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Health Systems Building Blocks - Coggle Diagram

- - - - culture can affect the implementation of policies
    - - ex. dengvaxia: cost-effectiveness that can improve the QOL of Filipino -> but it was withdrawn not because it is not effective, but rather there are people fabricated stories about the efficacy of the vaccine
        
        dahil marami ng ayaw, tinanggal na sya
      - governance has different levels
        
        WHO has requirements that needed to be obeyed by its member states
        
        natl gov decides specific laws on how to implement strategies
        
        DOH level specifc to health system: partner with different government agencies such as DILG
        
        ex. cancer law: joint memorandum with DILG: development of cancer preventive office
        
        mas maayos ang implementation of health strenghtening strategy dahil sa pagtutulungan ng different health levels
  - - - in the case of our country, we have many policies but the implementation of those is non-existent; hence losing accountability
    - - delegation or an understanding (either implicit or explicit) of how services are supplied
      - financing to ensure that adequate resources are available to deliver essential services
      - performance around the actual supply of services
      - receipt of relevant information to evaluate or monitor performance
      - enforcement, such as imposition of sanctions or the provision of rewards or performance
        
        incentives are decided on ntl gov lvl
  - - - pharmacovigilance
  - - - Purpose: create health policies
      - LHBs also decide the commodities they should purchase.
    - - RA 7160
        
        To propose to the sanggunian concerned, in accordance with standards and criteria set by the Department of Health, annual budgetary allocations for the operation and maintenance of health facilities and services within the municipality, city or province, as the case may be.
        
        To serve as an advisory committee to the sanggunian concerned on health matters such as, but not limited to, the necessity for, and application of, local appropriations for public health purposes.
        
        Consistent with the technical and administrative standards of the Department of Health, create committees which shall advise local health agencies on matters such as, but not limited to, personnel selection and promotion, bids and awards, grievance and complaints, personnel discipline, budget review, operations review and similar functions.
        
        TLDR; They decide the budget, the allocation of the workforce, and UHC adds function to LHBs
        
        requires health development plan to be created
      - RA 11223
        
        Set the overall health policy directions and strategic thrusts including the development and implementation of the integrated strategic and investment plans of the province-wide and city-wide health system.
        
        the LGU should have its own referral system; to guide the patients on what to do when sick (all of the processes involved)
        
        Oversee and coordinate the integration and delivery of health services across the health care continuum for province-wide and city-wide health systems.
        
        Manage the Special Health Fund (SHF).
        
        Combine funds that is coming from Philhealth or donations from NGOS/LGUs
        Special health fund should only be used for health and is only managed by the LHB
        
        Exercise administrative and technical supervision over health facilities and health human resources within their respective territorial jurisdiction
        
        Law includes health systems strengthening
        
        LGU should have its own referral system
        When patient’s sickness gets worse, the patient should know here to go - a patient navigator should be present in UHC law so that patient would know their next movement in the local health system
    - - Problem is that not all LGUs have a working LHB
      - They only develop LHBs when they have a * partner that capacitates them to establish an LHB
      - Community participation is the regular inquiry of the people for their needs.
      - Direct and regular consultations with the people were not very common
        
        It depends on the LGU / if they wanted to talk to their barangay about it
      - Negotiating health decision options were frequently done through informal channels
        
        E.g. Formal meetings are not held, “meetings” are usually informal and there is no proper documentation
      - Few NGO representatives are empowered in the LHB which harnesses their deeper involvement in community health matters
        
        In the process of devolution we want to know the needs of the community, thus we need high community participation
        
        Community participation is preferred
        
        If members are not empowered by LHB, it would be more difficult to have community participation
  - - - Whether countries have appropriate policies, strategies and codified approaches for HSG
        
        Example: plans for maternal and child health, communicable diseases
      - Determinants of healthcare-provision governance
        
        ownership arrangements
        
        decentralization
        
        stakeholder participation
        
        contextual factors
      - Who owns the RHU but they can partner institution to complete its services
    - - Whether rules and procedures are being effectively implemented or enforced, based on the experience of relevant stakeholders
        Check if the rules are complete and implemented correctly
- - - - At the govt level we have a tax based system from the GAA, but this isn't our lone source of funds during hospitalization (ex. Out of pocket expenses, priv insurance, philhealth)
    - - Describes the share of spending on health in each country relative to the size of its economy. It includes expenditures corresponding to the final consumption of health care goods and services and excludes investment, exports, and intermediate consumption.
        
        economy can be described as GDP
      - National Health Expenditure Sets
        
        transfers from government domestic revenue (allocated to health purposes)
        
        revenue of govt used for health
        
        ex. GAA and NTA
        
        internal transfer and grants
        
        social insurance contributions (Philhealth)
        
        social insurance contributions from employees
        
        Social insurance contributions from employers
        
        Social insurance contributions from self-employed
        
        Other social insurance contributions
        
        voluntary prepayment; other domestic revenues (private insurance
        
        Revenues from households
        Revenues from corporations
      - focuses on actual spending on healthcare goods and services within a year
  - - - With the broadening of its coverage under the UHC Act, the health sector is mandated to provide sufficient and high quality individual-based and population based health services
        PhilHealth has accredited a combination of public and private healthcare providers who can offer sufficient and accessible individual-based health services
      - benefit packages
        
        all case rates (ACR)
        
        in-patient for non-catastrophic OOP
        
        Z benefits
        
        for catastrophic OOP
        
        ex. open heart surgery
        
        SDG-related benefits
        
        for primary healthcare (e.g., HIV)
      - DRG-Based Global Budget
        
        diagnosis-related groups
        
        Patient classification system which utilizes an algorithm in assigning a case to a specific group by using a special backend system called a grouper. A DRG system classifies hospital cases into groups that are clinically similar and expected to use similar amounts of hospital resources. When used for payment, the amount per episode of care is fixed for patients within a single DRG category (based on average cost), regardless of the actual cost of care for that individual episode, but varies across DRG
        
        ex. diabetes, dyslipidemia, hypertension (pooled)
        
        actual groups are desgned by the country
        
        global budget
        
        An approach to the purchase of medical services by which health care provider negotiation concerning the costs of providing a specific package of medical benefits is based solely on a predetermined and fixed budget (prospective)
        
        RHU will get funds before the service. PhilHealth will give the budget based on the population, which will be used for a whole. It is not necessary if the pop used the budget or not
      - Pooling of Funds
        
        pursuant to RA 11223 (starting 2023)
        
        50% of the National Government share from the income of PAGCOR as provided for in Presidential Decree No. 1869, as amended
        40% of the Charity Fund, net of Documentary Stamp Tax Payments, and mandatory contributions of the PCSO as provided for in RA No. 1169, as amended
        
        Shall be transferred to PhilHealth for the improvement of its benefit packages that will cater to the vast majority of members here and abroad
        
        Benefits for improvement: medical and surgical procedures; expansion of case rates for hemodialysis up to 156 sessions; enhancement Z benefit packages for selected orthopedic implants, post kidney transplant, breast cancer, prostate cancer, cervical cancer, open heart surgery for children (ventricular septal defect and TOF); and physical medicine and rehabilitation
        
        ex.PCSO has z benefit packages for certain disease. PCSO will then give the budget to PhilHealth and PhilHealth will give the packages to the patients
  - - - catastrophic
        
        occurs when the amount a household pays out of pocket exceeds a predefined share of its capacity to pay for health care.
      - impoverishing
        
        occurs when individuals or households have to pay for health services directly from their own funds, pushing them below the poverty line or further into poverty
    - - four domains
        
        pagtitiis
        
        pangungutaing
        
        pagmamakaawa
        
        PhilHealth
    - - more than 60%
- - - - Expectation: Increase in inputs = Increase/better/improve service delivery and enhanced access to services
  - - - population based care
      - general programs
      - definition
        
        Using different disciplinary and professional perspectives as a collective or societal approach aimed at improving health, prolonging life and improving the quality of life among whole populations
        
        broad coverage of practice
      - elements
        
        surveillance
        
        governance
        
        financing
        
        health promotion
        
        health protection and legistaltion
        
        always think about the population levle intervention
        
        human resources and research
      - sometimes some subfunctions overlap with public health
      - greater variations in activities such as disease prevention, healthcare emergency preparedness, social participation and communication
        
        reflects to a great extent the differences in perspectives on what constitutes public health, in what degree healthcare should be considered in public operation
    - - patient-care based care
      - initial access of the patient to their health care provider
      - definition
        
        “First line health services” such as health centers, general practitioner practices or clinics – as the primary level of care because they are close to the people they serve, accessible to all, and able to address a wide range of health problems
        
        represents the first point of contact for unspecified and common health problems
        
        many services that fulfill a wider public health function are provided in primary care settings while in some countries primary care includes office-based specialists and fulfills a specialist care subfunction
        
        includes ancillary such as pharmacies, dialysis centers, and laboratories
        
        primary care or public health do not only involve gov owned institutions
        
        pharmacy in the ph is private practice
      - BHS are the most prominent health facility in the country
        
        most of the primary care facilites are owned by the gov
      - DOH required stricter accreditation for primary care faciliteis
        
        Primary Care Provider Network
        
        formation of a provider network between a primary care facility and a partner ancilliary facility
    - - specific services demanded
      - specialized training to provide intervention for the patient
      - definition
        
        frequently distinguished into secondary (local hospitals) and tertiary care (regional or national hospitals) in order to concentrate expertise and complex, high-cost resources
  - - - the degree which health services for individuals and pipulations increase the likelihood of desired health outcomes are consistent with current medical knowledge
      - important characteristics to check upon lookiing at health systems
        
        comprehensivenss
        
        we dont have any out-patient package for medicines: therefore, services given for out-patients are not comprehensive
        
        accessibility
        
        services are direclty and permanenlty accessible with no undue barriers of cost, language, culture, or geography
        
        coverage
        
        ○ Services are designed so that all people in a defined targeted population are covered
        
        continuity
        
        ○ Service deliveries are organized to provide an individual with continuity of care across the network of services, health conditions, levels of care and over the life cycle
        
        quality
        
        person-centeredness
        
        Services are organized around the person, not the disease or the financing
        We provide interventions that doesn’t deter based on the patient’s financial capabilities
        
        coordination
        
        Local area health service networks are actively coordinated across types of care, provider, levels of service delivery and for both routine and emergency preparedness
        
        accountability and efficiency
        
        Health services are well-managed so as to achieve the core elements described above with a minimum wastage of resources
        
        Managers are allocated the necessary authority to achieve planned objectives and held accountable for overall performance and resources
        
        Assessment includes appropriate mechanisms for the participation of the target population and civil society
    - - the absence of unfair, avoidable or rediable differences among groups of people, whether those groups are defined socially, economically , demographically, geographically or by other dimensions of inequality (e.g. sex gender, ethnicity, disability, or sexual orientation
    - - using available resources in the best way possible to achieve the health systems goals which implies making sure that the resources are used optimally without any wastage
        
        technical efficiency
        
        when the least possible amounts of inputs are used to produce a given amount of output
        
        allocative efficiency
        
        whether health inputs are allocated in a way that produces the optimal mix of health outputs to maximize the health of society
    - - adequacy
        
        is the money given to DOH adequate to implement health programs
      - allocative efficiency
        
        are resources assigned to the most productive interventions
      - technical efficiency
        
        have incremental expenditures been matched by increases in program outputs, and do they promote efficiency and accountability?
      - effectiveness
        
        has the earmarking policy resulted to real improvements in key target health and health access outcomes?
        
        takes into account 3 criteria: adequacy, allocative efficiency, and technical efficiency
- - - - no. of health workers per 10,000 population, by cadre
        
        cadre: type of health worker
      - indicator most commonly reported internationally and represents a critical starting point for understanding the health system resources situation in a country
        
        given we are able to count the number of healthcare workers per number of people in a country, we have a reference for quality standards
        
        500 nurses per 10k population, but only 300 nurses are present in the country, thus this city lacks man-power
    - - To show pathways of inequities or imbalances in the supply, deployment, and composition of HRH; monitored through:
        
        imbalances in occupation/specialty
        
        geographic representation
        
        institutions and services
        
        demographics
    - - annual number of graduates of health professions educational institutions per 100,000 population by level and field of education
  - - - From health workers’ education and training, licensing as health professionals, entry into the workforce, deployment and career development, exit from, and re-entry into the health labor market
        
        Exit from – migration, customer service agents
        Ex. trained as pharmacist but did not work as pharmacist
    - - no pharmacist
      - Developed and maintained by the DOH and the PRC through Section 25.c of RA 11223 (UHC Act) and DOH-PRC JAO No. 2021-0001 “Guidelines on the Establishment, Utilization and Maintenance of the National Health Workforce Registry”
      - Hospitals and other health facilities are required to provide HRH data to the NDHRIS to aggregate data to product statistical reports on the location, distribution and skills mix of HRH
        
        In terms of pharmacists, this registry only covers the facilities accredited by the DOH.
        
        Recall, manufacturers, distributors, multinational pharmaceutical companies are not DOH registered. Hence, they are not required to submit anything on this registry.
        Nevertheless, the PRC provides how many students passed or failed.
  - - - lack of accurate HRH information to guide planning and policyy
        
        No tracking of HRH; the only basis we have is from PRC on board passers. BUT did they actually work in the health labor market?
      - limited collaboration among stakeholders with multiple roles in the HRH management
        
        DOH and PRC have a joint administrative order, however they don't work together at all
        
        should include DOLE and DI for health worker immigrants
      - fragmented HRH governance and unclear accountabilities
        
        May beef sa isa’t-isa ang HRH.
        
        E.g. proposed bill on dispensing physicians: no clear roles.
        
        Governance is also unclear. HRH is being governed by PRC, however, they cannot dictate board passers on where they should work.
      - poor implementation of policies on HRH management and development
        
        Policies were created, but are they being used properly?
        E.g. CPD Law for HRH requires 15 units, however, it is a question on whether the units they get matches their work (kahit ano na lang daw yung kinukuha nila as long as makumpleto yung 15 units). It should be clear to HRH people that their chosen tracks should match their CPD units.
    - - inadequate number of health workers in the health sector
      - inequitable distribution of HRH
        
        In rural and urban settings, in community and hospital, regulatory, etc.
        Even as pharmacists, we aren’t able to clearly see the other roles of pharmacists because we highly value pharmacists in large companies than in other sectors.
  - - - They provide scholarships, grants, free education (UP) → pass the boards → become part of the pool of health workforce → get un/employed in the health sector or be out of the labor force (pharmacist ka tapos nag doctor ka afterwards) → if employed, you can be in the primary health care level, hospital level, OR you migrate.
        Migrations and going out of the labor workforce result in attrition of healthcare workers.
  - - - Distribution of HRH has always been significantly higher in urban or economically developed areas
      - There is a lack of working health workers in rural areas as compared to the actual density of healthcare workers and their target ratio.
        
        If we exceed the target ratio, then we can say that we have an adequate number of healthcare workers.
        
        Urban areas like NCR and CAR have high concentrations of healthcare workers.
        
        In contrast, Region IVB (which includes Mindoro), Region XII, and BARMM have less health workers when they are considerably rural and less economically developed comparatively.
        
        Even if the population of a region has a lot of healthcare workers, they would often migrate to another area to work
    - - key performance indicators or what they need to do to achieve the vision of Department of Health which is for the Filipinos to be the healthiest people in Asia by 2014
      - types
        
        KRA 1: HRH Data Governance
        
        They should have complete data on the human resources for health
        
        KRA 2: Health Education Strengthening
        
        That is why we have benchmarking on health-related courses and roadmaps that would help the career progression of healthcare workers
        
        KRA 3: HRH Welfare, Protection, Career Development
        
        What they can become when they do the j
        It is what they can become once they do their jobs right now, because HR resources for health should not be stagnant
        
        example
        
        When will they get promoted to the managerial position?
        
        What do they need to do to achieve their desired position like additional training?
        
        KRA 4: HRH Migration and Reintegration
        
        KRA 5: Institutionalization and Localization of the HRH Masterplan (HRHMP)
        
        KRA 6: Institutionalization and Strengthening of the HRH Network / DOH / Other involved Sectors
        
        Important because there is a need for improvement in the communication between or among the stakeholders.
  - - - economic
        
        high unemployment rate, limited job opportunities, low wages and per capita income, poor health infrastructure
      - job-related
        
        poor working conditions (low salary; disparity in pay between Phils and other countries), poor working environment (lack of equipment and supplies); excessive workloads; no health insurance
      - career-related
        
        inconsistencies in practice, outdated or inappropriate curricula, institutional politics, and limited opportunities for professional development, specialty training and promotion
    - - job-related
        
        higher income, job tenure, better benefits, and compensation packages
      - skills enhancements
        
        advanced knowledge and skills acquired by working in highly developed countries, a global career, marketability, and professional growth
        
        You cannot work as clinical pharmacists in other countries if you have not yet acquired your doctorate in pharmacy (i.e. PharmD diploma). This diploma is equivalent to residencies in different departments in the hospital. Compared to the Philippines, this diploma is only a baccalaureate degree.
      - personal and socio-economic
        
        improvement in QoL both for individual workers and their families, improvement in financial capacity, presence of relatives in the destination country
      - policy and institutional support
        
        destination countries’ visa provisions allow family members to join the migrating health worker
        
        Especially compared to healthcare workers compared to other occupations from the Philippines, when you work in another country, they would allow you to become a resident in that country.
      - other factors
        
        opportunity to travel
        
        sense of independence, existence of social networks which provide connections for employement
        
        increased demand for health professionals due to demographic conditions
  - - - Sometimes, there are programs that cater the curriculum of other countries (e.g. PharmD degrees, because these curricula are required for a Filipino pharmacist to work abroad).
      - This is done because there is a market for students who want to work abroad immediately.
    - - We want our local healthcare graduates to serve in the country because the country invested in the education of these students. However, this does not happen usually.
  - - - There is a scholarship specific for medicine and in return it is expected that you will render a return service not necessarily as DBM, but sometimes required to be specific to the LGU that granted the scholarship
  - - - Contributions of CHWs include increasing access to health care, improving the quality of care, reducing the costs of care, as well as broader social contributions
    - - At the primary health care level, RHU, BHCs or BHS, we have midwives or BHWs.
      - BHWs are important because they know the people in the community, and sometimes including their illnesses.
      - It is very important to make sure that the community accesses health care services since they provide navigation. BHWs also understand the needs of the community.
      - Hence, BHWs are necessary to be properly trained, and for them to also know their rights (ex. Magna carta for BHWs).
      - However, there are some LGUs / Baranggays who only select BHWs based on their own preference, personal agendas (like kakilala nila), or have been longtime BHWs.
      - It is essential that BHWs have adequate training (ex. NCII training). It is also essential that they know their roles as BHWs.
- - - - to achieve this objective, we need:
        
        National policies, standards, guidelines and regulations that support policy
        
        Information on prices, the status of international trade agreements and the capacity to set and negotiate prices
        
        Reliable manufacturing practices when they exist in-country and quality assessment of priority products
        
        Procurement, supply and storage, distribution systems that minimize leakage and other waste
        
        Support for rational use of medicines, commodities and equipment, through guidelines and strategies to assure adherence, reduce resistance, maximize patient safety and training
    - - Medicines that respond to the priority health needs of a specific population
      - WHO Model List of Essential Medicines:
        
        provides guidance for the development of national and institutional essential medicines lists; led to global acceptance of essential medicines as a powerful means of promoting health equity, pursuing universal health coverage, and ultimately, strengthening health systems
        
        fewer than PH
        
        PNF
  - - - WHO (2004)
      - Frost and Reich (2010)
      - WHO-MSH 2000 (Center for Pharmaceutical Management 2003)
      - very supply side except WHO-MSH 2000
    - - other determinants that are not related to medicines
        
        market forces
        
        innovation
        
        transparency
        
        donor's agenda and funding
      - domains affecting medications are important
        
        health information
        
        health financing
        
        health resource
      - perspectives
        
        patients, households, and communities
        
        health service providers
        
        policy makers
      - access to medine framework (WHO)
        
        availability
        
        geographic accessibility
        
        affordability
        
        quality
        
        appropriate use
  - - - The percentage of outlets where an individual medicine was found on the day of data collection
        
        e.g “meron po ba kayong metformin for TODAY” if wala, hindi siya available
        We want it to be high or >80%
    - - median price ratios (MPR)
        
        calculated by dividing the median local unit price by the median international reference unit price
      - Assessed as the number of days’ wages required by the lowest-paid unskilled government worker to purchase 7 days’ supply medicine to treat an acute condition, and 30 days for a chronic condition, based on standard treatment regimens.
  - - - they may think about the UHCQ
        
        Can you actually deliver services without providing medicines?
      - Every time you deliver services, you need to provide medicines to the patients because they are sick
        
        No medicine -> patient will not recover
      - If these medicines are not properly provided with good policy, they cannot be utilized properly
        
        The DOH can buy medicine but have only been expiring -> not useful anymore -> system is inefficient
    - - You want to protect new medicines because it is a way to provide incentives to those who do R&D
        
        It is competing in a way that we want medicines to be cheaper and we want more companies to manufacture the medicine
        
        There should be a way to have a middle ground
        
        What is the most efficient way to balance the competing policies para maayos yung pag provide ng medicines?
    - - ensuring availability of quality generic and innovative products
        
        monitoring product quality
        
        prequalifying supplies, products
        
        negotiating prices, quality, volume, supply-chain security
        
        promoting fair competition
        
        engaging in risk sharing agreements
        
        establishing patient across programs
      - improving equitable access
        
        understanding socioeconomic and geographic disease and utilization profiles
        
        assessing of household care seeking and barriers to care
        
        expanding provider networks
        
        targeting policies and programs to improve access for vulnerable populations
      - encouraging appropriate use
        
        implementing and updating standard treatment guidelines (STGs)
        
        matching essential medicines and reimbursements lists to STGs
        
        assessing provider performance
        
        managing care comprehesively
        
        implementing and monitoring policies to encourage clinically appropriate and cost-effective use
      - keeping costs affordable
        
        monitoring routine medicines expenditures by therapeutic area
        
        evaluating health technologies, budget impact
        
        assessing household medicines expenditure burden
        
        implementing and monitoring policies and programs to reduce waste, inappropriate use
    - - is the product really bioequivalent
    - - for fair competition
        
        That is why we have Philippine Competition Commission
        
        When multi-international companies have mergers, the Philippine Competition Commission evaluates if they are still competition in a fair market
- - - - Patient profile, Healthcare needs, Treatments to serve as basis for clinical decision-making
    - - Aggregate facility records and administrative sources such as drug procurement records which enable healthcare managers to determine resource needs, guide purchasing decisions for drugs, equipment, and supplies
      - develops community outreach
    - - essential for public ehalth decision making
      - generate information of not only about those who use the services but crucially about those who do not use them
    - - Primary source of data from developing countries that’s why there are a lot of PSA Household Surveys
      - Facility based statistics are of limited quality
      - Brings together information from facilities and communities with a main focus on defining problems and providing a timely basis for action
      - The need for timeliness of reporting and response and the requirement for effectiveness linkages to those in authority with the responsibility for disease control impose additional requirements on health information systems
  - - - electronic health record
        
        An electronic version of a patients medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports
        
        overall healh records throughout your life
        
        national or local government level
      - electronic medical record
        
        An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization
        
        institution based recionds
    - - Physician access to patient information, such as diagnoses, allergies, lab results, and medications.
      - Access to new and past test results among providers in multiple care settings.
      - Computerized provider order entry (CPOE).
        
        Computerized request for labs and medications
      - Computerized decision-support systems to prevent drug interactions and improve compliance with best practices.
        
        Check for drug interactions and incompatibilities
        
        Need not to memorize since it can be seen in the system
      - Secure electronic communication among providers and patients.
      - Patient access to health records, disease management tools, and health information resources.
      - Computerized administration processes, such as scheduling systems.
      - Standards-based electronic data storage and reporting for patient safety and disease surveillance efforts.
    - - International Classification of Diseases (ICD) is designed to promote international comparability in the collection, processing, classification, and presentation of mortality statistics
        
        We can combine all patient data
        
        PhilHealth can assess if we have an epidemic, for example, in an upper respiratory tract infection
        
        Coded din pag namatay ang patient
      - These coding rules improve the usefulness of mortality statistics by giving preference to certain categories, by consolidating conditions, and by systematically selecting a single cause of death from a reported sequence of conditions
        
        For pharmacovigilance, we have a VigiBase and MedRA (side effect for patients)
        
        If many were detected, there will be a signal
        
        For example, there is something wrong with Vancomycin dahil nagsusuka mga nagttake, so napprompt tayo.
    - - High capital cost and insufficient return on investment for small practices and safety net providers.
        
        RHU cannot carry the heavy costs
      - Underestimation of the organizational capabilities and change management required.
        
        Do we need an IT department to keep this system
      - Failure to redesign clinical processes and workflow to incorporate the technology systems.
        
        Required EMR, the med interns are tasked to do the inputting in the system
      - Concern that systems will become obsolete.
      - Lack of skilled resources for implementation and support.
      - Concern that current market systems are potentially not meeting the needs of rural health centers or federally qualified health centers (FQHC).
      - Concern regarding negative unintended consequences of technology.