing your teeth or stopping for a red light.”
At the very least, Schlosser makes it hard to go on eating fast food in blissful ignorance.
But in a larger sense, what “Fast Food Nation” criticizes is the very free-market enthusiasm that has made heroes of the burger fans Bill Gates and Warren Buffett, the latter of whom has famously been a major McDonald's shareholder.
Here is another side of the unfettered money culture that has been celebrated as an exciting orgy of entrepreneurialism and opportunity.
At one point, Schlosser quotes a scientist who specializes in food safety.
This man is discussing the meat industry's reluctance to perform certain tests on its products, but he could be talking about almost any of the questions Schlosser raises about the fast-food business — or, come to think of it, about the culture that takes that business for granted.
“If you don't know about a problem,” the man observes, “then you don't have to deal with it.”

A/Prof. Terry HANNAN Replied at 8:32 PM, 1 Jun 2015

This discussion has encouraged me to investigate existing documentation on this topic. In doing so I cam across a very interesting article in the International Journal of Medical Informatics. I tried to download the full text but was unable to do so. It has some excellent discussion points and photographic images that highlight the points being discussed.
Ole Andreas Alsos Anita Das Dag Svanæs Mobile health IT: The effect of user interface and form factor on doctor–patient communication. International Journal of Medical Informatics Volume 81, Issue 1, January 2012, Pages 12–28

Alvin Marcelo, MD Replied at 11:49 PM, 1 Jun 2015

Hello all. Thanks for the invitation to be a panelist. I am Alvin Marcelo, an associate professor of surgery and health informatics from the University of the Philippines Manila. I am also the chair of the Asia eHealth Information Network, a collection of eHealth advocates from ministries of health, ministries of ICT, academe, and non-government sector in Asia interested in supporting their national eHealth strategy implementation.

I think designing health technologies is difficult especially if we do not put ourselves in the shoes of the patient and/or of the health professional. In essence, health information flows from these two types of stakeholders and a keen understanding of how they view their world and their workflows is key to creating solutions that best fit their needs.

I am lucky to have been both provider and patient (twice over) and to have had the opportunity to see both their perspectives. What I can say is that looking for that win-win scenario is difficult. Health technology design that is easy for the patient may be difficult for the provider and vice-versa. It would be magnificent if a design can address the needs of both sectors without diminishing their smooth experience.

There is a saying that we must "start from where the people are". Maybe that is the key to good design --- understanding the people who should benefit from the technology.

David Aylward Replied at 12:07 AM, 2 Jun 2015

Wise words from Alvin Marcelo, one of the stars of eHealth for
disadvantaged populations all over the world.

A/Prof. Terry HANNAN Replied at 1:25 AM, 2 Jun 2015

Alvin, I am in total agreement with David on all aspects of his comments.
So here are my enquiries. Most systems we use and expect the patients to use remain fixed in the Microsoft or Apple interfaces (see attached 2 slide set) and these rarely (although Apple goes a long way towards it) act as truly functional interaction models for patients or care deliverers.
Are you able to give example (real or conceptualised) that make the ehealth interactions "natural or human"?
The example I have attached of Eleanor demonstrates an excellent example of thinking outside bubble in this field.

Attached resource:

Zach Landis-Lewis Replied at 6:33 AM, 2 Jun 2015

Greetings everyone,

It is an honor to participate as a panelist and to exchange insights and perspectives in this forum. I'm a postdoctoral scholar in the Department of Biomedical Informatics at the University of Pittsburgh, in the Center for Health Informatics for the Underserved ( Previously I was a software developer for Baobab Health Trust ( in Malawi and in Pittsburgh, Pennsylvania. In the coming months I will be joining the University of Michigan Medical School as an assistant professor in the Department of Learning Health Sciences, Division of Learning and Knowledge Systems (

I have been studying how to design software that generates actionable clinical performance feedback for healthcare providers in HIV/AIDS clinics in Malawi, to improve the quality and safety of care. I think a primary challenge for designing health technologies in low-resource settings is understanding ongoing change in clinical processes that creates gaps between the intended design of a system and the reality of the clinical environment. For example, in Malawi my colleagues and I learned that, to generate actionable performance feedback for healthcare providers, we will need to create tools to recognize cycles of change in clinical guidelines, software updates, clinic personnel, and disruptions to provision of care, all of which can interact to worsen the quality of clinical data.

I think that understanding the nature of these socio-technical gaps and how they are manifested in low-resource settings is one of the most important challenges for designing technology that better supports the work of healthcare providers and patients.


Krishna Man Shrestha Replied at 6:57 AM, 2 Jun 2015

Hi everyone,

I donot have any experience in Health IT but I would be delighted to
participate in this discussion

Luis Azpurua Replied at 8:41 AM, 2 Jun 2015

Hi all,

Living in Venezuela I want to share our reality:

Most of the underserved people live on shanty towns. It´s very difficult to have access there. On the other side, there is a lack of trained personal, scant material resourses and a few sprouts of health IT projects. But we have to figure out how to provide the best healthcare possible to these people. Almost everyone have a cell phone.

With this scenario, how can we use health IT to fulfill our needs? Could we use it to replace trained people? Can we teach plain people to use it? and Could this data be gathered in epidemiological centers or something like this?


Anjali Sastry Replied at 11:27 AM, 2 Jun 2015

Hello everyone, I am thrilled to join this panel. I teach and research global health delivery at Massachusetts Institute of Technology--and am a very proud collaborator with GHD. Over the past few years, I've experimented with new ways to bring design thinking and user-focused design principles to global health delivery, via an ongoing collaboration with Jose Colucci of design firm IDEO in Boston, and via my student teams who have embraced design principles in their collaborative projects with front-line global health organizations in low-resource settings.

Here's one idea I wanted to offer for thought: innovations in health IT are sorely needed everywhere, for sure. Yet at the same time many of the partners I work with have no online systems--no computers even, and often don't have access to mobile platforms. The reality is that many of the data collection and tracking tasks are being done ON PAPER. The challenge for all of us: can we bring UX thinking, user innovation, and design approaches to paper forms and paper data collection methods? Paper form design may not have the allure that mobile app design has, but it's what's needed in many cases. and, I think, improvements in paper-based methods--if done well--may also set the stage for IT design and implementation when the moment comes.

Is this something that you work on or have thought about? Who has developed innovations in paper-based data collection and use that we could learn from? How do we put the user--the clinicians, implementors, and patients--at the center of paper form design?

and is there a path for innovation and improvement in paper based methods to set the stage for IT solutions that will follow?

I welcome your thoughts!
Anjali Sastry

Marie Link Replied at 12:00 PM, 2 Jun 2015

Designing technology using consideration of human factors... EXCITING and Great to Hear!

I am a Pharmacist and Medication Safety Officer by training and own a HIT start-up called REMS LOGIC. For our beta design, we took this exact approach and developed a platform with a primary goal of making a simple user-interface. Although the information contained in the system is quite complex, we have been successful in our delivery and stayed true to our mission. The #1 feedback response from our users is how simple the system is to use!

We are currently underway with development of our next version V1.0 and scoping V2.0 (highly integrated platform). Our development roadmap extends far outside our current beta with vision to revolutionize drug safety across the healthcare continuum BUT in a way that is SIMPLE from a user design perspective. Our belief is, that people (healthcare workers) will elect to do the right thing, if you make it easy for them.

One main contributor to disparate IT systems today is that they are built to accommodate specific healthcare settings. Good Health IT design should follow the patient regardless of healthcare setting and knowledge delivery to various healthcare providers must be presented at the point where the information is relevant. I look forward to participating and hearing from this group!


Luqman Lawal Replied at 12:56 PM, 2 Jun 2015

Thank you so much for the invite as I am so interested in this topic. I would love to learn a lot from the discussion as I hope to pilot an e-health system in a State of a Subsaharan country in Africa. I will love to learn the different opportunities the electronic health system has provided in countries utilizing it as well as the challenges that has been encountered in rolling out an electronic health system.


Zach Landis-Lewis Replied at 2:29 PM, 2 Jun 2015

Hi Anjali,

Thank you for sharing some excellent questions. I'm reminded of a low-tech, paper-based innovation: using rubber stamp templates to put checklists or protocols on paper forms for certain patients.

Pratap Kumar of health-E-net discusses this idea towards the end of this video from Kenya:

I'm wondering if there are other examples of the use of rubber stamps to support clinical decision making and data collection. Like you mentioned, these could be used as incremental steps towards software-based solutions to follow.


Marie Connelly Replied at 4:58 PM, 2 Jun 2015

Anjali, thanks for this interesting question, and Zach for the resources! I wonder if there are other areas of government we might learn from here as well. Anjali's comments reminded me of an older piece in the New York Times on paper ballot design ( and an interesting interactive there which shows common problems—and solutions—for ballots ( Can we learn anything from this for improving paper forms in health care?

I hope our panel and community members will continue to share challenges they've encountered in designing health technologies, but perhaps it might be helpful to talk specifically about incorporating design into the development of health technologies: how do you define and scope the design work to be done on a project? How do you know when it's done, and how do you measure the success or failure of the design itself?

A/Prof. Terry HANNAN Replied at 5:51 PM, 2 Jun 2015

To Luis Azpurua, I think this is a great posting that Joaquin Blaya may be able to shed light on. He and Hamish Fraser have performed work in Peru and other South American states. Also Joaquin has built and application for chronic care. MiDoctor: mHealth tool on top of OpenMRS for chronic disease monitoring, here's a 3 minute video of it (

A/Prof. Terry HANNAN Replied at 6:07 PM, 2 Jun 2015

Anjali Sastry. What a wonderful input to the discussion. MANY domains of data capture in health care are not paperless. You asked for examples of where data capture may be of benefit using paper and / or e forms.
This was a fundamental component of the early (and I think remains) of the AMPATH system in Eldoret Kenya. I am attaching some files that show the efficiency of well designed conjoint data capture processes from the AMPATH project. [ ]
Note the decision support is built into the data capture device e.g. PALM device.
The photo of the two ladies with their records is where sharing and access to the records is fundamental to community education.

Attached resource:

christophe millien Replied at 10:02 PM, 2 Jun 2015

For the fist question : we know our project design is end when all stapes are completely done.
1- the title of the project
2- the purpose of the project
3- objectives are clearly difined
4- the time line of your project
5- implementation plan of your project and where you will realize it an for who.j
6- monitoring and evaluation plan of your project
7- expected outcome
8- necessary ressources for your project well difined
8- budget

Leonard Davolio Replied at 10:22 PM, 2 Jun 2015

If it's of interest, I recently attempted to draw wider attention to the
important yet sparse use of design in healthcare.

christophe millien Replied at 10:26 PM, 2 Jun 2015

You know you dising it right when you take into account all points et it base on real need of the population.
for example for an it system: your project dising is done base on all points upstaire and its utility is clearly difined in term of result

1- a good medical informatic system with a good capacity to generate good data.
2- favor a good scheduling system
3- favor a better interaction with the patient
4- favor a better quality of care With a better cost egficiency approach.

christophe millien Replied at 10:33 PM, 2 Jun 2015

You know your project will successful when it would like to solve a real problem that the population think important for him and the project must be taking by the population as its project and that means the project is a project of the population.

christophe millien Replied at 10:40 PM, 2 Jun 2015

That means how you make an it project important for the population. To show them your IT system will solve problem they have meet in all day activity and that can help them to have a better plan for their disease

christophe millien Replied at 10:44 PM, 2 Jun 2015

If your project is base on the need of the population they will buy it without concern. One important point is to make sure your project take into account the social economic reality of your population.

christophe millien Replied at 10:48 PM, 2 Jun 2015

For example how can you connet a big part of the population who have access to a smartphone to your hospital to kow is appointment for example Or about his medication.

Madhuri Gandikota Replied at 11:34 PM, 2 Jun 2015

Dear Members,

Thanks Rebecca for the invite. I have been following the discussion but as I was travelling anand hed was in a Health DataPalooza meeting at DC .

Based on the questions raised by the panelists, and the points to discuss. Some of my thoughts are to the questions are:

Q) When does the design of a project end, and how do you know if it's successful?

Some of the thoughts I was trained to think when designing a project is to consider

a) If the project is interesting, feasible, novel, and exciting to work on
b) Population to work on
c) Causes and outcomes
d) Factors that are associated with both cause and outcome
e) Factors that are modify both cause and outcome
f) The subsequent steps would be is to convey the message to the stakeholders of interest. Once the end user can comprehend your design, I feel you have reached the first milestone.
a) The next step would be the beautification of the design. This involves again which stakeholder you are targeting to. It would be important to know the demographics, cultural context, and the message you would want to convey.
b) The final step would be to touch the heart of the person. I feel the project would end once we really touch the heart of the person, that he/she cant get over it-just fall in love with the concept, then we have actually reached the goal.

Q) How will you know if you've designed it right?

Like any thing we do in our life, we will know that the project we designed is right, when we see, delight among the people who use it, be a value add , ease of adoption, perhaps requests for more designs.

• How do you incorporate design to try and make your implementation more likely to succeed?

In addition to design, I feel implementation requires much broader approval/consensus of all the stake holders. Practical aspects such as budgeting, training, willingness to embrace change are the key. Further, open-ness to take chance and test the new business idea is the first steps for successful implementation. This should be coupled with active adoption. I feel , it is very easy to be risk averse, but sometimes, testing the new idea is the back bone of evolution of a company/system.

• how do you get people to buy in to the fact that this is important and should be funded?

A new project warrants funding, some of the points that comes to my mind are if the project

a) Caters to unmet need and addresses the pain points
b) Changes the paradigm of present thinking
c) Opens up new avenues for further research,
d) Re-imagines the present way of addressing the problem
e) Addresses the need of all the stakeholders

In addition, to these answers to the panel members questions, there are several interesting points raised by the members.

I look forward to tune into these questions.

Mikael Gebre-Mariam Replied at 1:02 AM, 3 Jun 2015

Alvin, my question alludes back to your initial comment.

From your experiences at national and regional levels what role have you seen or do you see architecture and governance playing in the HIS design process?

Naomi Muinga Replied at 2:26 AM, 3 Jun 2015

Interesting discussion going on here

Anjali - you raise an important point. Improving paper data collection systems should really be our starting point as it allows for easy transfer to an e-form. There have been efforts in Kenya to create a structured form for admission of paediatric patients. The use of the paper forms has had a great impact on improvement of documentation see below. The form is now in extensive use in paediatric departments in Kenyan public hospitals.

The point I wanted to bring across is that from this we have been able to use the basic forms with extensions to create an eCRF for a clinical trial and currently a data collection tool for on going work. We happened to share the form with one of the developers we interacted with and they were able to incoporate the form into their EMR.

The benefits of this is that the data becomes easy to collect, manipulate and extract as it is structured. Moving to an eForm in places where the clinicians are already using the form would make the transition smoother and increase acceptance.

Attached resource:

Leonardo Leonidas Replied at 5:21 AM, 3 Jun 2015

Dear Dr. Joaquin Blaya,

My work here in the Philippines is trying to Reduce Diagnostic Errors
through writing at Inquirer, a Nationally distributed daily newspaper. I
also give talks at medical societies and medical colleges. And I am an
active blogger at different medical schools here in the Philippines and FB
medical groups.

I have given my Ten Commandments below to my students at Tufts University
School of Medicine and colleagues in the Philippines. This has been
distributed to members of Society to Improve Diagnosis Organization founded
by Mark Graber.

Ten Commandments to Reduce Diagnostic Errors

1.Thou shalt First "Do No Harm."

2. Thou shalt think
of serious and treatable conditions and act on them without delay.
3. Thou
shalt remember that Diagnosis is History, History, History. Then confirm
with clinical examination, labs, and more History.
4. Thou shalt request a test
only if it will change your plan or help in predicting the future.
5. Thou shalt
question "authority" such as your senior residents, consultants, experts,
or even National guidelines.
6. Thou shalt
continue the debate and questioning even though the data is "IN."
Thou shalt maintain a high index of suspicion for uncommon presentation of
8. Thou shalt recognize your own belief, biases, prejudices, and thinking
9. Thou shalt be way of your hunches and intuitions. It is
better to use Evidence Based Medicine.

10. Thou shalt have an iPad* or smartphone in your palm.

Please share if you agree with my 10C.

A/Prof. Terry HANNAN Replied at 5:53 AM, 3 Jun 2015

Naomi, the paper is a very good knowledge resource. When I read it I think I may have been one of the reviewers although my older memory may be failing me!!!!
For myself having been associated with the early phases of the MMRS, AMPATH projects this paper AFFIRMS the continued need for e-forms and paper forms as an OVERLAP phase of eHealth evolution.

Alvin Marcelo, MD Replied at 8:26 PM, 3 Jun 2015

Dear Mikael,

"From your experiences at national and regional levels what role have you seen or do you see architecture and governance playing in the HIS design process?"

I think governance and architecture play important (but often neglected) roles in HIS design (especially those at national scale). Both are risk-mitigating techniques -- governance sets directions (so it is clear which way the program goes) and architecture constrains the artifacts ("forcing" apps to reuse these artifacts as much as possible). Although governance and architecture appear to limit what is possible in terms of design, they actually enable structured interactions between architecture-compliant design.

Having said that, enterprise continuum (a concept by The Open Group Architecture Framework constrains architects to look sequentially at global, then regional, then national artifacts when designing their systems.

In summary, for countries that are resource constrained, it might be cost-effective if they have access to a common shared repository of enterprise architecture artifacts. From this repository, they can grab architectural designs that they can now use as constraints for their national HIS design. This makes it easier for developers to create applications that are now globally compliant (if they used global artifacts) regionally compliant (if regional artifacts) and nationally (if national-specific artifacts). The onus to the countries is that there are tremendous benefits if they adopt global artifacts.

Alvin Marcelo, MD Replied at 8:31 PM, 3 Jun 2015

In addition to my previous post, proceeding with health IT design without consideration of the overarching governance and architecture, will most probably result into siloed systems. I believe there is a sweet spot between the constraints of governance and architecture and the freedom of end-user application design. Developers should seek out that sweet spot because doing so makes their application a bona fide participant in a network of applications in the national health information system.

A/Prof. Terry HANNAN Replied at 9:35 PM, 3 Jun 2015

Alvin, a point of clarification please. My question relates to 'governance'. Does this term relate to the 'governance of the 'system' or the socio-political governance? Does the governance involve the 'collaboration' across all levels of the health system (eHealth) from governments to patients (end users)? I may be asking this question based on complete ignorance or 'dumbness'.

Alvin Marcelo, MD Replied at 10:03 PM, 3 Jun 2015

Dear Terry,

Apologies for the ambiguity --

To be clear, in my previous posts, I refer to "governance" as the mechanism
for a country (not just a project) to make decisions on priorities,
directions and resources pertaining to eHealth. This is usually led by the
ministry of health or a body authorized by the MOH. It is also
multi-sectoral since the components of a successful national eHealth/health
information system is hinged on the participation of several sectors of
society (healthcare, health insurance, ICT, public, private, academe,

A very useful document that is now becoming popular in Asia is the WHO-ITU
National eHealth Strategy Toolkit.

Without governance, anyone with a great eHealth idea is probably correct.
But with governance, there is now a system to assess which of these
brilliant ideas gets national investment.

A/Prof. Terry HANNAN Replied at 10:21 PM, 3 Jun 2015

Thanks Alvin. I have recommended this because of its clarity of thought and presentation.

christophe millien Replied at 7:39 AM, 4 Jun 2015

It's also important to see how we can organize IT in term of system to
work like a net work. And we need to select information that we can share
in the net work.

Mikael Gebre-Mariam Replied at 12:26 PM, 4 Jun 2015

Alvin, thanks for the input.

Following-up on your answer, cultivating architecture practices (e.g. enterprise architecture) and IT governance in the developing country context I'm sure can be political given potential conflicts in mandate between donor/implementing partner and MoHs and the need to address immediate and/or local needs vs. ensuring long-term enterprise-wide HIS coherence. The Ebola situation I feel is a case in point when it comes to IDSR and the parallel mHealth solutions that emerged. How have you managed this balance in the Philippians in your architecture-governance program?

Mikael Gebre-Mariam Replied at 12:32 PM, 4 Jun 2015

Sorry, that should be Philippines.

Aaron Beals Replied at 1:04 PM, 4 Jun 2015

Those of you discussing paper forms got me thinking about the separation of data and presentation layers, and called to mind the SMART Health IT initiative out of the ONC in the US, an initiative headed up by Kenneth Mandl. The principle behind the project is decoupling the data and presentation in order to create tailored UIs and give end users the ability to choose from a collection of front-end "apps".

Making an EMR SMART-capable means adhering to their API standard, or--better yet--using the new FHIR standard. We'll likely all grow old waiting for the big EMR vendors to adopt this model (at least an open-standard version of one), but it's encouraging to see a few of the smaller ones signing on.


Attached resources:

christophe millien Replied at 2:29 PM, 4 Jun 2015

Important point to consider is the legal aspect in using IT system in
medical information.

A/Prof. Terry HANNAN Replied at 5:18 PM, 4 Jun 2015

Mikael, your feedback to Alvin is very interesting and as I read the following "political given potential conflicts in mandate between donor/implementing partner and MoHs and the need to address immediate and/or local needs vs. ensuring long-term enterprise-wide HIS coherence" I thought of the AMPATH system in Kenya and the conflicts post-general elections. I have attached two documents that relate to those events. I hope they are of value.
As you are aware Alvin's scenario was how to manage post-typhoon natural disaster.

Attached resources:

Joaquin Blaya, PhD Replied at 8:33 PM, 5 Jun 2015

We wanted to thank your panelists and all of our members who participated
in this very lively and fruitful discussion. It has shed light on many
points key to health IT and we hope all of you have found it useful.

We look forward to more discussions.


Gerente de Desarrollo, eHealth Systems <>
Research Fellow, Escuela de Medicina de Harvard <>
Moderador, <>

Mikael Gebre-Mariam Replied at 1:17 PM, 6 Jun 2015

Thank you Terry!

Alvin Marcelo, MD Replied at 6:15 PM, 6 Jun 2015

Dear Mikael,

Yes, IT Governance and enterprise architecture are fundamentally political
despite being well formed frameworks. Having said that, it is therefore
important to make sure one has the right governance structure that can give
the property mandate behind these.

So if you are designing a national scale health application, then it should
be governed by a national level governance structure. Doing so enables your
app to be consistent with other national scale projects.

In the Philippines, a national eHealth steering committee was created led
by the minister of health sorted by the ministry of ICT, the national
health insurance agency and the national health sciences center. They are
accountable for the national eHealth strategy.

Under them is the national eHealth technical working group. They do the
heavy lifting on behalf of the steering committee.

The TWG evaluates the environment and crafts recommendations to the
steering committee who officially adopts them.

It is through this process where an enterprise architecture activity should
be designed and planned. Doing so clearly shows the degree of influence the
EA will have on the national eHealth landscape.

This is not just application design per se. This is about creating an
environment that will empower more developers to design compatible software
in an ecosystem.

Alvin Marcelo, MD Replied at 9:51 AM, 7 Jun 2015

Dear all,

As the week ends, I ask for your understanding if my posts had focused too much on the high-level aspects of governance, management, and enterprise architecture. I strongly believe if these three are done right and at the right sequence, then everything that Christophe Millien and others (such as Dr Leonidas) listed will have a nurturing environment where applications can prosper in an interoperable ecosystem. It is easy to design health applications but hard to make them scale to reach relevance in a country -- for apps to stick long enough to actually improve health outcomes....

Robert Morrow Replied at 10:37 AM, 7 Jun 2015

With all due respect, Dr. Marcelo, and speaking myself as a veteran community family physician in the Bronx, US, if you don't have your hands in up to the elbows in community based health practices, then the code is at best a pebble in your shoe. At worst, the code is a way to wall off useful work from provider to provider, and to shackle the activities of providers to an industrial-based model.
As we know, in general, industry serves the owners and their profits, not the providers nor the community.
In the US, where massive private health systems have turned into financial entities whose key purpose is growing by buying and selling other service entities, provision of care is replaced by the monetization of the smallest particles of the industrial process. This service to that monetization makes good health care difficult, makes implementation in response to community needs challenging, and makes the daily use of HIT a complex, difficult process, if repetitious. But the functionality of the health record reflects monetization of industrial elements far more than optimization of health and access to services. It replaces community networks with walls between providers.
In my mind, with my fingers at the keyboard as I care for people in the Bronx, this is the crux of the issues of coding the health record-open networks that work for the health of the public, or walls in the service to large, competitive corporate entities.
Bob Morrow, MD
Associate Clinical Professor of Family and Social Medicine
Albert Einstein College of Medicine

Paul Nelson Replied at 1:04 PM, 7 Jun 2015

GOVERNANCE. Is it not a recurring theme as our world on this day in time? We all grapple with reconciling the variety of adversities underlying the profound level of cognitive dissonance as we participate in the market places of KNOWLEDGE, RESOURCES and HUMAN DIGNITY? With the web access points offered by Terry, it seems to be the underlying theme in Australia, as it is for me in USA. They are in the second paradigm shift, we are in the first. Agony spreads unmercifully.

I leave the following admonition from Herbert A. Simon: For any group of people, the PARTICIPATION HYPOTHESIS states that "...significant changes in human behavior can be brought about rapidly only if the persons who are expected to change participate in deciding what the change shall be and how it shall be made."

The world-wide community, as signaled above, could start by working on a model Charter to be authorized by any nation as a basis for the GOVERNANCE of its institution with the authority and responsibility to sustain and adapt its electronic health record. If 5 - 7 of the developed nations (as defined by the U.N.) could propose and develop such a collaborative model for future implementation, the basis for helping all nations would be greatly augmented. It might take several years to refine, given our world's level of violence. How to start...

dian marandola Replied at 4:29 PM, 7 Jun 2015

A model charter that continues to gain momentum is - Take an action today to end poverty: Add your signature in support of the Social Protection Floor Initiative

Also, one can visit: High Commissioner for Human Rights site:

Alvin Marcelo, MD Replied at 5:35 PM, 7 Jun 2015

Dear Paul,

Would it be plausible if 5-7 developing nations be the ones to model the collaborative ‎model that you mentioned?

While it will be challenging for them, their resource-constrained nature 'forces' them to take a systematic approach to their national health information systems design. They also have less complexity and legacy systems to consider...


Alvin Marcelo, MD Replied at 5:42 PM, 7 Jun 2015

I a gree with Paul about  the important role of  participation. ‎When we developed our EMR, the first group of health workers who co-designed it felt a lot of ownership with the software  despite the bugs. We were surprised when the subsequent health workers (in other nearby facilities) showed a lot of resistance with the much-later bug-free version.

‎I propose that end-users participate in the design of the applications they will use. Yes it adds complexity (you might end up with different versions of your EMR) but nothing beats end-users staunchly defending something they feel was of their own creation.

Could EMR implementers learn from the maternal care program? When you nurture a being in your womb for nine months, then it becomes your own baby - flaws, flecks and all....and you care for it because it _is_ your own...

Amal Bholah Replied at 5:21 AM, 8 Jun 2015

The best design are these tools which are invisible yet remain practical and intuitive. Simplicity is the key to great products.

A/Prof. Terry HANNAN Replied at 6:25 AM, 8 Jun 2015

Amal, the KISS principle. Keep It Simple Stupid!

Jessica Ludvigsen Replied at 9:48 AM, 8 Jun 2015

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Pratap Kumar Replied at 2:13 PM, 8 Jun 2015

A first post to this group and will keep it simple! As Zach highlighted earlier in this discussion I've begun a quality improvement initiative in Kenya that uses very simple technology to bring clinical practice guidelines (CPGs) into the point of care. We use rubber stamps to print guideline templates that have been specially designed for use in clinics in low resource settings. The templates are part checklist and part adapted CPGs that reflect the challenges faced by individual clinics (e.g. no microscope or frequent shortages of first-line drugs). Providers participate in the design of the rubber stamp template, increasing their buy-in. Templates are designed to be easily filled in by the provider (using bubble sheet format) which can then be easily & automatically digitised using a mobile phone camera. Preliminary data from clinics in Nairobi's slums are really encouraging - antibiotic prescription rates in URTIs down from 95% to 45%, increased use of nitrofurantoin for UTI as first-line antibiotic, and increased documentation across the board. It's an example of simple front end tools (rubber stamps) with innovative mobile image processing tools to rapidly digitise and analyse data on paper charts. Happy to hear your thoughts and misgivings!

Alvin Marcelo, MD Replied at 11:40 AM, 10 Jun 2015

To Dr Bob Morrow: I agree and even at the clinic level there must be (and I am sure there is) governance -- the clinic owner. The clinician should have the liberty and leverage to design his own information system that works for him. If it's paper then that's it. It is fundamentally important that the patient receives the best care possible during that encounter and the clinician makes decisions on how to best deliver that.

A/Prof. Terry HANNAN Replied at 5:19 PM, 11 Jun 2015

I am aware that this discussion has "ended" however the GHDonline philosophy is that the discussions are never "closed"!!
The posting here is from the AMIA site with thanks to Dr Ross Koppel

Subject: [Implementation] - Similarities of interfaces and HIT-enhanced errors

RE: the demand/need for some reasonable similarities of interfaces: Of course it's important and of course it's usually ignored. AMIA did publish (in JAMIA) a task force report on safety and HIT. Blackford M and the AMIA task force wrote it (disclosure: I was one of the coauthors, and pushed hard on that issue of similarities of interfaces). To my knowledge, the report has not been consequential:
Clinicians working across different systems and devices find wildly varying interfaces and processes. Now, of course, the industry (including the ONC and AMIA) is saying that EHRs are low risk and need no FDA oversight. IMO, that's a classic need for a regulatory oversight or industry-standardization agreement.

I would urge folk to look up the work of a colleague, Harold Thimbleby (Univ of Swansea, Wales). Harold is a computer scientist who studies how we make errors with interfaces (smart pumps, computers, EHRs, calculators used by clinicians to determine doses, ATMs, etc).

Riddhi Doshi Replied at 8:36 PM, 11 Jun 2015


This is very interesting. Similarity of interfaces/Ehr would be a huge
steps towards interoperability and tranfer of medical records across
providers and health systems. Currently, practice groups within the same
hospital/healthcare system often use totally different EHRs and hence often
there are issues with transfer of health information within hospitals. One
hand often does not know what the other is doing and medical errors result
in grave adverse events (IOM report). EHR licenses, maintenance and
training are huge money makers in the US. In a recent 3 part series in the
NEJM, Dr. Rosenbaum advanced the argument that while there is data showing
that industry-physician influence can lead to unproductive outcomes (E.g.
the bias of small gifts, academic detailing), there is no proof that
consultancy for industry, industry funded research, or other (larger) ties
lead to improper scientific conclusions. Would it be appropriate for one to
consider the role of industry in the push for lack of regulations,
oversight and reluctance to make interfaces similar, as being driven by
conflict of interest and profits rather than public good?

Ignacio De Gabriel Hernández Replied at 9:49 AM, 12 Jun 2015

Recientemente estoy haciendo correcciones a mi quirófano (para cirugía de corta estancia..sólo tengo un quirófano y 4 habitaciones adjuntas..realizo procedimientos de corta estancia y todo ello lo hemos construido y diseñado con nuestros propios recursos económicos..pesada pero bella la experiencia..quisisrea que sí hay algún experto en el pánel sobre diseño de pequeñas unidades quirúrgicas de corta estancia,me de una orientación sobre cómo se organiza un centro de esterilizado en nuestro medio llamado CEYE..o proporcionarme literatura

Daniela Martinez Replied at 11:15 AM, 12 Jun 2015

Hola Ignacio,

Estas son las recomendaciones de la OPS, espero te sirva de algo.

Daniela M

Steven Wanyee Macharia Replied at 11:46 AM, 12 Jun 2015

Hi Pratap! very interesting work. Let's find time to connect and explore how we can leverage our work implementing POC EMR system with what you are doing with improving access to CPGs - I know other CQI groups we work with will be very interested to hear about your work.

Roseline Y. T Chesson Replied at 12:11 PM, 12 Jun 2015

Greetings Steven, I am very, very glad to hear of your great works. Health IT is my desire ways to apply my public health knowledge by wish I know that  it can have greater impact on my population. I hope to connect with you better to enable us do more works together. Please see my emeil address: . I would be grateful if you were to contact me.

Patrick Crisp Replied at 3:07 PM, 12 Jun 2015

In my opinion, having providers use the same interface is not going to fix the problem. There are many different ways to say the same thing in medicine and that is just in one language. Even with the same interface (unless it was totally restrictive), data would not be interchangeable. I think that the answer lies in the coding system that we use when we record data. We need a coding system that is comprehensive (e.g. problems, findings, investigations, procedures,medications,devices etc). It needs to be able to convey the same clinical meaning when the same concept is used no matter which language or dialect is used. Snomed CT is the only system that I have seen that can do this. If you build EHR systems that fully use Snomed CT, then you do not have to have the same user interface to be able to meaningfully exchange or extract data.

Thanks for this conversation.
Patrick Crisp

Luis Azpurua Replied at 6:33 AM, 14 Jun 2015

Ignacio de Gabriel Hernández:

Si necesitas mayor información / ayuda, puedes contactarme por el correo electrónico



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Joaquin Blaya, PhD Replied at 7:22 PM, 17 Sep 2015

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