THE SCOPE, CONTENT AND
OPPORTUNITIES FOR
TELEMEDICINE PRACTICE IN
JAMAICA
Prof Winston G Mendes Davidson Head School of Public Health & Health
Technology 15th November 2013
What is Telemedicine?
• Telemedicine is an Information Technology network of medical and allied expertise linked together for the purpose of delivering medical
services at a distance
Functional Definition: by
W. Mendes-Davidson 2004
WHY TELEMEDICINE?
Advance in the use of communication and information technology in medicine have become ubiquitous as technology becomes cheaper, more user friendly and creating greater diagnostic accuracy and efficiency in health management
The problems of multimedia real time transmission are rapidly diminishing
Better solutions at cheaper costs now becoming available than conventional solutions to health care
WHY TELEMEDICINE?
World Trade Organization (GATT) begins in force in January 2005 and competition in all services will be online in the global domain
All patients in the world will now belong to any Dr in any part of the world who has the capacity to communicate real time on the multimedia cellular telephones to the average citizen and to manage health info more efficiently.
Medical practice in the Caribbean will be marginalized in the medium term as competition now involves e-health solutions overseas i.e. international health conglomerates, including online pharmacies, therapies, systems and health institutions.
TELEMEDICINE: a) Content / Application side:- {i) Comprehensive; ii) Fragmented}
b) Support system / Infrastructure side
• Comprehensive • The content / application determines
the nature of the infrastructure • Holistic in scope content & extent of
population coverage • Requires a multi-service IP
broadband network infrastructure • Derives efficiencies because of
convergence of voice video and data • Sustainable telemedicine system
because of cost savings , stability and scalability
• Excellent platform for export of telemedicine services in the global domain
• Fragmented • The infrastructure determines the
nature of the content / application • Limited in scope content and extent
of population coverage • Does not require multi-service
broadband network as components of voice video and data may run independently
• Limited in scope and content and it is not sustainable as an national integrated telemedicine option (too costly)
• There are very few if any synergies with poor scalability
• Will not be able to export converged services for Medical Tourism
Expectations of the New Health
Economy?
HEALTH CARE DELIVERY OUTCOMES PATIENT CARE OUTCOMES
1. Greater and quicker access
2. Higher quality (best practice)
3. More affordable
4. More evidence based information
5. Greater transparency
6. Health care portability
7. Greater efficiency
8. Sustainability
9. High Ethical standards
1. Access anywhere at anytime
2. Best care standards
3. Least cost services
4. Informed patient decisions
5. Need to know what is happening at all times
6. Health care transferability
7. Least time and money spent for best outcomes
8. Interventions must be lasting
9. Patient rights protected and responsibilities known
The Emergence of the New Health Economy
Scientific &Technological Epochs and Health Care
Delivery Locations
1st wave (9000 yrs)
Age of Specialisation
2nd wave (300 yrs)
Industrial revolution
3rd wave (45yrs)
Artificial intelligence (nascent
ICT revolution)
4th wave The age of interactive
artificial intelligence (ICT rev.)
Globalisation ( The Outcome)
Home Care
Hospital Care
Ambulatory Care
Home Care
Anywhere Care
THE NEW HEALTH ECONOMY:
(ITS FUNDAMENTAL COMPONENTS)
1. Science and Technology- ICT: The driving
force/solutions
2. Epidemiology- The conditions
3. National Political / Economy- The circumstances
4. Organisational Structure- The contexts
5. Globalisation & Climate Change-The strategic
determinants
Source: W. Davidson. Oct; 2009. (copyright)
The Four Stages Theory of Prevention describes the
Scope, Content and Opportunities for Telemedicine
Practice
Prevention Harmonious adaptation
/ relationship with any
environment
(Healthy Lifestyle /
Wellness)
COMMUNITY
State of Wellness Non-Institutional
Response Institutional
Response
COMMUNITY
Risk reduction /
early diagnosis
Incidence intervention
measures
Treatment
and Repair
(Prevalence
intervention
Measures)
Rehab
intervention
measures
Rising Costs: Prof W. Davidson. 1999. (copyright)
PRE-PRIMARY PREVENTION
(Maintain Health & Wellness)
PRIMARY P REVENTION
(Decrease disease Incidence)
SECONDARY PREVENTION
(Decrease disease Prevalence)
TERTIARY PREVENTION
(Avert disease Chronicity)
Rehab
Response
SCIENCE AND TECHNOLOGY-
Component #1
The driving force/solutions
Representing the ICT driving
force from which we derive the
solutions to our health care
issues and challenges
Cultural Change in Technology
(The Techno-Philic Jamaica)
Focus on
Interaction!!
More connected
Users with global
Reach
Focused on
Transactions.
Accounting &
Order Processing
Focused on
Production.
BOMP
1970s 1980s & 90s 2000 & Beyond
11
All Digital Format – Converged Carrier technology: Multifunctional and portable End user technology; efficient health
care services delivery systems.
Data
• Text
• Graphics
• Access Control
• Systems
Voice
• SIP/H323
• Codec systems Developed
Video
• mpg4
• AVCHD
• HDMI
Global electronic traffic is moving rapidly to an all digital format.
Co
nve
rge
d C
arri
er
Tech
no
logy
Data
Voice Video
Carrier technology is becoming ubiquitous and vendor neutral.
End user technology is becoming multifunctional and portable. Health care delivery is no exception
Source: Unimedics
Jamaica by Comparison
0
20
40
60
80
100
120
Mobile subscribers - rates per 100 inhabitants
Mobile Subscribers
Jamaican Mobile Penetration
-
500,000.00
1,000,000.00
1,500,000.00
2,000,000.00
2,500,000.00
LIME DIGICEL CLARO Grand Total
Mobile Penetration - Jamaica
Number Postpaid
Number Prepaid
Total Active
14/11/2013 15 CreditFree Confidential
Mobile System the most efficient (Time To Market in Minutes)
Idea Conceived
Add developed
Target Selected
16
1. Target dataset uploaded on
portal
2. Message setup
3. Merge model setup
4. Duration parameters setup
5. Credit applied
6. Activate..
Delivered
Concurrently
and Immediately
Minutes
Telemedicine “The Mendes-Davidson Model” Seven Step Integrated, ICT Converged:
Telemedicine/Health Development Solution (The Structure)
Doctor on
Call.
Mobile
Devices; IP
Telephony
ISP
Web
Sites
Health Ecosystems
Development
HER: Video
Capture/Store Use of
Web Portals
1
2 3
4 STREAMING
Media
Network Consult
with Ecosystems
Carib. Health &
Environ Cable
TV Channel
5 Remote Serv.
Home Health;
Public Health;
Health
Tourism;
Region /Global
Export
Service;
Health Insurer.
Reform
Virtual
Health Tele-
medicine
Virtual
Health
Services
Providers;
Tele-
presence;
New Health
Cadre
Training
Program
/Services
6
7 Copyright: Author: Prof. Winston Davidson. Use of
part or all of this diagram must be with the permission
of the author. August 2001 Updated
Silver Gold Platinum
Tele-Med-Service Tele-Health-Global
Dr On Call
EHR (Electronic Health Record) / Data Infrastructure (UNIMEDICS)
Mendes Davidson Model: (The Function) Developing National and International integrated and Interoperable
WEB-BASED HEALTH ECOSYSTEMS
Each health ECOSYSTEM has its own web presence through the use of web portals and specially customized electronic health software configured to adapt to the health system and not the other way around, and as the need arises
Each ECOSYSTEM links with national and international ecosystems seamlessly riding on robust ubiquitous broadband platform
Utilizing integrated/converged voice, video and data systems with any compatible device mobile or otherwise
Each patient Dr/health team encounter forms the basic unit in an integrated national and global health ECOSYSTEM
What is Doctor on Call?
• Telephone Access to Medical Care for Everyone, Everywhere, Any-time at a Cost They Can Afford
• Doctor on Call is the Practice of Telephone Medicine where Medical Care is just a Telephone call away
• Estimated that 25% of Doctor’s interactions with patients are over the telephone
The Telephone: A significant tool in the practice of Medicine
Physicians Perspective: Uses and benefits of telephone medicine
– Augments issues raised at the office
– Give patients help with health care decisions at home
– Modify treatment for chronic disease(e.g., hypertension, diabetes mellitus) based on home monitoring
– Refill medications
– Give test results
– Diagnose problems early
– Prevent unnecessary emergency department visits
– Follow-up patients discharged from hospital
– Provide information on suicide hotlines and counseling
– Direct family members in CPR
• Recent study found that: 33% of patients would have gone to emergency department if they had been unable to reach the physician
• Only 8% went to the emergency department after telephone contact with a physician
Dr. On call will save frequency of emergency visits
The Application of IP telephony Interactive Voice Responses for Surveys, Research and Public health
surveillance
• Interactive Voice Response enable researchers to design and conduct research surveys “on-the-fly”
• Both Inbound and Outbound Surveys are Possible.
• Information and offers can be sent to survey participants.
• Use IP telephony platform for Public health and epidemiologic surveillance for outbreaks, epidemics and pandemics
Web Based EHR for All Drs, Health Institutions / Health & Allied Personnel Developed For Global use
HEALTH ECOSYSTEMS CONTENT INFRASTRUCTURE DESIGN
1. Office Schedule Module
2. Hospital / Institutional module
3. Institutional/Field database integration
4. Interface c 3rd party Scheduling
5. Billing Module
6. Interface c 3rd party Billing
7. Lab / HL7 interface
8. Soap notes
9. Medical/Surgical procedures
10. Online consultations
11. Prescriptions
12. Drug interactions
13. Connect Multiple Locations
14. Wireless access to the service
15. Voice recognition
16. PDA compatible / Mobile device integration
17. Cell phone compatible / Blue tooth
18. Capture and Store images (Using Lead Tool Components)
19. Multimedia patient file storage (Using Lead Tool Components)
20. Digital imaging (Dicom Imaging)
21. Reminders
22. Bilingual / Multilingual
23. Unlimited # of Active Users
24. Web Site interface / Customised Web Portals
25. E-mail contact
NEW UNIMEDICS EHR: At What Cost ? LOW
NECESSARY CATEGORIES OF STANDARDS REQUIRED FOR HEALTH
INFORMATION MANAGEMENT Identifiers
Codes &
Terminology
Content &
Formats
Messaging
Security &
Access Control
Patient Id
Disease Codes
ICD 10
Patient Enrollment –
Registration
HL7,
Authentication
Provider Id
Procedure Codes
CPT
Patient Medical
Records
Client based / Web
based (Universal
access EHR)
Access
Control
Payer Id
Observation
Codes
Billing
Formats
X12’s formats of data
elements, used
in Billing & Insurance
Claims
Non
Repudiation
Health Plan
Id
Drug Codes
Minimum
Data Sets
HIPAA ( Health
Insurance Portability
& Accountability
Act)
Privacy
Protection
Pharmacy Id
Nursing
Codes
Lab Formats
Non obtrusive inputs
Non
Repudiation
Clinical Telemedicine The Quality of Care
• This is what it is all about!!
• Results have been very good across the board
• Very good clinical result - solid studies in most
specialties - clinically comparable to person to
person when it is done right
• People get care and/or a timeliness they would
not have otherwise received
• Lower cost
Mobile devices in Multimedia health Data Transfer will become the most ubiquitous health care delivery systems
• These two services combined represent the most important lifeline to the survival of our countries now and in the future
The services sector & global competitiveness in Jamaica & the Caribbean
More developed in certain Caribbean countries but available
to all countries in the Caribbean
• What is the Evidence?:
• Sponsors
– Anchor Sponsors
– Partners
– Local
• Comprehensive Telemedicine Applied Research leading to
the development of: “The Mendes-Davidson Model”
Very advanced ICT infrastructure throughout the Caribbean combined with rigorous R&D
Home Telemedicine / Telehealth
• Patient monitoring
• Excellent clinical outcomes
• Compelling savings
• Rapidly evolving technology
• Markets / Applications
– Chronic disease, home, residential facilities
• AMD is rated second in this sector in US (Frost&Sullivan)
– Installations in 6 other countries
Epidemiology: Component #2
• The conditions
• Representing the prevailing patterns and
distribution of diseases and conditions: the health
status of the population which both influence and
determine the form and content of our national
policy, strategic plans and programmes,
implementation finance to achieve desirable
outcomes.
Leading causes of Death in Jamaica 1945-2005
1945 1982 1996 2005
Tuberculosis Cerebrovascular Disease
Malignant Neoplasm
Disease of the circulatory system
Heart Disease Heart Disease Cerebrovascular Disease
Neoplasms
Nephritis Malignant Neoplasm
Diabetes Mellitus Nutritional and endocrine diseases
Syphilis Hypertension Ischaemic Heart Disease
Diseases of the respiratory system
Pneumonia & Influenza
Diabetes Mellitus Other Heart Disease
Accidents and Injuries-(Accidents, poisoning and violence)
Chronic , non-communicable lifestyle diseases have emerged as the leading
causes of mortality and morbidity in Jamaica (65% deaths in Ja)
Source: Dr Tamu Davidson
LEADING CAUSES OF DEATH IN CAREC
COUNTRIES AROUND 2005
1. Ischemic heart disease 2. Cerebrovascular disease 3. Diabetes 4. HIV/AIDS 5. Prostate cancer 6. Hypertensive disease 7. Land transport accidents 8. Assault (homicide) 9. Certain conditions in perinatal
period 10.Influenza and pneumonia
1. Cerebrovascular disease 2. Ischemic heart disease 3. Diabetes 4. Hypertensive disease 5. HIV/AIDS 6. Heart failure / complications
ill-defined heart disease 7. Influenza and pneumonia 8. Breast cancer 9. Certain conditions in
perinatal period 10.Cancer of womb (Source PAHO/WHO)
Males Females
Relative Contribution of Services to GDP in Jamaica 2000-2005
Unit 2000 2001 2002 2003 2004 2005
GDP at Current Prices in purchasers' value $b 339.5 373.2 410.1 472.9 540.1 N/A
GDP in Producers' Value at Current Prices $b 316.6 349.9 383.5 439 498.7 N/A
GDP in Producers' Value at Constant (1996) Prices $b 223.8 227.1 229.5 235.2 237.4 240.8
Growth in GDP in Producers' Value at Constant (1996)
Prices % 0.7 1.5 1.1 2.3 0.9 1.4
Goods Production as % of Total Real GDP % 35.4 35.8 35.2 35 35.1 34.9
Agriculture " % 6.4 6.7 6.1 6.3 5.7 5.2
Mining " % 5.3 5.4 5.5 5.6 5.7 5.8
Manufacturing " % 14.2 14.1 13.9 13.4 13.7 13.4
Construction " 9.5 9.6 9.7 9.6 10 10.6
Services " % 71.9 70.8 71.6 71.8 71.9 71.9
Basic Services " % 16.5 16.9 17.7 18 17.9 18
Electricity & Water " % 3.8 3.8 3.9 4 4 4.1
Transport, Storage & Communication " % 12.6 13.1 13.7 13.9 13.9 13.9
Other Services " % 55.4 54.7 55.4 56.5 57.2 57.9
Imputed Services Charges % -7.3 -6.5 -6.8 -6.8 -7 -6.8
Source: Economic and Social Survey of Jamaica, PIOJ Website 2006
THE SERVICES SECTOR IS THE
LEADING SECTOR FOR WEALTH
CREATION IN JAMAICA
We are not yet fully awakened to
the possibilities of the role of the
health services sector in wealth
creation in the Jamaican economy
There has been very little creative
investment in the health sector
The cost and quality of health care and
the cost and quality of tourism in Jamaica
and the Caribbean is competitive with all
developed and developing countries
The services sector & global competitiveness
in Jamaica & the Caribbean
These two services combined
represent the most important
lifeline to the survival of our
countries now and in the future
The services sector & global
competitiveness in Jamaica & the
Caribbean
Immediate IT Activities
MOH Policy
Tele-consultations; Tele-surgery; Tele-Pediatrics
Tele-medical-education; Tele-Dermatology; Tele-pathology
Tele-radiology; Tele-Ophthalmology; Tele-Rehabilitation
Tele-conferencing; Tele-Mentoring; (35 other Specialties)
Access to health information on the internet;
Continuing Medical Education websites
Timely access to data that are easily manipulated for analysis, planning, monitoring indicators
Dr. On Call (Telephone Medicine)
Millions of $ Savings in Health budget
Global Medical Tourism
Global analysis indicates that the global medical tourism market comprised over 19 million trips in 2005, with a total value of $20 billion experiencing double-digit growth in medical tourism, which is forecast to grow to 40million trips, or 4% of global tourism volume by 2010. ( Source: International Travel Trade market)
The Global Medical Tourism market is valued at $40
billion. Thailand attracts 600 000 medical tourists per year and is projected to attract one million foreign patients. ( Source: Medical Tourism Assoc. Inc)
MEDICAL HEALTH TOURISM: File Portability , videoconferencing and Off-shoring Health Services to the USA: A very important health niche market
Results: National Chest Hospital NHF Funded Pilot of the National Telemedicine Project Established Jamaica’s Off-shoring Technical Capability
1. IT infrastructure for local area network established in National Chest Hospital (NCH)
2. Video-conferencing Infrastructure established and properly configured
3. Virtual private network established between NCH; Telemedicine Project
4. Video Conferencing link between NCH and South Baptist Hospital Established and operation verified.
5. NCH receiving full Wireless Broadband (512kbps) 6. Web-based Universal Electronic Health Record System established
and protocols tested and verified 7. Network protocols, Data security, HIPAA compliance, Dicom
standards, HL7 compatibility and other technical standards and protocols tested and verified
Healthy-----------At Risk- Early Sickness-- Late Sickness---------Recovery
Wellness / Healthy At Risk– Early Sickness Late Illness/ Recovery
Lifestyles / Convalescence
Wellness / Lifestyle
HEALTH TOURISM
Medical (Off-shoring)
HEALTH TOURISM
Retirement Villages/ Convalescent Homes
HEALTH TOURISM
Copyright: Dr. Winston Mendes Davidson 2004-09-29
Spas / Wellness Centres Ecotourism Centres / Alternative
Health / Ethno medicines/ Integrated Hotel Services
WELLNESS HEALTH TOURISM
Diagnostic/ Ambulatory
/Off-shoring/ Medical &
Hospital Services
MEDICAL HEALTH
TOURISM
Retirement Villages / Convalescence Homes / Specialized Elderly
Institutions / Off-shoring with Hotel Service
CONVALESCENT HEALTH TOURISM
Full Telemedicine Coverage
Wellness & Convalescent Caribbean Health Tourism
• Caribbean Therapy Hotels Must Be Professionally Branded
• Develop the highest therapeutic Standards
• Should begin as classy cottage type low maintenance facilities
• High level trained health service teams
• Telemedicine Services for prompt intervention
• Home type sun & sea type care facility with entertainment
“The Hotel is a Hospital (therapeutic centre) for well people, while the Hospital (therapeutic centre) is a Hotel for ill
people” (W. Mendes-Davidson, 1997).
Health Care Delivery, Organizational and
Management Structure/ Function: # 3
Representing the institutional contexts which
may help or harm our national strategic
health and development initiatives.
Telemedicine / ICT Infrastructure is the key
to implementing Health sector Reform
LOCATE PATIENT CARE AND SERVICE DELIVERY AT THE CENTRE OF THE HEALTH CARE
DELIVERY VALUE-CHAIN (HEALTH REFORM)
Clinical Telemedicine
• Hospital to Hospital / Clinic to Hospital
• Proven clinical results and savings
• Established technology
– Every medical specialty is supported
• Markets/applications
– Rural care delivery, prisons, military, skilled nursing
Training for local health export of services
Core Concept
The fusion of health, education and tourism and the preparation of human capital for its implementation
Target Population
1. Doctors / Dental Surgeons
2. Nurses
3. Pharmacists
4. Allied Health Workers & Caregivers
5. Educators; Human Resource Capacity Development (HRCD) Personnel
6. Tourism / Hotel / HRD Personnel
7. General population (Wellness / Life style / Alternative Health Therapists)
Does the Institutional capacity exist in Jamaica to be part of this trend?
The National Health Fund has the technology infrastructure to lead the process of building the National ICT capacity to satisfy the needs of the New Health Economy. They have the following:
National Health Record System ( Basic Web-Based EHR;
Unimedics)
Competent ICT Human resource on staff
Basic functional National ICT Network
Best institutional potential for implementing a comprehensive national telemedicine solutions
What practical solutions are possible to align Jamaica’s
Health Economy with the “New Health Economy” in the
Global Space?
THE NATIONAL TELEMEDICINE RESEARCH PROJECT /
MCSYSTEMS CONSORTIUM
GOVERNMENTAL INSTITUTIONAL CAPACITY-
(“THE NATIONAL HEALTH FUND”)
INVESTMENTS IN THE HEALTH SECTOR
(“PUBLIC / PRIVATE PARTNERSHIPS”)
SOME RECOMMENDATIONS FOR IMMEDIATE
CONSIDERATION
Begin health reform process to meet the challenges of the NEW HEALTH ECONOMY
Fundamental structural and organizational reform
Prepare manpower for the New health economy ; Tele-medicine, Telementoring, Telesurgery; Telepsychiatry; Telenursing, Health tourism; Telepaediatrics; Home Health; Health Tourism;
New Health Insurance systems and products.
Portable Health Information systems to integrate national health ecosystems and economy
Use the model of Centers of Excellence and Public Private Partnerships to develop the Global Multibillion $ Health Tourism enterprises as part of a viable Caribbean New Health Services System and Economy
Develop integrated health tourism enterprises in the global space