VOLUME

The twinning framework describes a model of collaboration and set of principles at each step, from initiation of the collaboration through the evaluation of results and reframing of projects as appropriate (Figure 1). The twinning framework was applied as the collaboration moved through initiation, implementation, monitoring and evaluation. Evaluation was viewed as an iterative process that informed next steps in the process as the collaboration developed.

Figure 1: Four steps in the twinning approach.

Initiation of the BDMS-OHSU international health alliance

The collaboration between Oregon Health & Science University (OHSU) and BDMS was formally established in 2014 to address the strengths of both institutions and to create opportunities for leveraging the expertise and experience of each party. Stemming from inter-professional student education and study abroad experiences over the previous eight years, OHSU chose to centralize its global footprint in Southeast Asia and established ‘OHSU Global’ in 2014. Two ‘OHSU Global’ faculty members visited the BDMS flagship hospital in 2014 to present OHSU strengths and the institutions’ interest in finding qualified Southeast Asian collaborators to help create and grow a formal international program for OHSU. From this initial meeting and subsequent video conferences between institutions, BDMS described their need for initial academic support in helping to create a Center of Excellence in Occupational Health (COE-OH) in Thailand. Thus, a five year, renewable Memorandum of Understanding was signed with distinguished collaborators in Southeast Asia, including BDMS in Bangkok, Thailand. The BDMS flagship hospital, located in Bangkok, was identified to serve as the home for regional activities of OHSU Global in Southeast Asia. BDMS is one of the largest private health system in Southeast Asia, comprising more than 43 hospitals across Thailand, and Cambodia. BDMS incorporates six hospital brands that care for a wide spectrum of patients across Thailand and Southeast Asia. BDMS is now poised to become the largest hospital systems among the Association of Southeast Asian Nations (ASEAN) as the ASEAN Economic Community (AEC) comes into effect in 2005. Due to the high prevalence of Thai workers, approximately 1/3 of BDMS hospitals (n=43) provide occupational health services with six hospitals providing comprehensive services: Bangkok Hospital Headquarters, Bangkok Phrapradaeng Hospital, Bangkok Rayong Hospital, Bangkok Hospital Hat Yai, Samitivej Sriracha Hospital, and Phyathai 2 Hospital. Of these six hospitals, only Samitivej Sriracha Hospital has a dedicated occupational health clinic, while the remaining five hospitals mix occupational check–up clients with general health check-up. Since 2014, the majority of clients to these six hospitals are corporate/insurance clients (57% in 2016), followed by self-pay clients (40%), and hospital staff (3%). Since 2014, BDMS has increased its number of occupational health providers in these six hospitals by 40.6%, representing 97 providers comprising occupational health physicians (n=40), nurses (n=50) and industrial hygienists (n=7).

Occupational health services and programs at BDMS

BDMS occupational health hospitals implement various intervention projects to improve individual health based on emergent need identified from health screenings (Table 3). For example, over the past three years, work-related hearing loss and ergonomic-related conditions have been clients’ primary complaints. Therefore, occupational health services have included ergonomic intervention programs aimed to improve worker’s heath and prevent musculoskeletal diseases, hearing conservation programs, and other health promotion programs that promote healthy lifestyles and reduce the risk for metabolic syndrome. Biological monitoring of chemicals and metabolites in workers’ urine over the past three years have revealed an urgent need to address environmental and occupational exposures among Thai workers.

Table 3: Top three abnormal findings identified by Bangkok Rayong Hospital in the past three years and corresponding number of corporate health intervention projects implemented across BDMS’s six comprehensive occupational health hospitals.

A needs assessment identified initial priorities for the COE-OH

In order to begin this effort, a needs assessment was conducted in May 2015 by an occupational medicine physician (Rischitelli) and certified industrial hygienist (Montgomery), based around the core competencies of occupational and environmental medicine defined by the American College of Occupational and Environmental Medicine29 and the World Health Organization (WHO).30 The assessment identified a particular need in Thailand for seminars and training in occupational health core areas. It also identified a parallel need for a health risk assessment platform that could be used with the Thai population for health promotion, measuring behavior change, and rooting high-quality operational research out of the COE-OH. In contrast to traditional occupational health programs in the U.S., Thailand offers universally-provided healthcare to all workers,1 thereby enhancing opportunities for implementing work-related occupational health programs while facilitating assessment of programmatic impact on organizational costs and health outcomes. This identification of direct benefits and contributions to overall worker health parallels the U.S. initiative identified by the National Institute of Occupational Safety and Health (NIOSH), termed Total Worker Health®. BDMS confirmed interest in offering occupational health programs for both BDMS employees and organizational clients for whom BDMS provides occupational Occupational health services and programs at BDMS BDMS occupational health hospitals implement various intervention projects to improve individual health based on emergent need identified from health screenings (Table 3). For example, over the past three years, work-related hearing loss and ergonomic-related conditions have been clients’ primary complaints. Therefore, occupational health services have included ergonomic intervention programs aimed to improve worker’s heath and prevent musculoskeletal diseases, hearing conservation programs, and other health promotion programs that promote healthy lifestyles and reduce the risk for metabolic syndrome. Biological monitoring of chemicals and metabolites in workers’ urine over the past three years have revealed an urgent need to address environmental and occupational exposures among Thai workers. health services. Thus, initial priorities for the COE-OH identified 1). Occupational health training, 2). A health risk assessment platform supporting health promotion, and 3). Research on the impact of offered worksite wellness programs on Thai employees31 (Figure 2).

Figure 2: Capacity-building foci of the Occupational Health Center of Excellence

Collaborative funding and joint ownership of COE-OH initiatives

Applying twinning principles, a joint leadership team was established that consisted of approximately three individuals per institution. This joint leadership team was responsible for decision-making, with ultimate oversight resting with the heads of both institutions, namely the BDMS CEO and the OHSU President. OHSU and BDMS agreed to match funding to pay for initial efforts. The joint leadership team agreed upon three capacity-building foci for the COE-OH (occupational health training, health promotion, and research development, Figure 2), with each having its own annually-renewed and agreed Scope of Work defining a mutually-acceptable set of activities in each focus area.

Implementation of foci activities based on shared priorities

Based on existing capacity and resources, Occupational Health Training and Health Promotion activities were developed and implemented in the first year, whereas research development followed as trust was established and the collaboration identified resources and expertise to lead key research development activities.

Occupational Health Training

Shared knowledge, peer-to-peer communication, and professional exchange are key tenets of the twinning framework, and were directly addressed via a jointly-developed educational program for Thai health care providers and occupational health practitioners. Based on the needs assessment, both parties identified gaps in occupational health education and training. Consistent with the twinning model’s emphasis on long-term relationships to allow for shared decision-making and collective efficacy,20 a three-year education plan was jointly developed to capitalize on the academic strengths of OHSU, existing training within the BDMS system, and shared willingness to volunteer significant time for curriculum development to ensure success. Trainings were developed by OHSU and conducted using a train-the-trainer model.32 U.S. case studies were utilized and discussed in application to Thai corporate case studies at the end of the workshop. Participants included clinicians, occupational health practitioners, key managers, and administrators including marketing officials. For some training, participants received a completion certificate with the BDMS-OHSU International Health Alliance’s dual logo upon completion. Specific trainings are described in Table 4, including the topic, target audience, and the number of trainees attending.

Table 4: Occupational health trainings using “Train-the-Trainer” approach

To ensure maintenance of the training program, a number of follow-up activities were developed and implemented, including monthly joint BDMS-OHSU industrial toxicology case conferences (which allowed for sharing of clinical cases and information amongst occupational medicine and toxicology peers attended by multiple BDMS/OHSU sites), opportunities for three clinical team members from BDMS to visit OHSU (e.g., Oregon Poison Center and other recommended toxicology training sites during the 2 week visit), as well as an Occupational Health professional exchange. In the exchange, two occupational health physicians and two occupational health nurses visited OHSU and related sites for 2 weeks to substantiate knowledge in industrial hygiene, occupational nursing, and occupational medicine in the United States. This exchange was followed by a full week training for an expanded group of BDMS practitioners on industrial hygiene, occupational health nursing and occupational health in Bangkok, led by OHSU industrial hygienist with support from two U.S. occupational health nurses. A functional capacity evaluation training workshop was also conducted for key rehabilitation/physical therapists in 2015 with follow-up training in 2016. Finally, an online learning platform was created by OHSU, with input on approach and functionality from the BDMS leadership team, to serve as a platform for regular exchange of didactic information in Occupational Health for healthcare providers and clients, and to create a host site for resources and summaries of important articles.

Health Promotion and Behavior Change

The COE-OH’s second focus revolved around enhancing opportunities for health promotion through the expansion of the existing employee check-up system offered annually to every Thai employee.31 Worksite wellness programs can result in significant healthcare cost savings and improve health outcomes, including diet, physical activity, physiologic changes (body mass index, blood cholesterol), and significantly greater smoking cessation.31 While the Thai government is on the forefront of preventive healthcare through the requirement of an annual physical for all employed individuals, there is no requirement for individual- or corporate -level feedback to promote or sustain healthy behaviors, such as good diet, adequate sleep, or appropriate exercise. Thus, implementation of a health promotion program with feedback to accompany the existing annual check-up was a priority for BDMS. The leadership team reviewed existing programs and jointly decided to expand a successful OHSU-developed health promotion program, “Let’s Get Healthy!” to deliver health promotion activities. A team of experts in occupational health, population science, and informatics was assembled from both institutions and began meeting monthly to 1) Identify how to best integrate the Let’s Get Healthy! Program into the annual employee check-up system; 2) Vet and approve health components to include in the package (Figure 3); 3) Develop a process for Thai translation and cultural adaptation of assessments and tailored feedback; 4) Complete Let’s Get Healthy!’s module implementation and data integration into the existing clinical check-up and electronic health record systems. Thai occupational health leaders, information technology specialists, and researchers from both institutions worked very closely on development and implementation of this program. Through monthly videoconferencing, regular email communication, and quarterly visits to Bangkok, the collaborators established a strong and lasting bonding where there is shared ownership of the adapted product, “Let’s Get Healthy!-Global”, its planned implementation, and resulting data over time. Thus, the twinning framework model developed a culturallyappropriate health promotion product that could rapidly assess employee health behaviors across workplaces in Thailand and other SE Asia regions. Consistent with efforts to promote opportunities for worksite health promotion, data captured on employee risk of metabolic syndrome33 and behavioral risk factors (sleep, diet and cognitive function) are stored in a secure data repository and used in aggregate to inform a corporate report for employers that describes the prevalence of metabolic syndrome among employees, stratified by gender, age group, worker type, and in relation to behavioral risk factors as measured by Let’s Get Healthy!-Global (e.g., sleep, diet, cognitive function). The desired function of this report is to guide employers in determining need and target audience for a tailored worksite wellness programs.

Figure 3: BDMS leadership determining Let’s Get Healthy! modules for initial inclusion (left). BDMS employees pilot testing new modules to review translation accuracy, content length, and feedback effectiveness (Right).

Development of Joint Research Capacity

The third identified focus area of the COE-OH developed capacity for ongoing research activities that advance both science and employee/patient wellness. The incorporation of Let’s Get Healthy!-Global into the BDMS annual checkup system provided a unique opportunity to develop an integrated, robust, and comprehensive research data repository containing clinical and behavioral data across a wide variety of worker types and industries.

Adaptation of existing informatics infrastructures to support research development

BDMS offers a rich infrastructure for data collection stemming from its already-existing health information systems (HIS) and electronic medical record (EMR) processes. The EMR is a digital/ computerized version of a paper chart that contains all of a patient’s medical history. However, similar to many hospital systems in the U.S., BDMS’s 43 hospitals used disparate HIS and EMR systems and not all were interoperable and consequently did not support integration of annual health check-up data into a single repository, nor were processes yet developed to support BDMS’s research mission. Thus, an architecture and schema that integrated BDMS healthcare data were developed to support research purposes. Specifically, informatics teams from OHSU and BDMS designed and developed an information architecture to integrate key data from the hospitals’ disparate EMRs, leveraging BDMS’s BExchange platform (BDMS’s Enterprise Patient Index system) into a third data system that would serve as a central repository for data consolidated across BDMS EMR platforms. This single repository, termed the Occupational Health Repository (OHR), holds checkup data for approved research projects. OHR contains integrated clinical data and Let’s Get Healthy!-Global data collected across many companies, industries, and hospital visits. Organized for easy use by researchers, it supports the use of healthcare data for research purposes and serves as a robust relational database permitting a variety of research activities, including intervention implementation and evaluation, cross-sectional risk assessment, and cohort analyses of disease risk using annual check-up data collected longitudinally.

Building capacity for human subject’s protections to support research activities

BDMS hospitals have existing patient consent procedures for delivery of healthcare services, though patient approval for the broad-based collection of their healthcare data for use in research was not implemented across all hospitals’ administrative procedures. Thus, initial collaboration activities prioritized the design and incorporation of patient consent processes, Institutional Review Board (IRB) approvals, and data governance processes that would support the collection and usage of BDMS data for ongoing research. Specifically, an OHR joint governance team, consisting of BDMS and OHSU researchers, developed policies and guiding procedures for OHR content, structures, and output formats. This team was tasked with ensuring compliance with both Thailand and U.S. human subjects’ protection regulations such that the team could review and approve data requests in line with scientific merit and feasibility. They also would ensure that researchers interested in utilizing OHR data have a) appropriate IRB project approvals in place prior to the release of any data; and b) that the researchers’ data request is consistent with and appropriate for their approved protocol. To facilitate research capacity-building, the team also arranged cross-institutional communications between IRBs at OHSU and BDMS to increase understanding of protocols and procedures related to using data repositories stemming from EHRs for research in the United States. The international communication helped to increase understanding and preparation of BDMS IRB when reviewing incoming protocols. Likewise, to facilitate the development of an overarching BDMS research protocol using the OHR, OHSU shared their approved protocols, consent form language, data sharing agreements, and other documentation that supported protocol development in Thai. The submitted protocol was the first of its kind at BDMS, a critical step that could be replicated or leveraged to accelerate interdisciplinary research across BDMS hospital systems and researchers. Together, these areas of work reflect a larger agreed-upon vision of building a COE-OH and expanding research opportunities across institutions, similar to other twinning projects aimed at improving health outcomes.11,22-26

Overall, the results of the international health alliance are measured in terms of the successful implementation of proposed programs, trainings and the development of shared resources that lay the groundwork for future research. Overall, and as described below in more detail, this alliance has resulted in the successful deployment of “Let’s Get Healthy!” and integration of Let’s Get Healthy! data with clinical data to inform reports to corporate clients. Training programs in occupational health and student exchanges have been developed and implemented, and approvals have been sought to allow for development and maintenance of a large data repository to support ongoing research.

Monitoring of Outcomes

The international health alliance outlined a logic model (Table 5) which applied twinning principles and approaches to accomplish each focus area. Working closely together, the team identified agreed targets, metrics for evaluation with timelines, and individual/ institutional responsibilities for reporting which were laid out in a jointly drafted document. In addition to each area of work for the three foci, detailed work plans were established and agreed to. For example, agreed upon measured outcomes for the training programs reflected the number of trainees as well as the number of training programs offered. In addition, an online learning process was developed to provide ongoing training resources and opportunities for information exchange between BDMS occupational medicine physicians and staff and their counterparts at OHSU using website analytics. The utility of the online learning process as well as the number of individuals who successfully complete all ten training modules are to receive a certificate of completion will be assessed. Finally, a long-term outcome of the educational aspects of this collaborative effort is the continued use of a newly created online platform for information sharing. While not yet measured, this will provide an opportunity to provide necessary feedback to update and adapt the training as is appropriate.

Measured outcomes of this work include the successful implementation of Let’s Get Healthy!-Global (LGH-G) as part of the employee check-up package in six hospitals, development of individualized feedback for LGH diet, sleep and cognitive function assessments, development of a real-time report to corporate clients describing metabolic syndrome prevalence of their employees with tailored recommendations, and the development of a data repository that supports ongoing research. These outcomes are beneficial to both institutions and will support the later development of health promotion interventions that may be tailored to worksites’ specific needs. A meaningful and lasting outcome of these collaborative activities has been the development of highly functioning team of individuals representing both institutions. This group continues to meet monthly, has participated in eight face-toface meetings and is able to sustain ongoing collaborations.

Table 5: Logic model guiding the international collaboration built upon the Twinning framework.

Figure 4: BDMS occupational health staff undergoing training in industrial toxicology and hazardous materials incident management.

Figure 5: BDMS nurses undergoing respirator fit testing as part of respirator fit testing as part of the occupational health nurse training with OHSU.

Occupational health training results

To date, training workshops have been held on five occupational health topics (toxicology, functional capacity evaluation and ergonomics, occupational health nursing, hazard recognition and control, and health and productivity management) resulting in the training of 115 occupational health providers who will disseminate accrued knowledge using the “train-the-trainer” approach. This initial success has led to an expansion of the annually-revised work plan to establish, implement and measure additional training programs. Language, time zone differences, geographic distance between participants internationally and within Southeast Asia inhibited real time exchange of information for professional collaboration and peer to peer interaction. To address these barriers, the teams agreed to implement an internet-based learning management system to allow for sharing of announcements, promotion of online forum discussions and consultations, facilitate an online journal club, and provide an eLibrary of resources. The leadership teams chose the Sakai learning management system (www.sakaiproject.org), an open source collaborative learning platform, because OHSU already used it successfully for its online courses. Content developed for the in-person classes was incorporated and adapted for online learning. Content from the health and productivity management (HPM) training was chosen for pilot development of an online course and was made available for participants in December 2016. Similar online training modules in toxicology and hazard recognition and control are in development and ultimately all ten of the ACOEM competencies will be represented. Participants are able to take the courses in a self-paced, distance learning format that encourages online discussion and demonstration of competency. Participants who complete the modules receive a certificate of completion for each individual module and a summary certificate when all ten modules are successfully completed. Ultimately, the goal of the online training and collaboration is to sustainably elevate the level of occupational health services and worker protection to an international standard and achieve regional and international excellence.

Health promotion results

Let’s Get Healthy! Global had been successfully implemented in six BDMS hospitals by the end of 2016, with immediate feedback to individuals based on their diet, sleep, and cognitive function results. All collected data on consented patients are housed in the developed OHR. Products developed in 2016 include an automated “Corporate Report” which provides employers with a summary of employee metabolic syndrome risk, as well as how employee diet, sleep, and cognitive function are related to metabolic syndrome risk. As described previously, the evaluation of Let’s Get Healthy! Global implementation and dissemination is an iterative process with results from the first two years of the collaboration guiding the development of new project modules to create a fully complete health risk assessment model. This U.S.-based risk assessment model will be adapted in 2017 to use data from the Thai employee population thereby defining culturally-appropriate risk strata for a Thai population. These additional modules will be developed jointly by BDMS and OHSU. Other 2017 activities will include the identification of a co-developed intervention for dissemination and implementation with corporate clients and targeting their health priorities.

Ongoing research results

Efforts in 2016 finalized the OHR, with a jointly-developed protocol submitted to BDMS’s IRB for review and approval. This protocol submission marks the first of its kind at BDMS. The OHR joint governance team continues to meet annually and by teleconference to review OHR data structures and will begin vetting data use requests in 2017. Additionally, consent form language will be made consistent across BDMS’ hospitals to permit data usage for research. Finally, as new health promotion modules become developed, the OHR will be adapted to accept the new variables and data. Thus, the OHR offers a rich source of occupational health data that will fuel the COE-OH’s mission and activities.

The international alliance that has been established between OHSU and BDMS has been highly successful to date, however, there have been challenges that are worth a mention. While language was not a significant barrier in discussions with clinicians and administrators, translation of all Let’s Get Healthy! modules was necessary. In some situations, simple direct translation was not feasible, for example some key concepts or words (e.g. “vigilance”, a word to assess attention within the cognitive function module) did not have a direct correlate in Thai. In these cases, it was necessary to ensure through translation, back translation, and pilot testing with individuals who spoke both languages fluently to ensure that the meaning of all surveys remained consistent. Cultural differences also came into play when developing appropriate individual survey feedback that was meaningful to Thai workers. Finally, as described previously, the need to provide trainings across large geographic differences and time zones created a scenario in which in person trainings were not always feasible. This issue was overcome through development and implementation of synchronous and asynchronous online training options.

A twinning framework offers a rich set of principles for establishing and building upon an international health alliance. Efforts by BDMS and OHSU continue to move forward successfully in each focus area (training, health promotion and research), with the collaboration about to enter its three year with mutually-agreed activities. The annual scope of work offers an excellent format for establishing goals and activities based on emergent needs which are consistent with available time and financial resources. Trust has been established and re-enforced through in-person visits which allow personnel from both sides to better learn about each other and their unique set of interests and skills. Growth in the coming years will focus on product development for reaching a broader cross-section of Thai workers, including health promotion activities for increasing healthy habits among the Thai workforce as well as OHR-based research which will be critical for establishing the prevalence of environmental and occupational exposures in Thailand. This research will feed-forward to training activities and health promotion interventions, thereby improving and continuing the cycle of occupational health services offered by BDMS across its hospital systems.

The alliance developed between OHSU and BDMS provides an excellent example of a twinning partnership that brings benefits to both partners and promises to support further research efforts and improvements to clinical service provision.