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

Technology Map

13

Source – International Telecommunications Union website.

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)

THE PROCESS AND LOGIC OF EFFICIENT HEALTHCARE SERVICE SYSTEMS

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

Primary health care renewal: The Foundation of the Health Reform Process

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