Telemedicine: potential for Telemedicine: potential for use use in developing country in developing country

environmentsenvironments

S. Yunkap KwankamS. Yunkap Kwankam

Department of Health Service ProvisionDepartment of Health Service Provision

Cluster on Evidence and Information for PolicyCluster on Evidence and Information for Policy

World Health OrganizationWorld Health OrganizationGeneva, SwitzerlandGeneva, Switzerland

OverviewOverview• What is telemedicine?What is telemedicine?

• The health systemThe health system

• Examples and potential of Examples and potential of telemedicinetelemedicine

• Use of ICT world wideUse of ICT world wide

• Contribution to strengthening healthContribution to strengthening health

• Partnerships - role for Civil SocietyPartnerships - role for Civil Society

• ConclusionConclusion

What is telemedicine?What is telemedicine?

Telemedicine:

• The delivery of health care services, where distance is a critical factor, by health care professionals using information and communications technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interest of advancing the health of individuals and their communities

- WHO (1997)

What is Telehealth?What is Telehealth?

Telehealth:Telehealth:

• The use of electronic information and The use of electronic information and communication technologies to support communication technologies to support long-distance clinical health care, long-distance clinical health care, patient and professional health-related patient and professional health-related education, public health and health education, public health and health administrationadministration

- US Office for the Advancement of Telehealth

What is eHealth?What is eHealth?

Source: The eHealth Landscape (2001)

Entire contents of the Library of Congress Entire contents of the Library of Congress transmitted in 30 minutestransmitted in 30 minutes

450,000 people communicating by telephone 450,000 people communicating by telephone simultaneously via the Internetsimultaneously via the Internet

all through a fiber smaller than diameter of all through a fiber smaller than diameter of human hair.human hair.

Capacity of ICTCapacity of ICT

US postal system delivered 101billion pieces of US postal system delivered 101billion pieces of mailsmails

618 billion email messages delivered in same 618 billion email messages delivered in same year in USyear in US

2005 - estimated 35 billion emails sent around 2005 - estimated 35 billion emails sent around the world dailythe world daily

ComparisonsComparisons

Health Health Health Health

ResponsivenessResponsivenessResponsivenessResponsiveness

Fairness in financingFairness in financingFairness in financingFairness in financing

LevelLevelLevelLevel DistributionDistributionDistributionDistribution

Goal - both level and distributionGoal - both level and distribution

ProvisionProvision

Revenue collectionRevenue collection

Fund poolingFund pooling

PurchasingPurchasing

Non-personal health Non-personal health servicesservices

Personal health Personal health servicesservices

FinancingFinancingS

tew

ard

ship

Ste

war

dsh

ip

Res

ou

rce

gen

erat

ion

Res

ou

rce

gen

erat

ion

Health system functionsHealth system functions

Intermediate goal - Effective Intermediate goal - Effective CoverageCoverage

AAccessibility ccessibility CoverageCoverage

AAccessibility ccessibility CoverageCoverage

AAvailability vailability CoverageCoverage

AAvailability vailability CoverageCoverage

AAcceptability cceptability CoverageCoverage

AAcceptability cceptability CoverageCoverage

AAffordability ffordability CoverageCoverage

AAffordability ffordability CoverageCoverage

Resource-Resource-constrained constrained

Quality Quality CoverageCoverage

Resource-Resource-constrained constrained

Quality Quality CoverageCoverage

EffectiveEffectiveCoverageCoverageEffectiveEffectiveCoverageCoverage

Intermediate Intermediate goalgoal

•Provider performanceProvider performance– Health gain - quality: effectiveness, Health gain - quality: effectiveness,

safetysafety– EfficiencyEfficiency

THE CHANGING PRACTICE ENVIRONMENT

Current ApproachCurrent Approach

Care based on visitsCare based on visits Professional autonomyProfessional autonomy Professionals control careProfessionals control care Provider recordsProvider records Decision based on experienceDecision based on experience Safety is individual issueSafety is individual issue Secrecy is necessarySecrecy is necessary The system reacts to needsThe system reacts to needs Cost not controlledCost not controlled Independent providersIndependent providers

New ModelNew Model

Continuous relationshipsContinuous relationships Customized patient careCustomized patient care Patient is source of controlPatient is source of control Information flows freelyInformation flows freely Evidence-based decisionsEvidence-based decisions Safety is a system propertySafety is a system property Transparency is necessaryTransparency is necessary Needs are anticipatedNeeds are anticipated Control costsControl costs Cooperation is a priorityCooperation is a priority

Source: Source: Janet M. Corrigan, Institute of Medicine Committee on the Quality of Health Care in AmericaJanet M. Corrigan, Institute of Medicine Committee on the Quality of Health Care in America

PERSPECTIVES OF PATIENT-BASED INFORMATION

INDIVIDUAL

- SEQUENCIAL- CHRONOLOGICAL- PROBLEM-ORIENTED- PERMANENCY- HISTORICAL RECOVERY- COMMUNICATION- RECENT EVENT RECOVERY DETAIL DIFFERENT “VISIONS” OF DATA DIFFERENT OUTPUTS INTENSIVE DATA MANIPULATION

GROUPS

- BY CLINICAL ATTRIBUTES CLINICAL FINDINGS REFERENCE GROUP COMPARISONS IDENTIFY ASSOCIATED ATTRIBUTES

- BY INTERVENTION CHARACTERISTICS MANAGEMENT AND REPORTING PROCESS CONTROL

POPULATION

- REFERENCE- HEALTH STATUS- SERVICE UTILIZATION AND PRODUCTION- RESEARCH

Telemedicine - examplesTelemedicine - examples

• Telemedicine in at least 60 WHO Telemedicine in at least 60 WHO Member StatesMember States

• Consultation, radiology, Consultation, radiology, cardiology, etc.cardiology, etc.

• Different types of infrastructure - Different types of infrastructure - POTS, ISDN, radio, satellitesPOTS, ISDN, radio, satellites

• different locations - clinic, home, different locations - clinic, home, mountain top, at seamountain top, at sea

Potential of Potential of telemedicinetelemedicine

• Improved accessImproved access

• Cost reductionCost reduction

• Informed policy and decision-makingInformed policy and decision-making

• Improved quality of care and delivery Improved quality of care and delivery systemssystems

Dramatic reduction in medical errorsDramatic reduction in medical errors

Greater recruitment and retention of health care workers due to Greater recruitment and retention of health care workers due to availability of ICT tools that improve the quality of work lifeavailability of ICT tools that improve the quality of work life

Greater access to health care professionals especially in remote and Greater access to health care professionals especially in remote and rural regions through Telehealthrural regions through Telehealth

Reduced physician and hospital visits, a reduction in duplication of Reduced physician and hospital visits, a reduction in duplication of services, improved efficiency and grater productivity through more services, improved efficiency and grater productivity through more effective data gathering and information sharingeffective data gathering and information sharing

Evidence-based care through best practices made possible by Evidence-based care through best practices made possible by integrated decision-support toolsintegrated decision-support tools

Potential for practice Potential for practice improvementimprovement

More knowledgeable workers through convenient More knowledgeable workers through convenient and accessible online continuing educationand accessible online continuing education

Improved patient care at the point of delivery Improved patient care at the point of delivery through better access to patient and clinical through better access to patient and clinical informationinformation

Greater system accountability with more information Greater system accountability with more information on the performance of health care organizations and on the performance of health care organizations and providersproviders

•Improved health system management, planning and Improved health system management, planning and research through better information.research through better information.

Potential for practice improvement Potential for practice improvement - 2- 2

25b-40b by giving US consumers the right 25b-40b by giving US consumers the right information, which could lead to better medical information, which could lead to better medical resultsresults

30b-40b from informed decision-making leading to 30b-40b from informed decision-making leading to more efficient use of medical and clinical resourcesmore efficient use of medical and clinical resources

30b-40b from use of electronic communications to 30b-40b from use of electronic communications to replace visits to primary care physicianreplace visits to primary care physician

•15b-20b savings in administrative costs by 15b-20b savings in administrative costs by eliminating the need to for care givers to recreate eliminating the need to for care givers to recreate records each time a patient moves or changes records each time a patient moves or changes medical plansmedical plans

Potential for cost Potential for cost savingssavings

Technology interventionTechnology intervention

Health System

Health outcomes

PolicyOrganization & management

Resourceinputs

Provision of health services:Provision of health services:• The combination of inputs into a The combination of inputs into a

production process that takes place in a production process that takes place in a

particular organizational setting and that particular organizational setting and that

leads to the delivery of a series of leads to the delivery of a series of

interventionsinterventions

Health services

Financing

THE DEVELOPMENT / ANALOG / DIGITAL DIVIDES BY INCOME

Source: Digital Opportunities Taskforce (DOT Force), 2000

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Population Television Telephone GDP Internet

Low Lower Middle Upper Middle High

Percentage of World Total

SELECTED TECHNOLOGY OUTPUTS BY REGION (1992-1997)

Source: Rodríguez F and Wilson E (InfoDev, World Bank 2000). Cited in [7], modified

Region Mobile Phones Pers Computers Fax Machines GPD per per 103 pop per 103 pop per 103 pop capita

OECD 102.21 195.37 31.43 20,113.5Eastern Europe & FSR 6.34 28.21 2.27 4,027.4East Asia 24.36 46.10 6.34 6,270.6Latin America & Caribbean 14.43 20.33 9.05 5,635.8Middle East 24.58 32.16 7.06 8,941.5Sub-Saharan Africa 1.61 5.05 1.66 1,971.5South Asia 0.69 4.72 1.60 1,764.3

THE RESEARCH & DEVELOPMENT DIVIDE BY REGION

GLOBAL INTERNET USERS (APRIL 2001)

Source: www.netsizer.com

TOTAL NUMBER OF USERS 427,213,610

47.95%

4.12%

0.38%

23.63%

18.58%

4.56%

0.78%North America

South America

Central America

Europe

Asia

Oceania

Africa

INTERNET USE - LANGUAGE

Source: Global Reach, Internet Statistics

Russian2.3%

Dutch2.1%

Portuguese2.5%

Other6.2%

French3.7%

Italian3.1%

Korean4.4%

Spanish4.5%

German 6.1%

Japanese8.6% Chinese

9.0%

English47.5%

NUMBER OF NATIVE SPEAKERS ONLINE (MARCH 2001)

Developing:Developing:84 % population84 % population

93% burden of disease93% burden of disease11% health spending11% health spending

6 % of hosts6 % of hosts

Developing:Developing:84 % population84 % population

93% burden of disease93% burden of disease11% health spending11% health spending

6 % of hosts6 % of hosts

Developed:Developed:16 % population16 % population

7% burden of disease 7% burden of disease 89% health spending89% health spending

94 % of hosts94 % of hosts

Developed:Developed:16 % population16 % population

7% burden of disease 7% burden of disease 89% health spending89% health spending

94 % of hosts94 % of hosts

Source: ITU 1999 “Challenges to the Network: Internet for Development”

Other

5.9%

Canada &

US

65.3%

Europe

22.4%

LAC

1.9%

Australia, Japan &

New Zealand

6.4%3.7 %

Developing

Asia-Pacific

Africa 0.3 %

Global Distributions: - Population, BoD, Health Spending, IP Hosts

GLOBAL INTERNET USERS

Source: International Telecommunication Union, 2000

0

50

100

150

200

250

300

350

Developed 30 47 77 124 180 232

Developing 3 7 13 25 51 83

1995 1996 1997 1998 1999 2000

4%

21%

6%

9%

15%

28%

0.1%0.1%

0.3% 0.5%

1%

1.6%

Penetration

Millions of Users

Driving force for Driving force for TelemedicineTelemedicine

• Driven by health needsDriven by health needs

• Not led by technologyNot led by technology

MissionMission

Improve health service delivery, in Improve health service delivery, in particular, and health system particular, and health system performance in general, through the performance in general, through the use of ICTs in countriesuse of ICTs in countries

Activity Activity areasareas

Developing the evidence base - best Developing the evidence base - best practicespractices

approaches, methods, tools and indicators for approaches, methods, tools and indicators for projectsprojects

capacity buildingcapacity building

resource generationresource generation

Resource generation - Resource generation - peoplepeople

• Multiple role of people - consumers, Multiple role of people - consumers, providers, contributors to financing, providers, contributors to financing, stewardsstewards

• “ “ .. the performance of the health .. the performance of the health care system depends, ultimately, on care system depends, ultimately, on the knowledge, skills and motivation the knowledge, skills and motivation of the people responsible for of the people responsible for delivering services” - delivering services” - WHR 2000WHR 2000

Generating - skills and Generating - skills and knowledgeknowledge

• Education, training and continuing Education, training and continuing professional development.professional development.

• Knowledge generationKnowledge generation

• knowledge systemsknowledge systems

• ProblemsProblems – Numerical imbalancesNumerical imbalances– Training and skill mix imbalanceTraining and skill mix imbalance– Distribution imbalancesDistribution imbalances

Improved access to health Improved access to health servicesservices

• Often Telemedicine trials inspired by lack of Often Telemedicine trials inspired by lack of access to servicesaccess to services

• Ethiopia - five radiologists cover entire countryEthiopia - five radiologists cover entire country

• Heartbeat Jordan projectHeartbeat Jordan project– Offered best access to target populationOffered best access to target population– improved economic and clinical efficiencyimproved economic and clinical efficiency– Raised quality of care deliveryRaised quality of care delivery– Early detection and non-invasive medical techniquesEarly detection and non-invasive medical techniques– Cost savings of $167 000 in one district in 3 months Cost savings of $167 000 in one district in 3 months

- per capita health spending $119 (commercial x-- per capita health spending $119 (commercial x-rate) $285 (ppp x-rate)rate) $285 (ppp x-rate)

InformedInformed policy making

• Benefits to service provisionBenefits to service provision– Using TM infrastructure to close loop on Using TM infrastructure to close loop on

data and information, horizontally and data and information, horizontally and verticallyvertically

– modern communications used to share modern communications used to share information seamlessly. Preserves information seamlessly. Preserves virtues of autonomy for providers, virtues of autonomy for providers, without fragmentationwithout fragmentation

Indicators of attainmentIndicators of attainment

• helping users to obtain services they helping users to obtain services they need, when and where need, when and where (Access)(Access)

• making health services work better making health services work better (Effectiveness)(Effectiveness)

• improving knowledge and skills of improving knowledge and skills of care givers care givers (Competence)(Competence)

• Help to improving relevance of Help to improving relevance of services services (Appropriateness)(Appropriateness)

Indicators of attainment - 2Indicators of attainment - 2

• getting best results at lowest cost getting best results at lowest cost (Technical Efficiency)(Technical Efficiency)

• help improve dignity of treatment, help improve dignity of treatment, autonomy of users, promptness of autonomy of users, promptness of attention and confidentiality attention and confidentiality (Responsiveness)(Responsiveness)

• Meeting expectations of population Meeting expectations of population (Responsiveness)(Responsiveness)

Barriers to widespread use of Barriers to widespread use of TelemedicineTelemedicine

• Multi-dimensional constructMulti-dimensional construct– technical knowledgetechnical knowledge– economic viabilityeconomic viability– organizational supportorganizational support– behavior modificationbehavior modification

Sustainability of Telemedicine Sustainability of Telemedicine projects?projects?

• Realization of benefits threatened by Realization of benefits threatened by lack of sustainabilitylack of sustainability

• Individual spending on health Individual spending on health insufficient to pay for cost of health insufficient to pay for cost of health care (insurance)care (insurance)

• In developing countries few providers In developing countries few providers can recover costs in Telemedicine can recover costs in Telemedicine projects - let alone make a profitprojects - let alone make a profit

Integrated Services Telehealth Integrated Services Telehealth Network (ISTN)Network (ISTN)

• Multiple services in value chain using Multiple services in value chain using Telehealth infrstructureTelehealth infrstructure

• Aggregation of usersAggregation of users

• Availability of LINCOS - Availability of LINCOS - multipurpose, multi-media self multipurpose, multi-media self powered, satellite communications powered, satellite communications unitsunits

CommunityCommunity

EquipmentSupplier

EquipmentSupplier

HospitalHospital

TelecomOperator

TelecomOperator

HealthServicesprovider

HealthServicesprovider

SystemIntegrator

CommunityCommunity

HealthFacility

HealthFacility

Serviceproviders

Serviceproviders

EquipmentSupplier

EquipmentSupplier

CommercialFacility

CommercialFacility

TelecomOperator

TelecomOperator

SystemIntegrator

Other WHO Other WHO effortsefforts

The Health Internetwork project The Health Internetwork project

Trade in health services via Trade in health services via telemedicinetelemedicine

Health InterNetwork: GoalsHealth InterNetwork: Goals• Improve global public healthImprove global public health by by

facilitating the flow of health facilitating the flow of health information worldwide, using information worldwide, using Internet technologies.Internet technologies.

• Enable more effective health Enable more effective health service deliveryservice delivery through through– access to high quality, relevant access to high quality, relevant

and timely information and timely information – better communication within the better communication within the

public health community.public health community.

ObjectivesObjectives• Support existing public health programs and Support existing public health programs and

prioritiespriorities through improved access and use of through improved access and use of information and communication technologies.information and communication technologies.

• Evaluate the impact of HIN on health service Evaluate the impact of HIN on health service deliverydelivery and, where feasible, on health and, where feasible, on health indicators.indicators.

• Assess the utility, relevance and impact of Assess the utility, relevance and impact of HINHIN in improving information access, in improving information access, exchange and use in the public health exchange and use in the public health community.community.

ConceptConcept

• Project cornerstonesProject cornerstones– Content: provided through an Content: provided through an

Internet portalInternet portal

– Connectivity: at selected Connectivity: at selected information access points in information access points in countriescountries

– Capacity: skills development for Capacity: skills development for public health information access, public health information access, management and usemanagement and use

FocusFocus

• Focus on public healthFocus on public health – Health service providersHealth service providers– Researchers and scientistsResearchers and scientists– Policy makers at all levelsPolicy makers at all levels

PartnershipsPartnerships

ITU e-commerce project ITU e-commerce project

Organizations in official relations with Organizations in official relations with WHOWHO

Role for Civil Role for Civil SocietySociety

Resolution WHA 40.25Resolution WHA 40.25

ObjectivesObjectives

PrivilegesPrivileges

ResponsibilitiesResponsibilities

ConclusionConclusion

Greatest potential for lasting impact lies Greatest potential for lasting impact lies with contributing to improving HSPwith contributing to improving HSP

Challenge Challenge Civil Society - develop Civil Society - develop innovative approaches for sustainable innovative approaches for sustainable application of telemedicine to improving application of telemedicine to improving health system objectiveshealth system objectives

Sharing not a zero-sum game- two Sharing not a zero-sum game- two candles shine better than onecandles shine better than one