COPING WITH CHRONIC DISEASE AMONG OLDER PERSONS IN ... · - Government is planning to scale-up the screening of hypertension and diabetes from 6 percent to 18 percent, for the adults

COPING WITH CHRONIC DISEASE AMONG OLDER PERSONS IN CAMBODIA USING ICTS

COPING WITH CHRONIC DISEASE AMONG OLDER PERSONS IN CAMBODIA

USING ICTS

UN/ESCAP Consulting Project

Prof. Dongik Oh, Ph.D., Department of Medical IT Engineering

Soonchunhyang University, Asan, Korea


Contents

+Motivation and Background - Outline of the study - Target diseases, Key factors (Diseases and ICT)

+Case Study - Korean, Canadian, Cambodia-Korea examples

+ ICT-based chronic disease service models - Four models

+ ICT-based programmes (strategies) - Five programmes (stretegies)

+Conclusion

* page 2 의료IT공학


* page 3

Outline of the study

+ Within the context of limited financial and health professional resources, it seems beneficial that many countries where conventional medical service infrastructures are poor adopt innovative methods to increase accessibility to healthcare services

+ Examined and suggest various ICT-based medical services (models and strategies) to see if they are implementable and useful to Southeast Asian countries, starting from Cambodia, which has relatively a good ICT infrastructure

+ Demonstrate that the use of ICT can help expand access to healthcare services and promote the rights of medically isolated people, especially the old and the rural area residents


* page 4

Target diseases + The world’s population is aging. But longer lifespan presents a

variety of challenges to the old population especially in the healthcare fields

+ Non-communicable diseases (NCDs) in Cambodia account for 59.94% of all deaths (2016) - Growing elderly population need for long-term care of well-known

NCD diseases such as hypertension and diabetes

+ Cambodian government stress that - “because of the increasing prevalence of NCDs, an aging population and

urbanization pose challenge the structure and delivery model of the health system” , so that “Further strengthening health promotion and primary and secondary prevention for NCDs to stem the growth of the conditions and reduce health care costs” is necessary (Health Strategic Plan3 (2016))


* page 5

Key factors

+ Aging (65 years old and above)

+ Life Expectancy at Birth

Target 2015 2050 World 8.3% 15.8% Southeast Asia 9.6%(2016) 21.1% Cambodia 5.7%(2020) 12.2% (6.7% in 2030) Korea 13.1% 40.1%(2060)

Target Age World 71.4 (2015) Southeast Asia 69.0 (2015) Cambodia 70.0 (2019) Korea 81.0 (2018)


* page 6

Key factors

+ Population Pyramids of Cambodia - Total population 16.3million (2018)

Cambodian population in 2010 and its projection for 2020 and 2030 (Source: Population Pyramids of the World 1950 to 2100. Available at https://www.populationpyramid.net/cambodia/)


* page 7

Key factors

+ Non-communicable disease (NCD) in Cambodia - NCDs account for 59.94% of deaths in 2016 which was 32% in 2000 - Death causes - All ages (2016)

- Cardiovascular disease (22.5%); Diabetes (2.2%) - Diagnostic stats – Age 25~64 (2013)

- Diabetes 2.9% (urban 5.6%; rural 2.3%) - Hypertension 11.2% (urban 16%; rural 10%)

- Government is planning to scale-up the screening of hypertension and diabetes from 6 percent to 18 percent, for the adults forty-year-old and older, by the year 2020


page 8

Key factors

+ Medical Professionals - Total of 19,457 public medical workers (2015) - Doctors(14%), Nurses(46%), Midwives(24%). Others(16%) - 0.168 doctor per 1,000 population (Southeast Asian country avg. : 0.534) - 45% works in the city (Urban population 23.8%) - 2/3 work privately as well (5,500 private licenced providers)


page 9

Key factors

+ Public Medical Facilities

Comments

Provincial Health District (PHD) One Provincial Hospital and up to 10 ODs; Provides CPA

Operational District (OD) Covers 10,000~20,000; At least one Referral Hospital and many HCs

Health centre (HC) Covers 10,000~20,000; 8~11 staffs (at least one doctor); 10km; 2hours distance; Provides MPA

Health Post Covers 2,000~3,000; 25km;

Type of facility Designated number Functioning 2012 Functioning 2013 Functioning 2017

National Hospitals 8 8 8 8

Operational Districts 81 81 81 100

Referral Hospitals: Provincial Hospitals Referral Hospitals

97 24 67

82 24 58

85 24 61

108 24 84

Health centres 1024 1020 1085 1190

Health Posts 86 86 119


page 10

Key factors

+ Public/Private Medical Service Usage - Total : Public 29%; Private 57%; Rural : Public 15%; Private 65% - Public focus on the preventive service; Private focus on the curative service

+ Government Administrative Structure - Population : 16.3 millions - 25 Provinces; 165 Districts; 1,646 Communes; 14,000+ Villages

+ Economy - GDP/person : $1,390 - Annual growing rate more than 7%


page 11

Key factors

Group Usage Remarks Year Mobile phone penetration

116.0% World 104.5% Southeast Asia : 125.0%

2017

Internet users 32.4% World : 45.8% Southeast Asia : 48.4%

2016

Average annual growth of Internet usage

62.0% Southeast Asia : 23.0% 2016

3G or 4G mobile communication coverage

83.9% Population percentage live in the region covered

2017

Smartphone usage by 75+ 4.5% Direct use of App. may be premature

2017

Smartphone usage by 25~74 39.8% Aged population of the future 2017

+ ICT related statistics


* page 12

Focus of the study

+ Examine the use of ICT-based preventive medicine in Cambodia, where medical services are relatively poor

+ The primary endpoint for this study is non-communicable diseases (NCDs), which account for 59.9% of all deaths in Cambodia

+ Focus is made especially on hypertension and diabetes, as they are often accompanied by complications when poorly managed, with the highest risk seen in elderly and rural populations

+ Three case studies are examined and based on various findings, four models and five strategies are devised and suggested


* page 13

Case study – I

+ Three types of telemonitoring and teleconsultation in urban areas, rural areas, and nursing homes in Korea for assessing chronic diseases, such as diabetes, obesity, and hypertension

+ Type 1: patients performed self-measurement and submitted their bio-information to doctors using smartphone App. Doctors monitored information and provided feedback directly to patients

+ Type 2: bio-information are collected at a healthcare facility. Resulting data were sent directly to the doctor. Teleconsultation was performed using the patients’ smartphone when necessary

+ Type 3: teleconsultation between physicians and patients at a nursing home was performed. Biosignal-measuring devices, such as BP monitors, glucometers, and SpO2 devices, were used


* page 14

Case study – I (cont.)

+ All three models allowed for prompt consultation between patients and physicians, enabling proper treatment when problems arose

+ Not surprisingly, this approach significantly improved individual’s health conditions and enhanced healthcare service quality overall, particularly for elderly and rural populations

+ However, the first model, with patient’s self-reported data, presented more challenges than the other models due to the variability in patient reports and the administrative burdens it posed


* page 15

Case study – II

+ Canada’s indigenous population in Saskatchewan, particularly in areas with few doctors, nurses are the major healthcare providers, similar to the situation in Cambodia

+ Nurses perform both diagnostic and prescribing functions. Nurses need quick access to effective tools and information resources

+ Mobile devices loaded with information frequently referenced in nursing practice were provided to all nurses (reference materials, manuals on diseases and disorders, a handbook on laboratory and diagnostic tests, and a drug guide)

+ Nurses frequently used the devices in care planning, to answer questions about diseases, and to educate clients and their families


* page 16

Case study – III

+ Two types of ICT-based service are implemented in Cambodia in 2014

+ Type 1 : Remote monitoring of diabetes & hypertension - An internal medicine doctor at Kossamak hospital with chronically ill

patients in Phnom Penh - Individuals regularly monitored their glucose levels and blood

pressure using devices provided. Patients sent data directly to the doctor using smart phones

- In cases of abnormal or suspicious findings, in-person visits were requested to address potential concerns


* page 17

Case study – III (cont.)

+ Type 2 : Teleconsultation between Cambodian and Korean doctors - Teleconsultation between doctors from three Cambodian hospitals

and one Korean hospital was conducted - Doctors discussed cases in teleconference-like settings, sharing

laboratory and imaging data, such as X-ray and CT films - Through the system, Cambodian doctors could obtain advice on

patient diagnoses and surgical planning - Local physicians were able to acquire more advanced and practical

clinical knowledge from their Korean counterparts - This service is still in operation every Wednesday 12:00pm ~1:00pm

+ Survey results show that doctors and patients are satisfied with the ICT-based service provided


* page 18

Development procedure

+ In order to have a solid planning and implementation, the developmental process needs to consider following steps: - Field opinions need to be reflected in the policy planning - Concerned parties’ understanding and cooperation is needed - A pilot project to establish the good practice is recommended

+ Based on several background reviews and program analyses, four models for use with rural and elderly NCD populations are devised. Five strategies to make models plausible are also suggested

+ Recommendations considered the provision of support using ICT-based technology, and implementability under the current public healthcare and governance structures of Cambodia


* page 19

+ Several visit to public facilities were made, and questions and consultation are done with local interest groups - The visits include two health centres, one village centre, one OD

office, one peer station, and one national hospital - The groups interviewed include medical doctors, nurses, midwives,

a village-chief, and a peer consultant

+ From the information and opinion gathered, the recommendation of this report tried to better reflect the concerns of the potential service providers and recipients

Development procedure (cont.)


* page 20

ICT-based chronic disease service models

+ To provide better care for chronic disease patients, especially the elderly and rural populations, four ICT-based service models for Cambodia are suggested

+ These models are derived from an analysis of exemplary systems, as well as analysis of the current public medical system structure and service provision of Cambodia

+ It is recommended to utilize existing infrastructure where possible, so the adoption of models are less challenging to healthcare providers and patients


* page 21

+ Disease screening and care processes are added to the list of routine practices performed at health centres (MPA)

+ Chronically ill patients regularly visit nearby health centres for check-ups, and their clinical data are collected and monitored by a team of doctors and nurses

+ These data are then recorded digitally, so that follow-up can be performed based on each patient’s medical history

+ In cases further examination is needed, teleconsultation or specialist visitation at a higher-level medical institution is arranged

1. Health-centre-based model


* page 22

1. Health-centre-based model (cont.)

+ ICT-based diagnostic materials will be prepared for use on mobile devices, and will include tools to assist decision making, including when to refer patients to higher-level hospitals - ICT-based system should be helpful in identifying potential

complications associated with hypertension and diabetes


* page 23

+ Utilizes Cambodia’s current administrative structure to serve chronically ill patients (Communes and village centres)

+ Blood-pressure–monitoring machines and glucometers need to be installed to enable regular monitoring of patient. Patients can obtain healthcare service at more convenient locations, thereby increasing program participation

+ The person in charge of the service should be trained to operate and maintain the medical and communications equipment

+ Patient data can be sent to health centres or referral hospitals for monitoring via the ICT application

2. Commune/Village-centre-based model


* page 24

+ Mobile access to guidelines and related information is also recommended to ensure proper service provision on site

+ When the data reflect the need for further examination, teleconsultation at a health centre or specialist visitation can be arranged

2. Commune/Village-centre-based model (cont.)


* page 25

+ Peer consultants (chronically ill patients) provide basic data-measuring services to other patients - Peers may also provide education and instruction to other patients

for health management, as in the Commune–based model

+ Maybe useful in smaller villages without a health centre nor other medical facility, or in remote places where health centre visitation is challenging

+ A similar program is currently operated by a non-governmental organization (MoPoTsyo) - However, a number of potential problems associated with the

program has also been identified, which needs to be resolved within the government healthcare service structure

3. Peer-station-based model


* page 26

+ This model can be implemented within the health centre’s existing outreach program - Nurses and midwives visit village centres regularly to assess

chronically ill patients - Household visits are also conducted, as necessary, which can be

extremely useful in providing care to elderly patients - Diagnosis-aiding materials will be prepared for use on mobile

devices in various decision-makings, such as the identification of potential complications associated with hypertension and diabetes

4. Outreach model


* page 27

+ Patient data can be entered using the mobile devices

+ ICT-based diagnostic and educational materials for the health centre-based model would be adequate for this model as well

4. Outreach model (cont.)


* page 28

ICT-based programmes (strategies)

+ To make four models to effectively deal with chronic disease, following pre-requisites are recommended - The system should be reasonable and beneficial both to service

providers (medical professionals and administration) and to service recipients (patients)

- The implementation should not be too complicated or expensive - The system needs to be operational even when external funding is

finished

+ Recommend five programmes (strategies), which are needed for the successful implementation of the suggested models


* page 29

+ When a case is suspected of being unusual or having complications, the patient should be sent to a specialized hospital for precise diagnosis and proper treatment

+ Currently, health centres refer such patients to upper-level hospitals, but the referral system should be implemented more actively to ensure proper care

+ When a visit to a hospital is not possible, ICT-based collaborations such as teleconsultation can be performed, so that proper and timely services are available to all patients

+ Apps. on mobile devices and desktop computers are adequate enough for this type of teleconsultation

1. Referral system


* page 30

+ Informative tools should be given to service providers for on-time and on-site decision making and patient care

+ The service providers may include medical professionals (doctors, nurses, midwives) and non-professional individuals (peers, village chiefs, commune workers, etc.)

+ Use of mobile devices are appropriate because they can carry up-to-date content and tools that are accessible online

+ An evidence-based practice (EBP) nursing application is recommended, which enables well-structured data entry, as well as reliable information-based decision-making support

2. Decision-making tools


* page 31

+ To recruit potential patients for screening - Information can be spread via mass media (SMS, TV, etc.) - It also can be done through the ordinary information delivery channels

of the communes and villages - Use of the outreach network and practical use of commune and village

centres may also be a viable option - Also, civil registration records may be used to identify potential patients

+ Screening needs to be conducted as early as possible - It can be performed through any of the four proposed models - Patients with diabetes and hypertension can be divided into

“observation,” “risk,” and “treatment” groups - Different service policies may be developed and applied to different

groups

3. Patient recruitment and screening


* page 32

+ Most ICT-based healthcare projects have terminated when financial and administrative support came to an end

+ Two examples that maybe useful for the sustainability are given

+ Example 1 : Telemedicine among medical institutes - Telemedicine with Soonchunhyang university hospital is in operation

for more than five years (2013~2019) with no continuing budget - Continuity is due to its usefulness (recipients need it), fellowship

(good relationships) between providers and receivers, its voluntary nature (participants serve with good will), and institutional (policy) support

4. Sustainable operation


* page 33

+ Example 2 : Recipients’ out-of-pocket (OOP) payment - For the programme to be durable, there should be financial support

for system operations including incentives for service providers - Governmental support is subject to national planning and budgeting,

and may not be feasible at this developmental stage of the country - A more practical solution is to charge patients a reasonable fee for

the service and to use these funds to cover the operational expenses

- MoPoTsyo adopted the idea of a nominal fee. When the programme begun in 2005 it was fully supported by external funding, but currently, 80% of the budget comes from patients’ OOP money

- This study suggests that government embrace the activities of MoPoTsyo and adapt the activities to suit the public health system

4. Sustainable operation (cont.)


* page 34

+ Better diagnosis and treatment of hypertension and diabetes are possible when data are collected over a long period of time

+ In Cambodia, personal medical records are not recorded digitally, making retrieval and examination difficult

+ Sharing of PHR data among medical service providers at various levels would enable more efficient management of patients

+ In all models proposed in this report, availability of such database will enable immediate detection and action against the diseases

+ The digitalization of PHRs is extremely important because the decision-making tools recommended in this report also rely on it

5. PHR and HIS system


* page 35

+ The recommendations made in this report may help the provision of more effective and efficient ICT-based medical services to Cambodia, particularly for the elderly and rural residents

+ Recommendations are based on the previous studies, visit and consultation with various related institutes and people, to reflect the concerns of the potential service providers and recipients

+ It is strongly believed that a well-organized program combined with an ICT-based support system will enable the delivery of better healthcare services to patients with chronic diseases

+ The service can, of course, be expanded further to many other areas of healthcare, including quality of life issues in elderly and rural populations

Conclusion


* page 36

Appendix


* page 37

Appendix


* page 38

Appendix


* page 39

Appendix


* page 40

Appendix


* page 41

Appendix


* page 42

Appendix


* page 43

Appendix


* page 44

Appendix

COPING WITH CHRONIC DISEASE AMONG OLDER PERSONS IN CAMBODIA USING ICTSContentsOutline of the studyTarget diseasesKey factorsKey factorsKey factorsKey factorsKey factorsKey factorsKey factorsFocus of the studyCase study – ICase study – I (cont.)Case study – IICase study – IIICase study – III (cont.)Development procedureSlide Number 19ICT-based chronic disease service modelsSlide Number 211. Health-centre-based model (cont.)Slide Number 23Slide Number 24Slide Number 25Slide Number 26Slide Number 27ICT-based programmes (strategies)Slide Number 29Slide Number 30Slide Number 31Slide Number 32Slide Number 33Slide Number 34Slide Number 35Slide Number 36Slide Number 37Slide Number 38Slide Number 39Slide Number 40Slide Number 41Slide Number 42Slide Number 43Slide Number 44

Documents

COPING WITH CHRONIC DISEASE AMONG OLDER PERSONS IN ... · - Government is planning to scale-up the screening of hypertension and diabetes from 6 percent to 18 percent, for the adults