K.R.P. Chapman
Consultant Surgeon, District General Hospital, Chilaw, Sri Lanka.
Email: keith_rpc@hotmail.com
S.M.K.D. Arunatileka
Senior Lecturer,
University of Colombo School of Computing,
35, Reid Avenue, Colombo 007, Sri Lanka.
Email:
shiromi_a@hotmail.comABSTRACT
This paper investigates the issues and challenges faced by patients in Sri Lanka, a developing country, with regard to inequality of resource distribution and the existing eHealth infrastructure. In order to solve these issues, it introduces a simple patient centric three phased eHealthcare strategy using an evolutionary approach which builds on the existing infrastructure. In phase one, the main emphasis is on setting up of an eConsultation Clinic to link the specialist in a general hospital in a city with a patient in a peripheral setting. This will consist of an eCare Clinic in a peripheral hospital, a web-based eHealth record system, m-Communication system and an e-Consultation centre with a medical specialist.
KEYWORDS
eClinic, eHealth, Telemedicine, eConsultation, Rural ICT Applications
1. INTRODUCTION
According to the national health policy of the country, the mission of healthcare is to ensure access to comprehensive, high quality, equitable, cost effective and sustainable health services. The average number of general practice consultations per year amount to 12.7 million (Ministry of Healthcare and Nutrition, 2004). Although there was no gender difference in out-patient attendance, children younger than 12 years accounted for 32.1% of consultations and the proportion of elderly at the consultations were significantly higher (Ministry of Healthcare and Nutrition, 2004). As hypertension and diseases of the upper respiratory tract are among the top ten causes of hospitalization and are more evident in the elderly population the proper follow up and monitoring of this category of patients can reduce the rate of hospital admissions considerably. This is one of the areas in which ICT can play a major role with regard to the Sri Lankan population.
2. THE SIGNIFICANCE OF THE RESEARCH
The broad aim of the health policy of Sri Lanka is to increase the life expectancy and the quality of life of its citizens. One of the strategic thrusts in healthcare is empowering communities towards more active participation on maintaining their health, strengthening the stewardship and management functions of the health system. According to the demographic studies and survey, the proportion of the population below 30 yrs has decreased (
http://earthtrends.wri.org/). On the other hand, the elderly population has increased. It must be stated that once such a scheme as telemedicine or telecare is in place, it will benefit all age groups with less cost to the individual and provide an adjunct to effective communication between healthcare workers and patients.
3. GLOBAL eHEALTH APPLICATIONS
Healthcare system is moving from a traditional hospital based system to a more patient centered approach (
http://earthtrends.wri.org/). ICT has been used in the health sector in developed countries which demonstrated a 50% reduction in mortality or 25% to 50% increase in productivity within the health care system (Greenberg, 2005). It has also been shown that a critical mass of professional and community users of ICT in health has not yet been reached in developing countries (Infodev, 2006).
There are many eHealth initiatives in developed countries. A few are stated below.
· Doctors and nurses transferring electronic medical records (using tablet PCs) on to mobile devices (PDAs) in Spain (ICT for Comfortable and Universal Access to Healthcare, 2005).
· 90% of doctors using EMR in Sweden/Denmark (ICT for Comfortable & Universal Access to Healthcare, 2005).
· Doctors from Spanish hospitals using satellite videoconferencing system & online consultations for specialized diagnosis in radiology, cardiology, surgery and dermatology (Monteagudo et al.,2006).
· Using wireless devices for ambulatory, mobile and remote patient monitoring and diagnosis (Miyazaki, 2005).
Developing and Least Developed Countries (LDCs) where per capita wealth is low have lower levels of tele-density. However, this has not prevented some countries in introducing ICT for healthcare. A few examples could be stated:
· India has many telemedicine, tele-education, tele-consultation and tele-follow up initiatives that have helped their rural population tremendously (Mishra, 2006, McNamara, 2006).
· In South Africa, mobile phones are used to send reminders to patients (Osterwalder, 2004).
· In Uganda, email enabled hand-helds to deliver reference material to health care workers (Egiebor, 2008).
· The Ruwanden AIDS center uses ICT for monitoring the delivery of drugs to patients/clinics (Donner, 2004).
According to Heeks (2002), properties of the information system can be changed to better match local realities to make them more receptive to information systems interventions.
4 THE SRI LANKAN SCENARIO
Sri Lanka has three main levels of curative healthcare institutions: primary level in the rural sector, secondary level in the peripheral or urban sector and tertiary level teaching and large hospitals in the cities. There are 10 tertiary level hospitals, 27 secondary level hospitals and over 285 primary health care institutions. It is also stated that 35% of the medical specialists in the curative sector are concentrated in the administrative district of Colombo.
It is said that the LDCs have the poorest information infrastructure. Sri Lanka is fortunate in that the penetration of fixed line and mobile technology to rural areas is increasing at a rapid pace. According to the Telecom Regulatory Commission (TRC) statistics, the number of cellular mobile subscribers are placed as over 9 Million. The mobile phone density (per 100 persons) is over 40 and the total tele-density (fixed and cellular) is nearly 60 in Sri Lanka (TRC). The rapidly growing population of elderly patients and the rising healthcare expenditure demands newer initiatives such as eHealth and Telemedicine (Telecommunications Issues and Health Care, 2007).
5. THE RESEARCH METHODOLOGY
This research consists of qualitative and quantitative aspects. Qualitative aspects are the virtual presence of the specialist, patient satisfaction, quality of service, comfortable environment for specialist and patient, knowledge transfer, etc. and quantitative aspects are the reduction in cost and time economy per patient, increase in the number of patients seen by a specialist, etc. Many research methodologies were considered, and action research was selected as the most appropriate methodology for this research due to its participatory nature (O'Leary, 2004, Kock, 2003).
6. THE PROPOSED SOLUTION & THE PILOT PROJECT
In a developing country, due to the resource restrictions, lack of funds, lack of proper infrastructure and low level of patient know-how, transfer of technology among the general public is slow. In order to move from proof-of-concept of a proposed solution, to the large scale implementation in the appropriate setting, the process has to solve an existing problem while offering huge benefits to the users.
It is also crucial that the process starts in a non-complicated environment which is easy to use by the patients, doctors and other healthcare workers. Therefore, the best would be to:
· Keep the technology simple and local and Build on existing technology being used by all,
· Involve the users in the design to feel ownership and Use a participatory approach to introduce ICT
· Use a strategy that is relatively resilient in the face of developing-world conditions and
· Strengthen the infrastructure and create a conducive environment for the society (Infodev, 2006).
This project is designed to be implemented in three phases using an evolutionary approach in order to have a smooth etransformation. The three phases are as follows:
· Phase One: eConsultation Clinic
· Phase Two: eSystems Integration
· Phase Three: Remote Patient Monitoring System
The pilot project for phase one will be carried out at a Base Hospital in Sri Lanka which will be the specialist e-consultation centre in collaboration with its peripheral hospitals and units which will act as e-care clinics.
6.1 Phase 1: The eConsultation Clinic
This paper will mainly focus on the phase 1 of the overall project which is the “eConsultation Clinic”. The main focus here is to link the specialist in a general hospital in a city with a patient in a peripheral setting via a doctor using easily acquirable relatively inexpensive technology that is currently being used. This simple concept can be done with a very little extension to the existing technology. The whole scenario for phase 1 will consist of four components which are : an eHealth Clinic in a peripheral hospital, a web-based eHealth record system, mCommunication system and an eConsultation centre with a specialist in a base hospital or above.
6.2 Phase 2 & 3 - eSystems Integration and Remote Patient Monitoring (RPM)
Lack of integration and interoperability across public health systems lead to the duplication of efforts and frustration among consultants, healthcare workers and patients as they are asked to provide the same information on multiple forms of varying formats on different instances (Sahay and Aktar, 2008). At this phase, data integration and linking of laboratories, radiological units, out patient clinics, wards, hospital reception and MOH clinics will come into existence. Phase 3 will incorporate Remote Patient Monitoring (RPM) where the patient is in the comfort of his own home/ hospital being monitored through wireless extra-corporeal sensors attached to the body.
7. PHASE ONE: THE eCONSULTATION CLINIC
7.1 The Peripheral eHealth Clinic
A District Hospital, Rural Hospital, MOH (Medical Officer of Health) or Peripheral Unit will form the first level of an eCare clinic. At this level of care, in a rural setting, a trained doctor competent in using a computer, Internet, E-mail, SMS (Short Messaging Service) and data recording experience is an essential factor. This doctor should have at his disposal, a computer, a printer, a high resolution digital camera, a webcam, broadband internet connection, headset or audio facility and telephone facility and a healthcare assistant (nursing officer).
7.2 Web based eHealth record system
The peripheral eCare clinic is connected through a web-based patient medical record (herein referred to as an e-health record). This consists of the patient profile and a detailed checklist for every visit to the e-care clinic. This could further be subdivided in to medical, surgical, dermatological, orthopedic or gynaecological data. The patient record checklist will contain data pertaining to the patient’s current complaints, condition of surgical wounds, general medical status such as blood pressure, pulse rate, respiratory rate, SPO2, peak respiratory flow rates, temperature, Haematological reports, Urine report, Radiological data, Ultrasound scan reports etc.
7.3 The mCommunication System
At the diagnosis stage of this research project, a preliminary survey was done and the results show that over 51% of the patients have access to their own personal mobile phone, out of which 50% use SMS tool for communication. Nearly 80% of patients have access to mobile phones through an immediate family member. Therefore, the m-communication system can be used for sending important information such as the Clinic date, Operation date, Medication, Re-admission date, etc. to patients using a mobile phone.
7.4 The eConsultation Center with a Specialist
The Specialist (consultant) is based at the Teaching Hospital, District General Hospital or Base Hospital at an eConsultancy centre which would also have the basic system requirements as in the rural eCare clinic. In addition to the specialist’s advice, Medical prescription notes, Diabetic advisory charts, postoperative mobility regimens, dietary advice etc. are transmitted to the rural eCare clinic via the web based system.
8. BENEFITS OF THE PROPOSED SOLUTION
Benefits To the Patient : The main beneficiary of this system is the patient as his travel expenditure and travel time will be reduced tremendously. Unnecessary secondary visits to tertiary centers and specialist clinics will be reduced. The greater benefit would be for patients on long term follow up at highly specialized clinics where laboratory results play a major role in chronic health evaluation e.g; patients with chronic renal failure.
Benefits For the Peripheral Hospitals : The cost of transfer of patients from peripheral hospitals to tertiary centers also can be drastically reduced. This will facilitate the availability of ambulances for critical and emergency transfers between institutions. The availability of patient health records electronically will help these hospitals to make pro-active decisions on resource allocations and patient care. Specialist hospitals and tertiary care institutes will have less congestion with regard to inward patients and clinic attendees
For the Specialist (Consultant) : The eSpecialist makes himself available across a distance at many e-clinics within the shortest possible time frame. This has the added impact of specialized care reaching out to the periphery. Needless to say that knowledge transfer occurs with benefit to the doctor at the peripheral e-clinic and a closer professional link is established between the specialist and the peripheral doctor.
9. ARCHITECTURE OF THE PROPOSED SOLUTION
In the patient centric web-based health information system, it was decided to use the FOSS approach (Free and Open Source Software) due to the low initial cost (as compared to proprietary s/w), the evolutionary nature (Nadkarni, 2004) proposed and the possibility of enhancing the software to suit local requirement that would provide inter-operability (Canfield K., 2004). The system will initially have five main sub systems. They are (i) Patient Management, (ii) Scheduling, (iii) eConsultation, (iv) mReminder and (v) User Management.
Some of the features and functionalities are:
· Patient login, eClinic login, Consultant login, Specialised eClinic login
· Patient Registration, Clinical Record System, Clinical Scheduling, eAppointment diary creation
· Medication (allergy and dosage checking), Prescriptions (with electronic signature)
· Integration of laboratory test results in to the MIS and the Decision Support System (DSS)
“Start small and Evolve” will be the overall approach used in the development of this phase.
Issues and Challenges of the Proposed Strategy: Patients may take time to adapt and build confidence in the system, hence a learning curve for both professionals and patients does exist. Patients may be concerned of doctors who are not physically present at the consultation and the specialist might not like assessing a patient who is only virtually present. The traditional “look, feel, listen” concept of clinical medicine is perceived in a different manner. Security and privacy is essential as confidential patient data is transferred over a nonproprietary public network.
10. CONCLUSION
This paper explores the benefits, issues and challenges in evolving healthcare methodology with regard to setting up of a realistic eHealth plan in a developing country. The existing ICT infrastructure in the Sri Lankan health setup can provide the initial platform to launch eClinics at the peripheral level. A phased approach is proposed to minimize initial huge expenditure and to optimally build on existing resources. Due to the increasing demand on healthcare institutions and systems to deliver better quality services for patients, ICT in Health has evolved to bridge the gap between the urban healthcare specialist and their rural patients. This phased approach will improve the quality of healthcare by way of enabling healthcare professionals to make better decisions on their patients.
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The concept authors are Dr. Keith R.P. Chapman, a Consultant General and Laparoscopic Surgeon, from the Ministry of Health and Nutrition and Dr. Shiromi Arunatileka, Senior Lecturer, University of Colombo School of Computing(UCSC). The Vidusuwa software was developed by a team from the UCSC consisting of staff and BICT degree students. The financial assistance for the ViduSuwa project is provided by the e-Society Programme of the Information and Communication Technology Agency of Sri Lanka (ICTA). The connectivity for the Pilot project is generously offered by Sri Lanka Telecom (SLT). Dr. Keith Chapman and Dr. Shiromi Arunatileka acknowledged the dedication and hard work of Dr. N. Nugaduwa, Consultant Surgeon, Marawila, Dr. Akarawita, Consultant Dermatologist, Chillaw and the Doctors and staff of Marawila, Dankotuwa and the National Hospital Colombo, who have contributed to making ViduSuwa a success.
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The 7Es in eTransformation - A Strategic eTransformation Model 
