Scaling up eHealth
in line with ICT
proliferation
Digital Health for rural
communities: Potential, Trends
and Challenges
ITU, 17th Sept. 2010
Hani Eskandar
ICT Applications and Cybersecurity Division
ITU Telecommunication Development Sector
(ITU-D)
Need 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.
2
Typical activities/transactions
within a Care process
Activities
Surveillance
Care program
management
Preventive
Care
|------------------------------------Patient Care Management-----------------------------|
Patient care
Support
Disaster Care
Management
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
3
Activities, Transactions, Info. Exchange
Activities
Transactions
Preventive
care
intervention
Public education
preventive care
Type of Information exchanged in the Data type Data
transaction
Size
for Information brochures
Transfer Mobility
mode
TAVI
M
S
M
Recorded Lectures
AV
L
S
M
Live shows
AV
L
R
P
Counselling
AVT
M
R
M
T
T
T
I
T
AVT
S
M
S
M
S
M
R
S
S
S
S
R
M
P
M
M
M
M
Announcements
Registration and cancellation forms, etc
Register patients into Patient demographic and referral notes
specific care programs Photo , biometric
Family history, patient history
Conferencing
Data type
Data Size
Mode of transfer
Mobility
Alphanumeric text – T
< 160 Bytes- Tiny (T)
Real Time – R
Mobility – M
Image – I
<32Kbytes – Small (S)
Store and forward - S
Portability - P
Video – V
<1Mbytes – Medium (M)
Waveform signal-S
<10Mbytes Large (L)
Audio –A
<100Mbytes - Very large (V)
>100Mbytes-Extremelylarge (E)
4
Surveillance
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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Surveillance
Connectivity
CDMA2000/
GPRS/
PSTN
(<64Kbps)
Care
Activity
Surveillance
Care transaction
type of Information exchanged
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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Surveillance
Real-Time Bio-Surveillance Program(RTBP):
Directorate of Public Health and Preventive Medicine, Tamil Nadu, India
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Patient 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.
8
Patient 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/healthworker/patient when the parameters go out of bounds.
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Patient Care Management
Connectivity
Care Activity
CDMA2000/
GPRS/
PSTN
(<64Kbps)
Patient care
management
Care transaction
type of Information exchanged
Consultation with Physician
Patient history data analysis, patient risk quantification, genetic/ familial predispositions,
allergies and adverse reactions to medication, medication history, Patient medical
record
Conferencing
Diagnostics, Medication, Treatment
Bio-chemical analysis of Blood, Urine, Stools reports, TMT, BP, Weight, Temperature,
etc.
Summary reports
Patient diagnostic data – Vital
Specialist report on disease stage, assessment of complications for treatment,
prognostic classification, rarity of disease condition, etc
Medication service order, prescription of diet and medication schedule , correlation of
symptom to schedule mismatch
Schedule and dosage tracking reports, Symptom and complication capture and alerts
Consultation with Physician
Prescription
Diagnostic (second opinion)
Diagnostic (second opinion)
Specialist Consultation
Specialist Consultation
Medication services
Medication services
Medication services
Therapy services
Therapy services
Ambulance services
Admission/Discharge/Transfer to hospital
Surgery
Clinical-waste Management
Patient Monitoring
Patient Monitoring
Patient Monitoring
Patient Monitoring
Counselling
Counselling
Financial Assistance
Financial Assistance
Financial Assistance
Financial Assistance
Inventory and door-to-door delivery scheduling.
Therapy service order, prescription of diet and schedule , correlation of symptom to
schedule mismatch
Therapy progress tracking form
Real time patient data monitoring
Bed booking, admission/ transfer form, discharge summary, legal forms
OT resource planning
Waste inventory, disposal order and tracking forms
Monitoring Configuration form, monitoring report
Recording of temperature, heart and respiration rate, BP, height ,weight ,urine, stools,
foetal heart rate, blood glucose, oxygen, etc
Signals such as ECG/EEG
Alert messages with critical information
Information brochures, FAQ
Tracker of Patient response to counselling
Telephonic support for education about insurance / other subsidy information brochure/
FAQ lists
Insurance/subsidy policy application forms, Claim forms, bills, claims processing
reports
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Collection follow-up calls
Claims audit reports
Example: Remote Patient monitoring system
Disaster 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 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
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Disaster Care Management
Disaster management and Proactive care in Tele-Health Network – Amrita
Institute of Medical Sciences(AIMS), Kerala, India
Broadband & eHealth
Connectivity
Care Activity
Care transaction
type of Information exchanged
ISDN/
DSL/
EDGE
(<256Kbps)
Surveillance
Conduct Screening tests
Conduct Screening tests
Conduct Screening tests
Conduct Screening tests
Conduct Screening tests
Diagnostic (second opinion)
Diagnostic (second opinion)
Diagnostic (second opinion)
Diagnostic (second opinion)
Biochemistry lab images
Microbiology images
Heart Sound, Audiogram
Ophthalmology tests
Endoscope, otoscope, dermoscope
ECG, PFT, EEG, etc
Heart Sound, Audiogram
Angiogram, Otoscope, Dermoscope
Microbiology, ECHO, Otoscope, endoscope,
Dermoscope video
Patient diagnostic data – general
Patient diagnostic data – Radiology
Follow up with patient for counselling and tracking of
medication
Patient training information (live/recorded)
Conferencing
Fleet management, other logistics support
Conferencing
Patient records, patient health trend report, progress
notes
Conferencing
Patient medical records
Conferencing from emergency site
Conferencing for Triage
Live video of affected area
Emergency training, counselling, consulting
Environmental surveillance reports
real time counselling and preventive care guidance
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Patient care
management
Specialist Consultation
Specialist Consultation
Medication services
Therapy services
Ambulance services
Ambulance services
Post-hospitalization follow up consultation
Post-hospitalization follow up consultation
Disaster care
management
Counselling
Financial Assistance
Emergency response
Triage
Triage
Triage
Triage
First aid
Broadband & eHealth
Connectivity Care Activity Care transaction
type of Information exchanged
VDSL/
CABLE/
EV-DO
(<10Mbps)
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)
Patient care
management
Care program Education and training for site staff
management
Live shows
Preventive
care
intervention
Public education for preventive care
Live shows
Patient care
management
Surgery
Sharing prior information with remote
experts
Conferencing during surgery with fail over
channel
Live local and remote monitoring of
apparatus & patient during surgery with
failover channel
Surgery
Surgery
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Conclusions
distribution of information data-size within transactions
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
extremely large
very large
large
medium
small
tiny
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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Conclusions
Nature of information access latency within transactions
100%
90%
80%
70%
60%
50%
40%
30%
20%
Real-time
10%
Store & Forward
0%
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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Conclusions
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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Conclusions
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.
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Thank you.