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BMC Medical Informatics and Decision Making
Logistics management information system performance for program drugs in public health facilities of East Wollega Zone, Oromia regional state, Ethiopia
Kefyalewu Tiye1 &
Tadesse Gudeta ORCID: orcid.org/0000-0002-5109-09532
BMC Medical Informatics and Decision Making volume 18, Article number: 133 (2018) Cite this article
Proper logistics management information system in the supply chain improves health outcomes by maintaining accurate and timely information. The purpose of this study was to determine program drugs logistics management information system performance in public health facilities of East Wollega Zone, Oromia Regional State.
A facility-based descriptive cross-sectional study design complemented with a qualitative method was conducted from April 01 to May 30, 2017. The quantitative data were gathered through reviewing logistics tools, a physical count of the selected program drugs, and interview of the pharmacy staffs. The evaluation of data quality was done on 134 RRFs and 805 bin-cards. A statistical package for social science version 20 was used to analyze the quantitative data. A chi-square test was performed to determine the association between dependent and independent variables. For the qualitative method, 11 face to face in-depth interviews were carried out, and the data were analyzed using thematic analysis technique.
Twenty three selected public health facilities were included in the study of which 39% of them had an automated recording system. Concerning the data quality, 65% of RRFs and 79.1% of bin-cards were accurately filled, and 97.8% of the reports were found to be complete. Sixty-nine percent of the facilities had timely submitted their report to the higher level and the reporting rate of the facilities was determined to be 97%. A significant association was observed between RRF data accuracy and type of profession, X2 (4, N = 134) =35.0, P = 0.040, trainings, X2 (2, N = 134) =37.12, P = 0.001, e-LMIS, X2 (2, N = 134) = 38.67, P = 0.03, educational status, X2 (2,N = 134) = 90.38, P = 0.012, & supervision, X2 (2, N = 134) = 94.03,P < 0.001. Shortage of skilled human resources and poor commitment of the staffs were identified to be the major bottlenecks of logistics management information system performances.
The facilities' report submission rates were promising yet the quality of the reports need improvement. Poor data quality was more likely because of weak supportive supervision and the information system being managed by non-pharmacy professionals.
A quality health service requires the availability of safe, effective, affordable and qualified drugs in adequate quantity at all times with appropriate dose and dosage forms. However, managing drug supply is a very complex process that requires a strong organizational structure, and integrated supply chain [1]. It involves a number of interrelated logistics functions accompanied by appropriate support functions in a supply chain and governed by stringent policy and legal framework [2]. These functions can be kept effective and integrated well if quality information moves up and downstream of a supply chain [3]. Thus, a properly managed information systems should be established in each health supply chain facilities.
Logistics management information system (LMIS) across all the supply chain levels increases program impacts, i.e. maintains commodity availability and improves service seeking of the community, enhances the quality of care, increases professional satisfaction and morale. Motivated staff are more likely to deliver a higher quality of service, improves efficiency and effectiveness [4].
A logistics management information system is a subset of organizations total information systems. It involves records and reports used to gather, analyze, and validate data from all levels of the logistics system that can be used to make logistics decisions and manage the supply chain [5, 6]. Therefore, logistics records are important parts of every logistics system. The records are intended to gather & record vital logistics data at each level of the health care system. The data are then combined to form logistics reports, which are used for critical decision-making about resupply quantities, forecasting, and procurement decisions [7].
Based on the actions taken on supplies in the logistics system (i.e. storing, moving and using the supplies), three basic types of logistics records are used to monitor and track the status of the products in the pipeline. It includes stock keeping records, transaction records, and consumption records. Stock keeping records hold information about products in a storage e.g. bin-cards and stock-cards whereas the transaction records keep information about products being moved e.g. report & resupply forms (RRFs), internal facility & resupply forms (IFRRs), different vouchers & etc. The consumption records maintain information about products being consumed at the health facility e.g. patient registration book [8, 9].
The quality and timeliness of the LMIS records and reports have a sound impact on the sustainable accessibility of essential medicines [10]. Supply chain facilities including service delivery points (SDP) should maintain the data quality of their LMIS tools and also submit their reports within the specified schedule, especially for program drugs like HIV, TB, malaria, maternal and child health (MCH) and family planning products [1]. The first three problems are the major global public health threats and cause substantial morbidity, mortality, negative socio-economic impacts, and human suffering. MCH and family planning are also the major challenges in low-income countries next to HIV, TB, and malaria [11, 12]. Products for these problems are not easily accessible in developing countries; they are obtained through the financial aid of non-governmental organizations from international suppliers [13]. Therefore, to minimize the procurement lead times and unnecessary costs, quality and timely information is mandatory [14]. Lack of access to essential health products in the majority of developing countries, particularly in sub-Saharan Africa is mostly due to poor LMIS data quality and absence of real-time information [15]. For instance, a study conducted in Tanzania in 2006 indicated, data for logistic decision-making in the public health system was largely unavailable, resulting in the procurement and distribution decisions based on incomplete information. Even, there was a poor integration of the different logistics functional processes, from procurement to inventory management which led to inefficiencies and minimal logistics data visibility within a central medical store and in zones and health facilities [16]. A cross-sectional study conducted in Malawi also indicated that lack of integrated information systems and poor data quality in the majority of public health facilities have resulted in poor data visibility and difficulty in decision making [6]. In 2012, systems for improved access to pharmaceuticals and services (SIAPS) conducted an assessment on implementation and use of LMIS in Mali and identified a number of problems including inaccessibility of data for supply chain managers, weak reporting systems, as well as the follow of inaccurate and untimely information in the supply chain system of the country [17]. A similar study in Lesotho showed that incorrect recording of data on stock cards & reports, delayed report submission, lack of uniform and simple data collection tools made logistics decision very challenging which in turn led to frequent stock-outs of medicines and health commodities [18].
An information system fails because of different factors and challenges including chronic stock outs, poor supervision, and monitoring, the absence of regular reporting of stock level and consumption trends, lack of top management support [19]. A study conducted in Ghana also revealed that shortage of health service providers, inadequate logistics recording & reporting tools, and lack of appropriate essential data from the service delivery points, lack of commitments are some of the major challenges negatively affecting logistics management in the healthcare facilities [20].
In Ethiopia, studies on logistics management information system are very limited and even most of them are simply surveys reporting a description of the LMIS operating across the health facilities. Therefore, the aim of this study was to evaluate the logistics management information system performance for program drugs and also explore the associated challenges in the public health facilities of East Wollega Zone, Oromia regional state, Ethiopia.
The study was conducted in selected public health facilities of East Wollega zone, Oromia regional state, Western Ethiopia. East Wollega zone covers a land mass of 13,820.23 km2 that is 3.97% of Oromia land coverage. It is administratively sub-divided into seventeen districts. The zone is delivering health services to the community with three hospitals, sixty-one health centers (one NGO) and 294 health posts. It has 1093 different health professionals (i.e.106 pharmacy, 677 health extension workers, and 395 administrative workers) [source, East Wollega Zonal health office].
Study design and period
The study employed a facility based cross-sectional descriptive study design complemented with a qualitative study to evaluate the LMIS performance of the facilities including data quality, reporting rates, and the associated challenges. The study was conducted from April 01 to May 30, 2017.
Study population and sampling procedures
Twenty-three public health facilities, i.e., three public hospitals and 20 health centers were included in the study. Logistics records and reports from each facility were reviewed to evaluate data quality and reporting rates. The recording and reporting tools were proportionally selected from each facility. The sampling process of the elements (i.e.documents & personnel) is shown in the diagram below (Fig. 1). The sample size of the health facilities was determined based on the USAID delivery project guideline (i.e., a logistics indicators assessment tool) that recommends taking at least 15% of the total facilities to increase the power of generalizability [21]. Accordingly, twenty-three health facilities were taken from a total of 63 public health facilities. The health centers were clustered based on their geographical distribution (districts). Those health centers which manage common program drugs were conveniently selected from each cluster until the required sample size was achieved. The hospitals were included by default since they are situated in different districts and also manage all the program drugs. Regarding documents, two LMIS tools (report and requisition forms (RRFs) and bin-cards) were reviewed to evaluate data quality since they are the most commonly used tools to record and transfer data in the public health facilities in Ethiopia. According to the integrated pharmaceutical logistics system (IPLS) of Ethiopia, public health facilities (hospitals and health centers) are expected to submit their RRFs to higher level bimonthly [8]. Accordingly, the report and requisition forms of one year, i.e., six RRFs from each health facility were planned for review. Unfortunately, four of the health facilities submitted only five of the expected total reports. Thus, 134 RRFs were reviewed to evaluate the data quality of the reports.
Flow diagram showing documents and personnel selection for the study
The data accuracy of RRF was evaluated by computing the discrepancy between the stock record balance on the bin-cards and RRFs. For this purpose, the date and document number of the transactions were checked to pick the corresponding bin-cards. The other type of LMIS tool reviewed for data accuracy was bin-card. The sample size of the bin-cards was determined based on the number of products included in the study. Sixty specific program drugs were managed by the health facilities of which 35 were common to the study facilities [Source, East Wollega zonal health office]. Therefore, 35 bin-cards from each health facility were reviewed to determine LMIS record accuracy. The study also assessed the availability and utilization of other logistics tools like internal facility report and requisition form (IFRR). IFRR is a document used by dispensaries within the health facilities to report drug consumption to a medical store and request quantities for the next consumption.
Measurements of LMIS data quality and facility reporting rates
The data quality of LMIS was measured using indicators such as accuracy, completeness, and timeliness.
The data record accuracy measures whether stock balances on bin-cards are similar to the actual inventory on hand.
This can be determined using the following formula:
$$ \mathrm{Record}\ \mathrm{accuracy}=\frac{\Big(\mathrm{Ending}\ \mathrm{balance}\ \mathrm{on}\ \mathrm{bin} \operatorname {card}-\mathrm{physical}\ \mathrm{stock}\ \mathrm{counts}}{\mathrm{physical}\ \mathrm{stock}\ \mathrm{counts}}\ast 100 $$
Accuracy in transferring data from records (e.g. bin-cards) to the LMIS reporting forms (e.g. RRFs) provides information on how well the health facilities are accurately tracking their inventories and transferring this information to the LMIS report forms. It is determined using the following formula;
$$ \mathrm{Data}\ \mathrm{transfer}\ \mathrm{accuracy}=\frac{\Big(\mathrm{stock}\ \mathrm{balance}\ \mathrm{on}\ \mathrm{RRFs}-\mathrm{Ending}\ \mathrm{balance}\ \mathrm{on}\ \mathrm{bin}-\mathrm{cards}\ }{\mathrm{Ending}\ \mathrm{balance}\ \mathrm{on}\ \mathrm{bin}-\mathrm{cards}} \ast 100 $$
The completeness of reports: Data from five major program drugs (i.e. HIV, opportunistic infection (OI), TB, malaria, and family planning included in the RRF) were used to check the completeness of the reports. A report is considered complete if all the columns for each product listed in the report are filled in for at least one product listed under each program unless the facility does not manage the product [22].
Timeliness: As per the integrated pharmaceutical logistics system (IPLS) of Ethiopia, A report is said to be timely submitted if,
The health centers directly submit their RRF to the higher supplier (PFSA) until the 10th day after the reporting period or if they submit to woreda health office until the 5th day after the reporting period and
The hospitals submit their reports to pharmaceutical fund and supply agency (PFSA) or regional health bureau until the 10th day after the reporting period [8]
Facility reporting rates: The facility reporting rate was computed using the following formula (2).
$$ \mathrm{Reporting}\ \mathrm{rate}=\frac{\left(\mathrm{number}\ \mathrm{of}\ \mathrm{facilities}\ \mathrm{submit}\mathrm{ted}\ \mathrm{the}\mathrm{ir}\ \mathrm{report}\ \mathrm{in}\ \mathrm{the}\ \mathrm{specified}\ \mathrm{schedule}\right)\ }{\mathrm{a}\ \mathrm{total}\ \mathrm{number}\ \mathrm{of}\ \mathrm{facilities}\ \mathrm{expected}\ \mathrm{to}\ \mathrm{submit}\ \mathrm{the}\mathrm{ir}\ \mathrm{report}}\ast 100 $$
Data collection procedures
Semi-structured questionnaires and checklists adapted from USAID deliver guidelines were used to collect the necessary data. Socio-demographic data, facilities' reporting rates, availability and utilization of reporting and recording formats, data quality of RRF & bin-cards and factors associated with LMIS performance were collected. The data were gathered through a physical count of drugs, review of relevant documents, and interview of the health facility store managers and pharmacy heads. Regarding document review, logistic reports of one year and recording tools (bin-cards) on the day of the visit were evaluated.
Data processing & analysis
A statistical package for social sciences (SPSS) version 20 was used to encode and analyze data. Descriptive and inferential statistical analyses were done and the outputs were then summarized using tables & figures. A chi-square test was run to determine the associations between the dependent and independent variables. A critical values p < 0.05 were considered as statistically significant.
For the qualitative study
Eleven face to face in-depth interviews were conducted to collect qualitative data. The participants had experience of greater than 5 years in health logistics management. Currently, storekeepers and pharmacy heads of the public health facilities in Ethiopia play the lion's share of logistics management practice. Therefore, six storekeepers and five pharmacy heads were selected based on their service experience. The interviews were conducted by one of the researchers to maintain the consistency of information.Written informed consent was obtained from the participants to audiotape the interview. The interviews were conducted in a local language Afan Oromo, and it was tape recorded. The participants were asked in-depth and probing questions to get broad information on the topic of interest. Each interview on average took 20 min. The record was then transcribed to English language by the researchers and verified by two experts from Jimma University academic staffs. Then, the findings were analyzed manually using the thematic analysis technique. Accordingly, the authors familiarized themselves with the data by taking notes of the interview. The data were then coded by using a table in a word document. The coded data were organized to search for themes. The final step was naming and describing the themes and producing the report.
A pilot study was conducted in 5% of the facilities to check the data collection tools for its contents and any ambiguous questions. The facilities involved in pretest were excluded from the actual study. The data collectors were also trained for 30 min on how to complete the tools. On top of that, the principal investigators closely supervised the data collectors. Each time after data collection, the questionnaires were checked for completeness.
Bin-card accuracy: is a measure of a discrepancy between the stock balance on bin-cards and physical count of the products
RRFs data accuracy: is a measure of a discrepancy between the stock balance on RRFs and ending balance on bin-cards. Accordingly, the record/report is said to be accurate if zero discrepancies are calculated and near accurate if the discrepancy is ±10% and non-accurate if the difference is > ±10% [22]. However, for the purpose of the chi-square test, the near accurate outcome variable was merged to not accurate
Completeness: A report is considered complete if all the columns for each product listed in the report are filled in for at least one product listed under each program unless the facility does not manage the product.
Data quality: it is the accuracy, completeness, and timeliness of logistics data.
Program drugs: in the current study are drugs used to treat or prevent TB/ leprosy, HIV/AIDS, malaria, maternal & child health (MCH) & family planning used both in health centers and hospitals.
Pharmacy professionals: in the current study include pharmacists (degree holders), and pharmacy technicians (diploma holders)
Timelines: the reporting schedule in which the facilities are expected to submit their reports (RRFs) to the next higher officials. According to IPLS of Ethiopia [8], the report is said to be submitted timely if
○ The hospitals submit their reports to pharmaceutical fund and supply agency (PFSA) or regional health bureau until the 10th day after the reporting period, and
○ The health centers directly submit their RRF to the higher supplier (PFSA) until the 10th day after the reporting period or if they submit to woreda health office until the 5th day after the reporting period.
Training: training in this study refers to a short-term supply chain training which might improve the logistics information system, e.g.integrated pharmaceutical logistics system (IPLS) training.
Service year: The pharmacy staffs service experience on logistics management.
Feedback report: Is a type of report used by the suppliers to inform lower level facilities about their performance
Supervision: An activity carried out by the top level management of the health facilities' and higher officials outside the facilities (e.g.District/Woreda health office and zonal health office) to oversee the logistics management practice of the facilities.
The socio-demographic characteristics of staffs
Sixty-one staff of different professions were working under pharmacy units of the facilities, of which 37 (60.7%) were pharmacy professionals. The majority of the staff, 57 (93.4%) were male. Regarding educational qualification, 30 (49.2%) of the staff were degree holders, and the remaining 31 (50.8%) were diploma qualifiers. Forty-one (67.2%) of the staff had service year of less than 5. More than half, 33 (54.1%) of the staff were working in the dispensary and 23 (37.7%) were serving as storekeepers (Table 1).
Table 1 The profile of the staffs working under pharmacy units of the public health facilities in the East Wollega zone, May 30/2017 (hospitals = 3, health centers = 20)
Staffs empowerment
Integrated pharmaceutical logistics system /LMIS training
From the total of 61 pharmacy staff in the study facilities, 47 (75.8%) had received IPLS/ LMIS training. Per type of facility,18 (66.7%) of the hospitals' staff and 28 (82.9%) of the health centers' staff had received the training. Of the trained staff, 3 (16.7%) of the hospitals' and 19 (67.9%) of the health centers' staff were working on LMIS management (Fig. 2).
Staff training on IPLS/LMIS & their current practice in selected public health facilities of East Wollega zone, May 30/2017 (Hospitals = 3, health centers = 20)
Supervision and feedback support from top level management
Twenty-two (95.56%) of the study facilities had received supportive supervision, and 10 (43.48%) of the facilities had received a feedback report. Among the facilities that received supportive supervision, 11 (50%) of them received quarterly, and only 2 (9%) of them received annually. Based on the type of facility, 19 (95%) of the health centers and all of the hospitals had received the supervision. Two (67%) of the hospitals had got supervision quarterly, and the health centers had also received quarterly, 9 (47.4%) and semi-annually, 8 (42.1%). Seven (35%) of the health centers and all of the hospitals had received feedback from the higher level. Of the facilities that had received feedback, 6 (60%) of them received semiannually, and 4 (40%) of them received quarterly. However, the disaggregated data revealed that 2 (66.7%) of the hospitals and 5 (71.4%) of the health centers had received feedback quarterly and semi-annually respectively (Fig. 3).
The frequency of supervision & feedback report from the higher level management in selected public health facilities of East Wollega zone, May 30/2017 (Hospitals = 3, health centers = 20)
Availability of LMIS tools & its utilization
All of the study facilities had a manual LMIS reporting and recording formats, and also used them to capture logistics data. Regarding e-LMIS, all of the hospitals had an automated recording and reporting system, but it was functional in 2/3 (66.7%) of the hospitals. However, only 6 (30%) of the health centers had an automated LMIS (Table 2).
Table 2 Availability and utilization of LMIS reporting and recording formats in selected public health facilities of East Wollega zone, May30/2017. (Hospitals = 3, health centers = 20)
Data quality of LMIS report and records
RRF data quality
The data quality of RRF was assessed using indicators such as accuracy, timeliness, and completeness. Accordingly, of the total sampled RRF, 89 (64.6%) of them were accurately filled, and 43 (31.2%) were found to be inaccurate. However, when we consider by facility type, the hospitals and the health centers respectively filled 13 (72%) and 77 (63.9%) of their RRFs accurately (Fig. 4).
The accuracy of RRF data by facility type and the overall aggregate performance of selected public health facilities in East Wollega zone, May 30/2017
From inferential statistical analysis, RRF data accuracy had a significant association with staff training, X2 (2, N = 134) =37.12, P = 0.001, level of education, X2 (2,N = 134) = 90.38, P = 0.012, type of profession, X2 (4, N = 134) = 35.0,P = 0.040, availability of electronic bin-cards, X2 (2, N = 134) = 38.67,P = 0.030, supervision, X2 (2, N = 134) =94.03, P < 0.001 and feedback X2 (2, N = 134) = 21.68, P = 0.045 (Table 3).
Table 3 The association of RRF data accuracy, and possible contributing factors in the selected public health facilities of East Wollega zone, May30/2017
Report submission rates, timeliness, and completeness of the reports
Regarding reporting performance, the study facilities had a reporting rate of 97% (i.e.134 out of 138 RRFs were submitted), yet only 16 (69.4%) of the facilities' timely submitted their reports. Of the total reports submitted to the next higher level, 135 (97.8%) of them were found to be complete (Fig. 5).
Distribution of facilities' reporting rates & timelines and completeness of RRFs in selected public health facilities of East Wollega zone, May30/2017
Bin-card data accuracy
A physical count was conducted to determine if a discrepancy exists between a physical stock on hand in the storeroom and ending balance on bin-cards. Accordingly, of the total sampled bin-cards, 647 (80.36%) of the records were found to be accurate, and 129 (16%) were inaccurate. However, the health centers had recorded 576 (82.3%) of their bin-cards accurately, and the hospitals had 71 (67.7%) accurate & 28 (27%) inaccurate bin-cards (Fig. 6).
The accuracy of bin-cards by facility type and the overall performance of the selected public health facilities in East Wollega zone, May30/2017
A chi-square test was done to determine if an association exists between bin-card data accuracy and possible factors. Consequently, a significant association was observed between bin-card data quality and supervision, X2 (2, N = 805) =7.92, P = 0.019 & type of profession, X2 (2, N = 805) =6.39, P = 0.041 (Table 4).
Table 4 The association of bin-card data accuracy, and possible contributing factors in the selected public health facilities of East Wollega zone, May30/2017
Qualitative results
Face to face in-depth interview was conducted to explore the challenges associated with LMIS performance.The participants were selected based on their service experience in pharmaceutical logistics management. Accordingly, six storekeepers and five pharmacy heads with service year of greater than five were involved. The key informants identified various types of problems, and the findings were then thematically analyzed by categorizing based on the feature of the data.
Human resource and staff's commitment related challenges
Human resource-related challenges
Maintaining quality pharmacy services requires adequate skilled human resources. However, the number of pharmacy professionals in the selected public health facilities was not adequate. The main reasons mentioned by the interviewees were high staff attrition rate, few pharmacy professionals in the market, and the government and private higher institutions are producing a limited number of pharmacy professionals. One of the pharmacy heads explained the problem as follows,
"Since the majority of the pharmacy professionals in Ethiopia are not satisfied with their current profession (because of salary and lack of recognition from the government), a significant number of pharmacists and pharmacy technicians are shifting to other business fields. Unless the government timely solves the issue, for instance, through promoting private colleges to produce at least diploma graduates, and also fulfill the needs of the pharmacists as much as possible, the problem will get more burdensome in the future. Currently, we use the available staffs more to dispense drugs than managing logistics information."
The study also explored that the shortage of pharmacists and pharmacy technicians levied burdens on the available staff. In the majority of the study facilities, a single person had multiple responsibilities. For instance, an individual assigned to work on LMIS also had responsibilities of carrying out other pharmacy activities. One of the key informants (KI) reported that,
"Currently, in my facility, I have a responsibility of dispensing drugs, managing store and preparing LMIS reports. Thus, I could not get sufficient time to update the logistics records. I have recommended the facilities to recruit additional staffs."
Staffs' commitment related challenges
Most of the interviewees, especially the pharmacy heads mentioned that lack of staff commitment was one of the challenges influencing the pharmacy activities. The problem was even more severe among the staffs in the rural health facilities. The key informants mentioned some of the reasons behind the issue. For example, poor infrastructures, job dissatisfaction, lack of technologies, and inadequate incentives particularly a limited opportunity for further education discouraged the workers not to execute their tasks properly. One of the pharmacy head tried to elucidate the situation as follows,
"When we recommend the staffs working in dispensing units to record and report logistics data properly, they feel discomfort and prefer to resign their job. Their main reasons are inadequate incentives, lack of electronic LMIS devices, and electric power interruptions."
Managerial related problems
Poor supportive supervision and feedback
The facilities were also facing poor management support to manage their information systems effectively. In the majority of the study facilities, the top-level managers were not considering LMIS as a basic pharmacy service. As a result, the staff lacked the inspiration to manage logistics data appropriately, and therefore, the majority of them relied on guesswork. They stated that weak supportive supervision and poor constructive feedbacks on LMIS management led to unreliable data quality. One of the interviewees reported that,
"I believe that supportive supervision has a profound impact in filling knowledge gaps and also encouraging workers. However, in our facility, there is irregular supervision with no feedback. Some of the supervisors are negligent. They usually visit the facility with no comment and back to their office."
Poor communication between the health facility managers and suppliers
For better decision-making, the facilities and the corresponding suppliers should have a regular communication on the current logistics management practice and challenges in the health facilities and at supplier point. Otherwise, the decisions that do not involve both parties will discourage the lower level staffs to maintain quality information. In the current study, poor communication between the health facilities and pharmaceutical fund and supply agency (PFSA) was among the challenges that affect the logistics management information systems.
This can be exemplified by one of a KI as follows:
"Urging the facilities to prepare & send RRF regularly is one strong side of PFSA to enhance reporting rates. However, on the other hand, we request the PFSA a double quantity of the actual demand, since it commonly provides less than the required amount. Such practice discourages us to submit a quality report."
Availability of standard logistics recording and reporting tools/formats and proper use of these tools have a substantial role in the implementation of effective and efficient logistics management information systems [22]. In the present study, almost all types of the recording and reporting formats were 100% available and entirely used in the facilities to record and report logistics data. This is in line with the study done in East Shewa zone on inventory management performance [23] and the study conducted in Addis Ababa on logistics management information system of laboratory commodities [24], in which the study facilities had the required logistics recording and reporting tools or formats and use them to capture essential logistics data. However, the majority of the facility in a current study, particularly health centers (70% of health centers) were relying on paper-based activities, only 2/3 the hospitals were using automated recording systems. The result is similar to the study conducted in Kenya on the utilization of healthcare information, wherein the facilities mainly depend on a paper-based reporting system and poorly supported by an automated system [25]. Nevertheless, electronic recording and reporting system enhances the logistics management information system (LMIS) performances through reducing errors & task burden, saving time, and improving reporting rates [26]. The poor utilization of electronic LMIS might be because of frequent power interruption, inadequate skilled human resources and the geographical location of the health facilities where electric power was completely unavailable.
Regarding data quality of reports, it has substantial impacts on the quality of health care and even on government budgets for the maintenance of health services. Therefore, every facility in a supply chain needs to improve its data quality and timely share it to maintain health care at an optimal level [27]. In the current study, of the total sampled RRFs, 64.6% were accurate, 69.4% were timely reported and 97.8% of the reports were found to be complete. These indicate the facilities' weak performance in recording their logistics data and reporting to the next higher level. The findings are slightly lower than the assessment conducted by SIAPS in Cameroon and Burundi, wherein the accuracy and timeliness of their reports were 75% & 90%, respectively [28]. The reason might be a difference in the degree of commitments by higher officials in providing regular supportive supervision and feedback on the facilities performances and a shortage of skilled human resources. Factors including staff training, availability of an electronic recording system, and the educational level of staffs might also be significantly affecting the data quality of LMIS in the present study.
Regarding a report submission rate, the health facilities of the current study submitted 97% of the expected reports to the pharmaceutical fund and supply agency of Ethiopia (PFSA). This is higher than that of the study done in Malawi and Nigeria, where the reporting rates were 58% & 12.3%, respectively [6, 29]. The difference might be due to the urging principle of PFSA, i.e., forced ordering system. Such system pushes the facility to prepare and submit their reports bi-monthly to timely forecast the facilities need ("no report no drug principle").
The inventory record accuracy is one of the components of data quality that has a paramount impact on a report data accuracy. The present study revealed that from the total of reviewed bin-cards in the selected health facilities, 79.1% were accurately recorded (had similar data with physical count). It is higher compared to previous studies including the study conducted in Addis Ababa on a logistics management information system for laboratory commodities & South Sudan on pharmaceutical logistics management, where the facilities in both studies had inventory record accuracy of 38.9% & 27%, respectively [24, 26]. The difference might be because of the number and types of facilities selected for the studies and the size of the study area. For instance, the study done in South Sudan covered four geographical sites (four states) and private pharmacies In the same fashion, the study conducted in Addis Ababa included a higher number of facilities (i.e.43 health facilities) compared to the current study, where only 23 facilities evaluated. As limitations, because of budget constraints, the present study was limited to the evaluation of commonly and consistently used documents in the health facilities for decision-making. The study also did not include health posts. Because, in Ethiopia, health posts manage only a few program drugs like family planning and other medicines for minor ailments. It would be good if the study evaluated an information system at the supplier points too. Therefore, the future studies can involve both health facilities and immediate suppliers to investigate the management information system at both sides and also explore the possible challenges the facilities and suppliers are experiencing.
From this study, we concluded that the facility report quality and inventory record accuracy require improvements, nonetheless, their reporting rate was encouraging. The major challenges that influence the facilities to manage their information system appropriately were identified to be a shortage of pharmacy professionals, lack of commitment from top-level management and inability to implement automated recording and reporting system. The study also identified staffs that have taken integrated pharmaceutical logistics system training yet not contributed to a logistics management information system and even not volunteers to do so. Their main reasons were the burden of tasks and absence of an automated recording system in the facilities. Generally, factors like training of staffs, availability of automated record systems, supportive supervision and feedback report had a significant association with the RRF data accuracy. Therefore, pharmaceutical fund and supply agency and partners should increase their frequency of supportive supervision and also provide constructive feedback to the facilities. The facilities, especially the health centers together with the concerned stakeholders, should strengthen their LMIS by implementing automated recording systems.
Confidence of interval
e-LMIS:
Electronic logistics management information system
IFRR:
Internal facility report & requisition form
IPLS:
Integrated pharmaceutical logistics system
LIAT:
Logistics indicator assessment tool
MCH & FP:
Maternal, and child health & family planning
PFSA:
Pharmaceutical fund and supply agency
RRF:
Report and requisition form
USAID:
United states agency for international development
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Kumurya AS. Supply chain Management of Health Commodities and Logistics: fundamental components of booming medical laboratory services. EUR J Logist. 2015;3(4):62–72.
USAID | DELIVER PROJECT. Computerizing Logistics Management Information Systems: A Program Manager's Guide [Internet]. 2012 [Accessed 19 Feb 2017]. p. 1–59. Available from: http://www.villagereach.org/wp-content/uploads/2013/07/CompLMIS_PMG-1.pdf.
USAID | DELIVER PROJECT. Malawi : Assessment of the Integrated Logistics Management Information System Review of the Processes and Software Tools [Internet]. 2013 [Accessed 15 Mar 2017]. Available from: http://apps.who.int/medicinedocs/documents/s21886en/s21886en.pdf.
Management Sciences for Health. Pharmaceutical management information system. MSD-3: Managing Access to Medicines and Other Health Technologies; 2011. p. 20.
Pharmaceutical fund and supply agency. Standard operating procedures (SOP) manual for integrated pharmaceutical logistics system in health facilities of Ethiopia 1st edition. Addis Ababa: Ethiopian pharmaceutical fund and supply agency; 2014.
USAID | DELIVER PROJECT TO 1, editor. The logistics handbook a practical guide for the supply chain Management of Health Commodities; 2011. p. 2011.
World Health Organization. WHO Essential Medicines and Health Products Strategic Framework 2016–2030. [Internet]. Geneva; 2016 [Accessed 7 Sep 2018 ]. p. 11. Available from: http://www.who.int/medicines/publications/Towards_Access_2030_Final.pdf.
Vitoria M, Granich R, Gilks CF, Gunneberg C, Hosseini M, Were W, et al. The global fight against HIV/AIDS, tuberculosis, and malaria: current status and future perspectives. Am J Clin Pathol. 2009;131(6):844–8.
Zakiyah N, van Asselt ADI, Roijmans F, Postma MJ. Economic evaluation of family planning interventions in low and middle-income countries; a systematic review. PLoS One. 2016;11(12):1–19.
Reich MR, Bery P. Expanding Global Access to ARVs: The Challenges of Prices and Patents [Internet]. Academic Press. New York; 2005 [Accessed 8 Sep 2018]. p. 324–350. Available from: https://cdn1.sph.harvard.edu/wp-content/uploads/sites/480/2013/01/Reich_Bery_AIDS_drugs.pdf.
Lee HL, Padmanabhan V, Whang S. Information distortion in a supply chain: the bullwhip effect. Manag Sci. 1997;43(4):546–58.
Wagenaar BH, Gimbel S, Hoek R, Pfeiffer J, Michel C, Manuel JL, et al. Stock-outs of essential health products in Mozambique - longitudinal analyses from 2011 to 2013. Tropical Med Int Health. 2014;19(7):791–801.
Supply Chain Management System; USAID | DELIVER PROJECT Task Order 7. Health logistics in Tanzania: Timeline of Accomplishments for Supply Chain Interventions. [Internet]. Arlington; 2016 [Accessed 10 Sep 2018]. p. 10–51. Available from: https://www.jsi.com/JSIInternet/Inc/Common/_download_pub.cfm?id=17395&lid=3.
Systems for Improved Access to Pharmaceuticals and Services. Strengthening Pharmaceutical Systems Program: Activity and Product Status Report, [Internet]. US Agency for International Development. Arlington:; 2012 [Accessed 11 Sep 2018]. Available from: http://siapsprogram.org/wp-content/uploads/2012/12/SIAPS-PY1-Q4-Report-web.pdf.
Systems for Improved Access to Pharmaceuticals and Services. Design, Implementation, and Use of Pharmaceutical Logistics Management Information Systems (LMIS) [Internet]. Arlington; 2012 [Accessed 10 Sep 2018]. Available from: http://siapsprogram.org/publication/altview/lmis-technical-brief-the-usaid-siaps-best-practices-in-the-design-implementation-and-use-of-pharmaceutical-logistics-management-information-systems/english/.
Chen H, Hailey D, Wang N, Yu P. A review of data quality assessment methods for public health information systems. Int J Environ Res Public Health. 2014;11(5):5170–207.
Manso JF, Annan J, Anane SS. Assessment of logistics Management in Ghana Health Service. Int J Bus Soc Res. 2013;3(8):75–87.
USAID | DELIVER PROJECT. Logistics System Assessment Tool (LSAT) [Internet]. Arlington: USAID | DELIVER PROJECT, Task Order 1. 2009 [Accessed 25 Mar 2017]. Available from: http://pdf.usaid.gov/pdf_docs/Pnado527.pdf.
Shewarega. et.al. Ethiopia: National Survey of the Integrated Pharmaceutical Logistics System [Internet]. Arlington: USAID | DELIVER PROJECTTask Order 4, and Pharmaceuticals Fund and Supply Agency (PFSA). 2015 [Accessed 7 Sep 2018]. Available from: http://apps.who.int/medicinedocs/documents/s21807en/s21807en.pdf.
Gurmu TG, Ibrahim AJ. Inventory management performance of key essential medicines in health facilities of east Shewa zone, Oromia regional state, Ethiopia. Cukurova Med J. 2017;42(2):277–91.
Desale A, Taye B, Belay G, Nigatu A. Assessment of laboratory logistics management information system practice for HIV/AIDS and tuberculosis laboratory commodities in selected public health facilities in Addis Ababa, Ethiopia. Pan African Medical Journal. 2013;15:46.
Obwocha W, Ayodo G, Nyangura A, Thomas O. Utilization of healthcare information among health Care Workers in Gucha Subcounty, Kisii County, Kenya. J Heal Educ Res. 2016;04(04):192. https://doi.org/10.4172/2380-5439.1000192.
Mochache D, Chinyanganya F, Ngidari J. Pharmaceutical logistics assessment in South Sudan [internet]. Juba; 2011 [Accessed 29 Jan 2017]. Available from: http://apps.who.int/medicinedocs/documents/s19289en/s19289en.pdf.
World Health Organization. Improving Data Quality: A Guide for Developing Countries [Internet]. Geneva; 2003 [Accessed 2 Feb 2017]. p. 12. Available from: http://www.globalhealthworkforce.org/resources/who_improving_data_quality.pdf.
SIAPS. Systems for Improved Access to Pharmaceutical Services Annual Report: Project year 3, October 2013–September 2014. Arlington: Management Sciences for Health; 2014.
Bock A, Tien M, Igharo E, Adedeji O, Agudelo J. Nigeria: Contraceptive logistics management system assessment report. Arlington: USAID | DELIVER PROJECT, task Order 1; 2011. https://esaro.unfpa.org/sites/default/files/pub-pdf/Nigeria_contlogimanaasse.pdf.
The authors would like to thank Jimma University for facilitating the study. We are also grateful to East Wollega Zone health facilities for providing us with all the necessary data. The authors would also like to thank the staff of Jimma University, Dr.Legese Chelkeba (a clinical pharmacist) and Mr.Fanta Gashe (assistant professor) for their unreserved support in revising the final manuscript. The last but not least of our acknowledgment goes to global health supply chain program-procurement and supply management (GHSC-PSM) for financial support.
Global health supply chain program-procurement and supply management (GHSC-PSM) has financially supported the study by covering stationary materials and data collection costs.
The data sets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Nekemte Referral Hospital, East Wollega Zone, Oromia regional state, Ethiopia
Kefyalewu Tiye
Pharmaceutical supply chain management specialist, School of Pharmacy, Faculty of Health Sciences, Jimma University, Jimma, Ethiopia
Tadesse Gudeta
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KT involved in reviewing articles, data collection process, involved in data analysis, Interpreted data, participated in the sequence alignment and drafted the manuscript.TG also reviewed articles, participated in the design of the study and performed the statistical analysis, interpreted data, drafted the manuscript and communicated for publication. Both authors read and approved the final manuscript.
Correspondence to Tadesse Gudeta.
Ethical approval was granted by the institutional review board of Jimma University (ref.IHRPGC/799/207) on 03 April 2017. Then a permission letter was obtained from Oromia regional health bureau, East Wollega Zonal health office, and the Woreda health office sequentially. Finally, the health facilities were communicated using letters received from higher officials. During data collection, the professional and social ethics were maintained, and the names of the facilities and personnel involved in the study were not stated on the data collection tools. The participants were asked to sign a consent form to confirm their willingness to take part in the study.
Tiye, K., Gudeta, T. Logistics management information system performance for program drugs in public health facilities of East Wollega Zone, Oromia regional state, Ethiopia. BMC Med Inform Decis Mak 18, 133 (2018) doi:10.1186/s12911-018-0720-9
Logistics management information system
Health facility
Program drugs
Healthcare Information Systems


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The NBN Phony war is over
Created: Fri, 10/17/2014 - 17:18
Author: Mark A Gregory
This week in Business Spectator the end of the NBN phony war is cause for celebration. The telecommunications industry has finally shifted to ask the hard questions of a government policy for a second best broadband network that will do nothing for Australia's economy when compared with countries that have adopted a fibre to the premises rollout. Will the Competitive Carriers Coalition become more vocal in coming months and try to force the government to review the most contentious aspects of the Coalition's NBN plan?
Read the full article below
The Coalition's plan for a better National Broadband Network (NBN) was announced in April 2013 and it has taken just 18 months for the extent of the damage that will be caused by the government's flawed broadband plan to become known.
The efforts of Telstra's competitors to build a hopeful veneer in the last twelve months have all but crumbled and the industry silence that has marked the phony war is now over.
As we head into one of the most chaotic and unproductive periods in the history of an Australian industry there appears to be only one winner and it's not the Australian public.
Let the battle begin anew
The telecommunications industry is quickly realising that it's time to renew the battle with the government lest all opportunity will be lost.
The Competitive Carriers Coalition's (CCC) opening salvo on October 2 held nothing back when it described the government's keystone review of the NBN as "nothing more than rehashed, discredited theoretical arguments promoted by opponents of regulatory reform and the NBN."
The CCC's statement went on to say that "the time for historical revisionism and point scoring is long gone. The priority for the Government should be speeding up the structural separation of Telstra, the building of the NBN and the reduction of prices for basic services to all Australians, which remain disgracefully high – among the highest in the developed world."
Telstra's main rival Singtel-Optus entered the fray on October 8 when chairman Paul O'Sullivan called for Telstra to be broken up using the model similar to that adopted in the UK with BT Group.
O'Sullivan is concerned that Telstra will use the $8.4 billion that it is forecast to receive from NBN Co over the next five years to strengthen its market dominance, stating "if Telstra is going to have a key role to play in the NBN because we are now dependent on their copper in order to get from the node to the home, then there is a huge conflict of interest if they are owning and operating that network."
His point that "competition in telecommunications in Australia is under more threat than at any time since it was introduced in 1992" does not appear to be a concern for the Coalition government. The communications minister Malcolm Turnbull has not deemed it necessary to respond to what's essentially a strong rebuke for the government's lemon of a broadband plan.
Telstra's response to O'Sullivan's comments on October 9 was informative because it confirms that the incumbent has no intention of voluntarily splitting into two companies. It is rethinking its position on undertaking voluntary separation and wants to use the current discussions with government to enhance its dominant position.
The argument provided by Telstra's executive director of regulatory affairs Jane van Beelen that "these debates have already been had in Parliament, at industry events, in the media and through numerous Government reviews" provides a very slanted view of history and the strongest guidance to date that Telstra will not voluntarily take steps to head off what will inevitably be government intervention to break up the company.
It's not possible to have an open and competitive industry where there is one dominant company with more than 50 per cent of the customers and more than 70 per cent of revenues.
And to make matters worse the government appears determined to put into action a flawed plan that will not only entrench Telstra's dominant position but also let it slowly squeeze the competition using anti-competitive internal subsidies with the profits arising from the ownership of key properties and infrastructure.
The Telstra conundrum
In the decades since the telecommunications market reform and deregulation began in 1997 successive Australian governments have been confronted with the Telstra conundrum and the task of creating an open and competitive telecommunications market.
There are four options:
Telstra remains a single entity
Telstra undertakes structural separation but retains a centralised accounting system that would permit full or partial revenue redistribution between the wholesale and retail divisions. An example of a partial cross-subsidy is shifting revenues or profits from the wholesale division to the retail division or vice versa
Telstra undertakes structural separation and the wholesale and retail divisions operate separate unlinked accounting systems that prohibit revenues from one division being transferred to the other division
Telstra splits into two companies – wholesale and retail
Countries around the world are grappling with the dominance of incumbent telcos, so Australia's Telstra conundrum is not unique. O'Sullivan has pointed out that there's a need to push Telstra towards the UK BT model, which is similar to option 3, but van Beelen's rather frank response suggests that any attempt to shift Telstra away from option 2 will be strenuously resisted.
Telecom New Zealand was split into two companies in 2012 and what's interesting about the Telecom New Zealand split into Chorus (wholesale) and Spark (retail) was the retention by Spark of the backhaul network on top of the mobile network.
What the New Zealand experience shows is that splitting Telstra into two companies is doable and the asset distribution can be tweaked when the split occurs so we should watch Chorus and Spark with interest over the next five years.
Coalition's Telstra tax
The cost of retaining the copper access network and associated infrastructure for the Coalition's multi-technology mix NBN plan was always going to balloon and the government has remained steadfast in the face of repeated warnings.
Telstra's increased involvement with the NBN resulting in increased direct or indirect costs (including double dipping) to consumers associated with the retention of the copper access network can be classified as the Coalition government's inadvertent 'Telstra Tax'.
The first component of the 'Telstra Tax' was made public this week when Telstra asked the Australian Competition and Consumer Commission (ACCC) for permission to raise charges for access to its fixed-line wholesale products and services by about $50 million per year (7.2 per cent) over the next four years arguing that the cost of maintaining, upgrading and operating aspects of its existing wholesale network, prior to handing the infrastructure to NBN Co, were not taken into account in the original NBN Co agreement.
And Telstra has also correctly argued that the slow pace of the NBN rollout has increased costs that should be taken into account when the ACCC considers this matter. NBN Co has been negotiating with Telstra for two and a half years in the last four, so it is little wonder that the rollout is glacial.
The government might argue that Telstra's decision to seek a price increase is not of its making but the fact is the government's decision to redirect the NBN was always going to slow the rollout, create uncertainty, increase costs and strengthen Telstra's ability to take control.
No more changes
Telstra CEO David Thodey speaking after Telstra's annual general meeting in Brisbane on October 14 stated that the company was seeking clarification from the government about what would happen if there were future NBN policy changes.
"There's a shared desire from the government, the NBN and ourselves to get it done as quickly as possible. But there's quite a few regulatory issues to work through. We've made really good progress on the contractual side, but it's still got a way to run.
"We do say that it's very dependent on the government processes, but it's getting through all the considerations involved in moving to fibre to the node and how customers are treated in that process."
What this means is that Telstra wants regulatory changes to be agreed to prior to signing off on the renegotiated NBN Co agreement and this includes protection from an incoming Labor government.
Preventing a future Labor government redirecting the NBN back to a FTTP network for 93 per cent of Australians will be difficult to do but Telstra is well aware that significant penalty clauses included in the renegotiated NBN Co agreement could effectively prevent this from occurring.
The ACCC is a party to the renegotiation of agreement between NBN Co and Telstra so it would fall to the ACCC chairman Rod Sims to explain what could only be described as an attempt by the Coalition government to saddle Australians with a white elephant. Thodey hinted at the ACCC hurdle when he stated that there were a "few regulatory issues to work through."
Only a royal commission will be able to find out why Telstra is insisting on a favourable regulatory scenario and penalty clauses now when it could have taken this step with the first NBN Co agreement, effectively preventing the incoming Coalition government from implementing a MTM NBN.
Could it be that Telstra was not happy with the first NBN Co agreement and was looking forward to the day when it could get a much better deal from a Coalition government?
Malcolm in the middle?
Turnbull has been absent from the debate for the past month and it's time that he explains why the Coalition government appears to have lost control over the telecommunications portfolio.
A short list of questions that Turnbull has been avoiding includes:
What are the current and projected FTTP and FTTN rollout costs and whatever happened to his pledge that NBN Co would be open and transparent?
Why is NBN Co's FTTP rollout slowing and what is really happening in Tasmania?
Why has Telstra not signed the renegotiated NBN Co agreement which the government said would be completed last June?
What extra goodies does Telstra want in the new agreement that it now says will not be completed until sometime in 2015?
It is time for Turnbull to speak up.
Mark Gregory is a Senior Lecturer in the School of Electrical and Computer Engineering at RMIT University
NBN Network Design Rules highlight problems ahead
What should be done with the NBN when the rollout ends?
NBN Tax yet another mistep
ACCC says no to domestic mobile roaming
Chaotic plan for regional comms
Tweets by _markagregory
Simplenews subscription
Spooks form a view on TelcoLand
Report opens up NBN data models
Adelaide lights up giga-future
Australia seeks ITU influence
Social sidebar
Fibre on Demand
FTTN
FTTP
Geo-Blocking
NG-PON2
Universal Service
© COPYRIGHT Gregory's Take

redpajama_set_name: RedPajamaCommonCrawl


Beechford is a small seaside town on the northern coast of Tasmania. This chart by Richard Hall (October 1859) shows plans for a proposed subdivision of land across Curries River from the actual township of Beechford to the south. Now part of the Five Mile Bluff Conservation Area, it seems that plans to subdivide were later abandoned. The "harbour for boats" may have been rather challenging for early settlers, who could only enter the river at high tide after negotiating the "flat ironstone rocks".


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Article by Stacie from Scarsdale10583 on the Distinguished Alumni Awards
posted by Ricardo Garcia-Amaya | 52rd
Stacie M. Waldman from Scarsdale10583.com wrote a piece on our Distinguished Alumni Awards ceremony.
The 2013 Scarsdale High School Distinguished Alumni Awards ceremony on Saturday November 16 began with a warm introduction by Alejandro Garcia-Amaya and Julian Stein, board members of the Scarsdale Alumni Association. Kenneth Bonamo, Principal of Scarsdale High School (SHS) followed with a brief welcoming of the distinguished alumni, telling them that the message they send to students is, "Greatness is within your reach." Several alumni spent time on Friday, November 15th speaking with students in their classrooms. Nine alumni in all were honored; here are their inspirational stories:
The first person to be honored was Judy Cheng-Hopkins ('70), a past honoree who was unable to make it to the previous ceremony. Cheng-Hopkins came to the U.S. as a Malaysian exchange student with the American Field Service in 1969. Her host family was socially and politically progressive, which helped shape her experience in America. After high school, she enrolled in college in the U.S. and then earned her Master's Degree in in Economic Development from Columbia University. After graduating, Cheng-Hopkins secured a position at the United Nations Development Program and worked in Sub-Saharan Africa for many years. In 1997, she became a Director at the World Food Program. In 2006, she was appointed as the Assistant High Commissioner for Operations, one of the highest positions within the UN. In this impressive role, she is in charge of helping high-conflict, war-torn countries and regions determine a plan for sustaining peace once a commitment to peace has been established. She believes that her experience at SHS made her what she is today, and her education taught her how to write and read well. "And 40 years later, I remember almost all of my teacher's names," she concluded.
To read the rest of the article please click here.


A limited number of rooms have been held at the conference rate of $299/night (rate quoted exclusive of applicable state and local taxes). The rate will be honored until October 31, or until rooms are sold out. Reservations received after this date will be accepted on a space and rate availability basis.
Use "G-IIN2" as the group name to receive the conference room rate.
You may also contact the hotel directly: Hyatt Regency San Francisco Airport at 650-347-1234.
Designed for on-the-go guests, Hyatt Regency San Francisco Airport is a sleek hotel just five minutes from SFO. Feel at home in rooms with bay views and chic on-site dining options. Access San Francisco International Airport aboard the complimentary shuttle and downtown Burlingame with complimentary trolley service.


Investing in cryptocurrencies comes with its own risks as well as rewards.
Therefore, you need to invest strategically in order to maximize your return on investment and minimize your risks. There are specific strategies you need to adopt to ensure a successful cryptocurrency investment and building your portfolio.
Therefore the first thing you ought to do is to study the space.
Firstly, remember to sign up for your digital wallet, and deposit your fiat currency and purchase the top 2 cryptocurrencies: Bitcoin and Ethereum.
When you get the hang of it, you'll realize that your investment will build up eventually from $500 to $1000, from $1000 to possibly $100,000! Always remember to do your part in getting to know more of the cryptocurrency market as there is always something new to look into.
Be strategic in your investment and only investment in what you know!


Determining the data requirements for coverage is becoming an increasingly frustrating issue for diagnostics manufacturers, which face rising demands for evidence but continued lack of clarity about payer standards for evidence-based decision-making, leading many to ask the question, "Why can't payers just tell us what their standards are?" Complicating the picture is that diagnostics can come to market via different pathways with different levels of supporting evidence (e.g., companion diagnostics reviewed by FDA for clinical validity with the companion therapeutic and tests developed, validated, and introduced to the market by laboratories).
The panelists – who represented leaders from industry, non-profit advocacy, and government working to create solutions for some of these market access barriers – noted a couple of issues at play. One is that having a payer "pick list" or hard criteria for coverage removes the flexibility that is so often needed in these gray-area coverage decisions. The second is that given the volume of products they are evaluating, most payers don't have the bandwidth to be experts in the nuances of the trial design for every technology. Third is that across all stakeholders, there is a wide range of knowledge on innovative products and personalized medicine and that basic education for the majority of stakeholders to better understand these products is lacking.
Several lessons and next steps came out of this discussion. First, panelists agreed that there must be more education for all stakeholders so that each stakeholder can actually evaluate novel products appropriately, a key finding echoed throughout the day. Second, the emphasis on outcomes must shift from only clinical outcomes to clinical outcomes and quality of life for patients. Finally, all panelists agreed the ideal situation is open, trusting lines of communication and split of the responsibility according to expertise.
At the end of the day, it may be incumbent on the molecular diagnostic community to shape the paradigm for evidence requirements so that payers can act as enablers, rather than watchdogs.
The September 14, 2012 (11:59 PM ET) deadline for submitting public comment on the Draft Methodology Report recently published by the Patient-Centered Outcomes Research Institute's (PCORI) Methodology Committee quickly approaches.
We encourage you all to submit comment as the revised version will be considered for adoption by the PCORI Board of Governors at its November 2012 public meeting in Boston, Mass.
PCORI was designed to do something new and very different – to define how practical, feasible, and useful patient-centered research is to be conducted and the legislation authorizing it directed the methodology committee to address the role of molecular and genetic variation in comparative effectiveness research. With this bold goal outlined, the Personalized Medicine Coalition (PMC) issued its comments to Dr. Joe Selby and Dr. Sherine Gabriel, the Executive Director and Chair of PCORI on September 13, 2012. You can find a copy of that letter here.
Heterogeneity of Treatment Effectiveness Standards: Recommend that either a separate section on standards for biomarkers and genetic variables be added to the report or an additional section on heterogeneity of treatment effectiveness be developed to guide the use of biomarker data in patient-centered outcomes research.
Diagnostic Test Study Standards: Develop a new paradigm for collecting and analyzing evidence by recommending variations in new clinical trial design, using patient registries to identify respondents, analyzing archived biospecimens, and implementing retrospective analysis of laboratory data.
Stakeholder Engagement: Release a table outlining the categories of specific comments received in all future comment submission periods with an explanation of how PCORI addressed the comments as a way to re-emphasize the importance of stakeholder engagement.
The Patient-Centered Outcomes Research Institute (PCORI) announced this week the public comment period for its landmark draft Methodology Report, which proposes standards for the conduct of patient-centered outcomes research. While the draft report came out last month, the comment period closes on Friday, September 14, 2012.
The Personalized Medicine Coalition (PMC) has a long history with PCORI starting from when the legislation creating it was being drafted. We advocated for recognition of personalized medicine in the conduct of comparative effectiveness research, which was incorporated into the legislation. PMC's methodology committee is charged with ensuring that the research funded by PCORI examines, among other things, research question responses based on patient molecular subgroup.
As part of the comment period announcement, PCORI stated that feedback received during the comment period would be reviewed for potential incorporation into a revised version of the report. The revised version will be considered for adoption by the PCORI Board of Governors at its November 2012 public meeting in Boston, Mass. We have previously urged PCORI to be explicit in how the public comments are considered and incorporated. That, and other institutional development, is essential for the proper functioning of the organization.
The current report does not adequately address personalized medicine as an important factor in improving health outcomes through patient-centered outcomes research methodology. PMC will comment on the methodology report, and we urge our member organizations and others to do the same. Active input from the community is required so that the research will live up to the high expectations that we have for it.
The Patient-Centered Outcomes Research Institute's (PCORI) Board of Governors held a conference call meeting Wednesday afternoon. During the call, they announced the finalization of their research agenda and discussed changes made from the initial draft in response to stakeholder comments.
Given the many criticisms PCORI received for being too broad and vague in its draft, I was surprised by how quickly the research agenda was finalized. I was gratified that the Institute publicly detailed how stakeholder comments shaped the final agenda, as urged by the Personalized Medicine Coalition (PMC) in our letter to the Institute last month.
Last week, PCORI Executive Director Joe Selby also addressed PMC's public policy committee, discussed the Institute's rationale for its agenda – which was short on specifics – and answered questions from PMC members.
During his talk, Selby shared that PCORI's goal for its research agenda was to be a foundation for future work. Through funding announcements, the Institute hopes to solicit a broad range of research proposals that will offer many options on approaches to implement and conditions to study.
Selby suggested that PCORI aims to keep the door open to provide funding for comparative effectiveness research (CER) studies that may benefit small subpopulations or rare disease research, and not to fund only research addressing common conditions such as heart disease, depression or diabetes. However, several PMC members pointed out that ultimately PCORI's funding decisions will pick winners and losers.
Selby encouraged the submission of proposals to the Institute for studies designed to demonstrate what types of treatments will work for different subgroups of patients (as PMC believes all CER studies should aim to do). PMC was disappointed that he did not commit the Institute to such an approach as we believe the statute requires, although he noted that research announcements will solicit thematic proposals in addition to disease-specific ones that may address some personalized medicine topics.
PMC Members asked Dr. Selby about the development of PCORI's infrastructure and questioned whether the Institute has what it needs to align CER with personalized medicine. As I noted previously, PMC does not believe that the Institute has developed the internal structure necessary to carry out its mission at this time. Dr. Selby informed the PMC policy committee that PCORI welcomes its feedback about how to assure that funded CER-studies align with personalized medicine through its open meetings, public comments, and advisory committees.
To facilitate personalized medicine, CER must explain not only what works best – but also for whom. The future of medicine depends on a careful and critical answer to this critical question. We are not yet sure that PCORI has embraced this idea. For example, when the Board met to discuss altering the research agenda based on public comment, it tried to more clearly define the need to study personalized medicine. It failed to cite the most common definition of personalized medicine, and instead, discussed mostly demographic characteristics. The PMC will respond to the altered language with the expectation that the definition of personalized medicine will be accepted into the research agenda language. This is the most basic, first step to aligning CER with personalized medicine.
We valued Dr. Selby's willingness to dialog with the PMC community and look forward to continued engagement with PCORI to ensure that CER can be supportive of quality health information, tailored to patients' values and individual biology.
As I mentioned previously, the Patient-Centered Outcomes Research Institute (PCORI) issued its draft research priorities earlier this year. The Personalized Medicine Coalition (PMC) provided comments on the draft that outline how PCORI must address fundamental structural issues to meet Congressional intent. Specifically, the intent is that the research overseen and conducted by PCORI should support personalized medicine and align comparative effectiveness research with personalized medicine.
1. Define a public engagement process: PCORI should outline a transparent process for obtaining input from all stakeholders, including patients, clinical experts and scientists, and detail how stakeholder input will be used. One possibility is to assemble all comments in a document and demonstrate how they informed the final draft.
2. Establish a personalized medicine expert advisory panel: PCORI has the statutory authority to create expert advisory panels, on any topic, to carry out its mission. To assist PCORI with assuring that its work supports personalized medicine, PMC strongly requests that PCORI develop an expert advisory panel devoted to personalized medicine. As an educational organization dedicated to advancing the field and populated by stakeholders from all sectors of the health care universe, the PMC Clinical Science Committee offers its assistance in identifying potential members for this proposed expert advisory panel.
3. Improve the science behind comparative effectiveness research (CER): One of PCORI's Congressionally mandated tasks is to improve the quality of CER by incorporating new information and technological innovations into its studies, reviewing and updating the evidence as necessary and identifying future research that is needed to address information gaps. PMC suggests creating the infrastructure (and the processes) to achieve this goal now as the foundations of the organization are being established.
4. Make the research priorities more specific: The PCORI draft research priorities envisioned by statute were broad, encompassing all aspects of the health care system that relate to high-quality, effective patient care–and specific, calling for a transparent process to identify and prioritize research topics based on explicit criteria and public input. PMC strongly suggests that PCORI's materials address the second point, assuming that the statute envisions a broad scope of research.
5. Develop in-house capacity to engage broad scientific and clinical expertise: The mission of PCORI is unique and to carry it out PCORI must call on the capacity of a unique set of individuals to develop calls for research proposals, evaluate them, make awards, follow the progress of the research, and engage the public at all steps in the process. Having this infrastructure "in-house" is a necessary step in the Institute's development.
We look forward to working with PCORI on these initiatives to strengthen its research agenda and infrastructure. Personalized CER has great potential to elevate the quality of care in the United States and we are ready to do our part.
Today, I had the privilege of addressing the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors on behalf of the Personalized Medicine Coalition (PMC). As noted in my previous blog on its member selection, the PCORI Board of Governors was established by the Patient Protection and Affordable Care Act and is tasked with assisting patients, clinicians, purchasers, and policymakers in making informed, evidence-based, health decisions.
As a science-driven organization, PMC supports health decisions made on sound science. When working with legislative drafters and the community to develop the legislation creating PCORI, we recognized the need to ensure that the research supported by this group must be personalized and continually updated. The resulting law creating PCORI aligned the principles of personalized medicine with those of comparative effectiveness research. It underscores the importance of eliminating an "average effects" approach to CER, which obscures subgroup differences and skews treatment decision-making away from individualized care.
To make sure this opportunity is realized, we requested that the Board designate an ad hoc committee on personalized medicine to work with both the Board and the Methodology Committee. We believe that such an ad hoc committee will help the Board and methodology committee comply with the Congressional intent that the research overseen and conducted by PCORI be personalized when appropriate. High levels of communication and collaboration have been essential to the advancement of personalized medicine, and the same will hold true for advancing CER that is aligned with personalized medicine.
Achieving alignment between CER and personalized medicine holds substantial opportunities, but we realize it will be challenging. These challenges cut across a range of issues, from study designs, to operating procedures, to research priorities. An ad hoc committee will provide a venue for bringing a diversity of expertise and perspectives together to focus on this common objective. Such a group will help in coordinating research across a range of public and private sector activities and ensure that the most relevant evidence gaps and research questions are identified related to personalized medicine, and will help with matching study designs to questions.
The science of personalized medicine is fast moving and sometimes highly specialized. Legislation and regulation takes time to catch up. The personalized medicine community is committed to seeing that PCORI's research keeps pace with scientific advancement and welcomes the opportunity to achieve this end.
We are at a crossroads of research, regulation and legislation. It is an exciting time!
I just got back from a meeting of the Board of Governors of the Patient-Centered Outcomes Research Institute in New York City. PCORI, as you probably know, is the independent Institute established by the health reform law to conduct comparative clinical effectiveness research. Regarding CER and personalized medicine, I'll say now what I said late in late 2009: in the midst of the debate over health care reform — it remains to be seen whether CER will align with personalized medicine. CER that aligns with personalized medicine should be patient-centered, because it will be structured to recognize and respect patient differences.
We've made important progress toward that goal, with CER statute for the first time referencing genetics and individual patient difference. I am hopeful we'll eventually get there, but we're not there yet. Personalized medicine was, as far as I saw, mentioned only once during the PCORI Board meeting. NIH Director Francis Collins raised it during a discussion of the report from the PCORI Methodology Committee. Commenting on the Committee's charter and the "perceived tension between CER and personalized medicine," he said he "would hope that the Methodology Committee would take that on," and suggested emphasizing alignment with personalized medicine and patient preferences in the document. I applaud Dr. Collins for raising this point, but we will need more voices joining him to make sure the Board and Methodology Committee to integrate CER and PM. It seems to reinforce some concerns expressed earlier by PMC about lack of an expert in genomics or personalized medicine on the Methodology Committee. The idea proposed by PMC of creating an advisory panel on personalized medicine and innovation could be one step to help ensure alignment between CER and personalized medicine.
One of the big news items from the PCORI Board meeting was the appointment of Dr. Joe Selby as the PCORI Executive Director. I was heartened by Dr. Selby's comments at the meeting, in which he stressed the importance of hearing from, and focusing on, patients. It will be equally important for Dr. Selby and the additional staff he hires to understand that part of the Institute's charge from Congress is to account for genomics and subpopulation differences. Failure to do so will prevent us from realizing the potential for personalized medicine to improve health care quality and value.
The next meeting of the PCORI Board of Governors is in Washington, D.C. on July 18 and 19th. I hope you'll join me there in support of comparative clinical effectiveness research that is centered on patient needs and aligned with personalized medicine.
The Government Accountability Office (GAO) today announced the members of the Methodology Committee for the Patient Centered Outcomes Research Institute (PCORI). We don't dispute the credentials of the 17 appointed members, and we appreciate NIH Director Francis Collins' participation on the committee. Yet it is nonetheless disappointing to see that none of these appointed members from the private sector bring expertise in personalized medicine, particularly since including experts in genomics was one of the specific fields identified in statute. This will make it all the more important for leaders in the personalized medicine field to continue to advocate for alignment of PM and CER in development of research methods and study designs. For the past year, the Personalized Medicine Coalition (PMC) has been a strong advocate in support of CER that is aligned with personalized medicine. In October, PMC submitted a letter to GAO nominating ten experts in personalized medicine from across academia and industry. While many on the methodology committee bring strong expertise in their research fields, the lack of in-depth expertise in genomics and personalized medicine will make it more challenging to advance research methods that are aligned with personalized medicine and recognize "advances in medical technology" as specified by statute.
Perhaps the PCORI Board could create an ad hoc advisory panel focused on personalized medicine and innovation that would help to ensure that sufficient focus is brought to these important issues as PCORI moves forward with developing research methods and priorities . Having such a committee could help PCORI fulfill other mandates such as public engagement, stakeholder representation, and keeping the science up-to-date.
In June, PMC nominated a slate of individuals representing the diversity of our coalition including representatives from patient advocacy groups, hospitals and health systems, the pharmaceutical and diagnostics industries, and public health agencies for appointment to the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors. We were pleased that the Government Accountability Office (GAO) included Pfizer's Chief Medical Officer Dr. Freda Lewis-Hall, a PMC nominee with expertise in and a commitment to personalized medicine, as a member of the PCORI Board of Governors.
But while we thank GAO for selecting a group of individuals for the PCORI Board of Governors who are committed to improving the health of the American people through research that will, we hope, improve outcomes, we also recognize that our work is not finished. We must continue to advocate for personalized medicine both with the PCORI Board of Governors and eventually with its Methodology Committee, to ensure that comparative effectiveness research considers population subtypes, individual variation, and personalized medicine in general.
The 21-member PCORI Board of Governors, established by the Patient Protection and Affordable Care Act, is tasked with assisting patients, clinicians, purchasers, and policymakers in making informed, evidence-based, health decisions. It will identify research priorities, carry out a research agenda, and receive support from a Methodology Committee and expert advisory panels.
We were disappointed that the newly selected members of the PCORI Board of Governors did not include more individuals with specific expertise in personalized medicine, in particular, individuals representing small, innovative diagnostics companies. Small diagnostics companies, which develop new tests for detecting disease, are central to the field of personalized medicine and will play a necessary and important role in the research PCORI will conduct. We hope that the yet-to-be-named Methodology Committee will include more representation from this important sector.


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Q: Communication between two unreachable hosts in a network I needed to send a file between two computers which both have firewalls. A server, which is contactable, is available to coordinate the transfer. I know the server can act as a "proxy" between the peers i.e. file is uploaded to the server and then downloaded by the other peer. However is it possible to arrange direct communication, without using the servers bandwidth? Is this what a vpn can do?
Thanks

A: VPN (virtual private network) is for ALLOWING communication over public (untrusted, NOT private) networks.  Not what you want here, if this is all on private networks.  If it's over the internet, then yes, a VPN for EACH machine is a reasonable solution, but that would only allow you the machines to talk to the central server privately.  Then you still have to arrange file sharing.  That too should be easy enough, using the file sharing built into windows, or using Samba.
Assuming the machines AREN'T on private networks:
The big question is: WHY have a firewall between two machines, if you want them to be able to talk to each other.  Unless the third-party machine is going to add security, then it's senseless to have the extra overhead.  Just allow the first machine (or both) to contact the other, and transfer designated files.
If you really want to use the third-party machine (and don't have a hardware router that can do it), the easiest solution would be use the third machine as a router, so it's simply passing the communications data around, but not storing it.

A: A VPN could be used to solve these types of problems, but it's not the best appproach.  A VPN is used to give access from a client on one network to the resources on another network via a host.  The problem is, a VPN will effectively make the client act as if it's sitting on the very same network it's being given access to so any printers, fileshares, etc. would also be available to it unless confirgured not to be.
An easier solution would be to open up certain ports between the machines and use solutions like scp or webdav (if you're limited to port 80).  I'm not sure what ports are open/closed and the network structure/security restrictions.  There are many variables to consider.

A: You have a couple of options other than staging the file on the middle server, both of which will require use of the server in the middle's bandwidth as the other two can not directly talk to each other.
1) Set up a proxy server on the middle server, this is a software installation / copnfiguration. This can be done clear text or encrypted if required.
2) Setup the middle server to offer VPN services for one or both machines to see each other's networks. This is also a software installation / configuration. VPN's are encrypted.
You did not say why the two are firewalled from each other, and modifying the firewall configuration is not an option. It would be more efficient, and probably more secure to do as mentioned above and open up the firewalls on both sides for a specific port for specific hosts to directly transfer the files and not require the middle server.

A: One word: Hamachi.
It's a small program you install on the two individual machines, and then it uses a central server to INITIATE the connection, but tunnels directly between the two machines. It appears as another network interface on the computer, as a VPN would.
It runs on a variety of platforms, some easier to use than others (Windows = uber easy, *nix = easy for a *nix expert, OSX = difficult for average user). It has trouble behind proxies, but for a NATted connection it should be fine.

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