Scaling up eHealth in line with ICT proliferation

Digital Health for rural communities: Potential, Trends and ChallengesITU, 17th Sept. 2010

Hani EskandarICT Applications and Cybersecurity DivisionITU Telecommunication Development Sector (ITU-D)

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Need for rapid eHealth proliferationNeed for rapid eHealth proliferation

o Proliferation rate of Tele-health services needs to race against disease incidence and prevalence rates in next decade.

o The economic burden of disease measured in disease-adjusted life years (DALY) translates to a loss of productivity to over $200 Trillion! in India.

o It is important to understand which Tele-Health services can be proliferated immediately with available infrastructure and which additional services can be added as the infrastructure is transformed.

o This will make it easier to decide on investment priorities for ICT adoption in Tele-Health

Methodology: identify which activities, transactions and information exchange events are achievable at various

levels of infrastructure maturity and computer interfaces at the user end.

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Typical activities/transactionsTypical activities/transactionswithin a Care process within a Care process

Care program management Surveillance

Preventive Care

|------------------------------------Patient Care Management-----------------------------| Patient care Support

Disaster Care ManagementActivities

Transactions

Source: ITU. Findings demonstrated in this presentation are based on a field survey of real-life application scenarios that was conducted covering over 26 Tele-Health initiatives from a mix of private, government and NGO managed care delivery organizations across India for the ITU by Dr. P.S. Ramkumar. The report will be published on the ITU website on: http://www.itu.int/ITU-D/cyb/app/e-health.html

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Activities, Transactions, Info. ExchangeActivities, Transactions, Info. ExchangeActivities Transactions Type of Information exchanged in the

transactionData type Data

SizeTransfer mode

Mobility

Preventive care intervention

Public education for preventive care

Information brochures TAVI M S M

Recorded Lectures AV L S M

Live shows AV L R P

Counselling AVT M R M

Announcements T S R M

Registration and cancellation forms, etc T M S P

Register patients into specific care programs

Patient demographic and referral notes T S S M

Photo , biometric I M S M

Family history, patient history T S S M

Conferencing AVT M R M

Data type Data Size Mode of transfer Mobility

Alphanumeric text – T

Image – I

Video – V

Waveform signal-S

Audio –A

< 160 Bytes- Tiny (T)

<32Kbytes – Small (S)

<1Mbytes – Medium (M)

<10Mbytes Large (L)

<100Mbytes - Very large (V)

>100Mbytes-Extremelylarge (E)

Real Time – R

Store and forward - S

Mobility – M

Portability - P

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SurveillanceSurveillance

o A large scale health care system will develop, deploy and manage care programs of relevance to the needs of citizens within their categories of focus (e.g. elderly population, disabled population, mother and child care, AIDs, Cancer, Malaria, etc.)

o It is important to form a surveillance network that gathers demographic and environmental information in regions of governance.

o Based on the analysis of such data the care program then identifies

prioritized target zones and needs of the disease management / living conditions to be addressed.

o The care program can then engage appropriate human resources such as health workers, nurses and doctors, trained according for timely intervention in regions of priority.

Fewer types of information exchanges are needed in surveillance phase than curative and palliative phases of

the care delivery process -> it is relatively cheaper, simpler and easier from a technical standpoint to induce ICT

transformation in this phase.

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SurveillanceSurveillance

Connectivity Care Activity

Care transaction type of Information exchanged

CDMA2000/ GPRS/ PSTN (<64Kbps)

Surveillance Register citizen for screening Citizen details

Conduct Screening tests ECG /PFT

Conduct Screening tests HR/BP/Temperature/weight/etc

Conduct Screening tests Screening reports

Conduct Screening tests Lifestyle issues

Trending of health indicators Regional, seasonal and sporadic disease incidence, morbidity-mortality reports, etc.

Environment monitoring Hygiene, pollution levels in air/water/food, industrial efflux, pests, insects, climatic change, etc.

Genetic and habitual risk profile known/unknown symptoms of genetic disorders, ethnic predisposition, habitual disorders, etc in target population

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SurveillanceSurveillanceReal-Time Bio-Surveillance Program(RTBP):

Directorate of Public Health and Preventive Medicine, Tamil Nadu, India

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Patient Care ManagementPatient Care Management

o Covers the curative and palliative care workflow delivered in hospitals, ambulances, clinics and homes of patients as needed.

o Citizens identified as patients may be referred to appropriate physicians where the patient’s case file can be provided electronically.

o Patients can be studied remotely and be prescribed specific medication, treatment or further detailed diagnostics/observations to assess the situation and plan treatment.

o Patients identified for emergency care get transferred to emergency management facilities immediately.

o In cases where hospitalization is not required, the treatment could be self-managed by training the patient or with assistance of health workers/nurses.

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Patient Care ManagementPatient Care Management

o In case patient goes through a surgery, the local doctor can seek guidance of remotely located experts. Such collaboration can electronically share patient history and data from monitoring apparatus, and discuss through audio/video conference before, during and after the operation.

o For Post hospitalization, the patient’s recovery can be remotely monitored in follow up consultations with the physician by sharing medication, treatment and symptomatic response data of the patient, as recorded by the health workers.

o In special situations, one can also employ patient monitors which can automatically track the specified symptoms/parameters within specified bounds and alert the care-taker/health-worker/patient when the parameters go out of bounds.

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Patient Care ManagementPatient Care ManagementConnectivity Care Activity Care transaction type of Information exchanged

CDMA2000/ GPRS/ PSTN (<64Kbps)

Patient care management

Consultation with Physician Patient history data analysis, patient risk quantification, genetic/ familial predispositions, allergies and adverse reactions to medication, medication history, Patient medical record

Consultation with Physician ConferencingPrescription Diagnostics, Medication, TreatmentDiagnostic (second opinion) Bio-chemical analysis of Blood, Urine, Stools reports, TMT, BP, Weight, Temperature,

etc.Diagnostic (second opinion) Summary reportsSpecialist Consultation Patient diagnostic data – Vital Specialist Consultation Specialist report on disease stage, assessment of complications for treatment,

prognostic classification, rarity of disease condition, etcMedication services Medication service order, prescription of diet and medication schedule , correlation of

symptom to schedule mismatchMedication services Schedule and dosage tracking reports, Symptom and complication capture and alerts

Medication services Inventory and door-to-door delivery scheduling.Therapy services Therapy service order, prescription of diet and schedule , correlation of symptom to

schedule mismatchTherapy services Therapy progress tracking formAmbulance services Real time patient data monitoringAdmission/Discharge/Transfer to hospital Bed booking, admission/ transfer form, discharge summary, legal forms

Surgery OT resource planningClinical-waste Management Waste inventory, disposal order and tracking formsPatient Monitoring Monitoring Configuration form, monitoring reportPatient Monitoring Recording of temperature, heart and respiration rate, BP, height ,weight ,urine, stools,

foetal heart rate, blood glucose, oxygen, etcPatient Monitoring Signals such as ECG/EEGPatient Monitoring Alert messages with critical informationCounselling Information brochures, FAQCounselling Tracker of Patient response to counsellingFinancial Assistance Telephonic support for education about insurance / other subsidy information

brochure/ FAQ listsFinancial Assistance Insurance/subsidy policy application forms, Claim forms, bills, claims processing

reportsFinancial Assistance Collection follow-up callsFinancial Assistance Claims audit reports

Example: Remote Patient monitoring systemExample: Remote Patient monitoring system

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Disaster Care ManagementDisaster Care Management

o Disasters may demand the system for large scale training, deployments and management of resources at very short notice in order to prevent/contain outbreak of diseases and casualty.

o From assessment of situation to planning, training, execution, tracking and steering the entire action plan, these activities may utilize services of Patient Care, Prevention, etc. but with independent, parallel governance and priorities.

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Disaster Care ManagementDisaster Care Management

Connectivity Care Activity Care transaction Type of Information exchanged

CDMA2000/ GPRS/ PSTN (<64Kbps)

Disaster care management

Emergency response Real time vital signs of patients

Emergency response Abnormality alerts from monitoring

Emergency response Emergency admission forms

Triage Disaster assessment form, disaster management protocol, resource allocation form

Emergency care Emergency treatment plan, health Insurance /subsidy information form, specialist notes

Emergency care Patient tagging, patient vital signs and other medical parameters monitor

First aid Primary symptoms capture

Disaster Care ManagementDisaster Care ManagementDisaster management and Proactive care in Tele-Health Network – Amrita

Institute of Medical Sciences(AIMS), Kerala, India

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Broadband & eHealthBroadband & eHealth

Connectivity Care Activity Care transaction type of Information exchanged

ISDN/DSL/ EDGE (<256Kbps)

Surveillance Conduct Screening tests Biochemistry lab imagesConduct Screening tests Microbiology imagesConduct Screening tests Heart Sound, AudiogramConduct Screening tests Ophthalmology testsConduct Screening tests Endoscope, otoscope, dermoscope

Patient care management

Diagnostic (second opinion) ECG, PFT, EEG, etcDiagnostic (second opinion) Heart Sound, AudiogramDiagnostic (second opinion) Angiogram, Otoscope, DermoscopeDiagnostic (second opinion) Microbiology, ECHO, Otoscope, endoscope,

Dermoscope videoSpecialist Consultation Patient diagnostic data – generalSpecialist Consultation Patient diagnostic data – RadiologyMedication services Follow up with patient for counselling and tracking of

medicationTherapy services Patient training information (live/recorded)Ambulance services ConferencingAmbulance services Fleet management, other logistics supportPost-hospitalization follow up consultation ConferencingPost-hospitalization follow up consultation Patient records, patient health trend report, progress

notesCounselling ConferencingFinancial Assistance Patient medical records

Disaster care management

Emergency response Conferencing from emergency siteTriage Conferencing for TriageTriage Live video of affected areaTriage Emergency training, counselling, consultingTriage Environmental surveillance reportsFirst aid real time counselling and preventive care guidance

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Broadband & eHealthBroadband & eHealth

Connectivity Care Activity Care transaction type of Information exchanged

VDSL/ CABLE/ EV-DO (<10Mbps)

Patient care management

Diagnostic (second opinion) Ultrasound, Mammogram, X-ray, CT, MRI imaging, Ophthalmoscope and slit-lamp

Specialist Consultation Patient diagnostic data - Pathology

Diagnostic (second opinion) Pathology imaging

VSAT/ HDSL/ XWIFI (<1Mbps)

Care program management

Education and training for site staff Live shows

Preventive care intervention

Public education for preventive care Live shows

Patient care management

Surgery Sharing prior information with remote experts

Surgery Conferencing during surgery with fail over channel

Surgery Live local and remote monitoring of apparatus & patient during surgery with failover channel

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ConclusionsConclusions

It is observed that 25% to 60% of the information exchange in 95% of the transactions falls in the ‘small’ data size category. Only in a couple of cases such as full-slide pathology reporting, etc. extremely high data size is observed.

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ConclusionsConclusions

Over 85% of the transactions can employ store and forward methods ranging between 35% to 100% of information exchanges within the transactions. About 45% of the transactions can be completely handled using store forward methods.

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ConclusionsConclusions

o Several proof points of benefits have been demonstrated in terms savings in travel time, expense and effort of patients; timely intervention and containment of disease outbreaks and emergency; proactive care delivery; reduced human error and misplacement of patient data, etc.

o SMS and Web-based routine data capture for demographic, environmental surveillance and patient monitoring have been demonstrated using basic cell phones.

o Mobile Vans with various functionalities from screening to minor OT have been deployed routinely to reach out to remote rural areas.

o Transmission of vital signs and video conferencing data have been demonstrated at 64 Kbps links. o Most of the transactions that are needed in surveillance and preventive care are possible with existing infrastructure.

o Employing surveillance to identify the disease outbreaks in its early stages and delivering timely preventive cure requires lesser expenditure and infrastructure than curative and palliative stages.

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ConclusionsConclusions

There is no need to wait for new infrastructure, many

ICT enabled care services can be designed around existing infrastructure which needs to be done with

utmost urgency, to save DALY losses.

Thank you.