ieee report forma rural district health office data connectivity and ehealth record system version 2

8/14/2019 IEEE Report Forma Rural District Health Office Data Connectivity and eHealth Record System version 2

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IEEE GHTC2012 Young Professional Project ContentTeam 4 1

AbstractProper provision of healthcare in rural areas for

providers is considered to be a major challenge. The people who

live in rural areas face some different health issues than people

who live in urban areas. Accessing health care in these areas is a

problem due to the availability of resources (doctors and medical

equipment) and the long distances between residences and health

care facilities. The major challenges are data connectivity of

rural health district offices & electronic records of individuals. In

this paper, we propose a solution set around a mobile based IVR

system to address these challenges. We conducted analysis on the

use cases for the solution and have presented the usage. We have

also included spatial mapping, social collaboration, economic and

power considerations

I ndex Terms Medical information systems, Mobile

communication, Public healthcare, Rural areas, social networks

I. INTRODUCTIONAccess to primary healthcare facilities for people especiallythose who are living in remote and rural areas is a majorconcern for any developing nation. Proper medical aid, limitedtrained medical staff, availability of doctors at the time ofexigencies etc. are some of the distant dreams for people

living in these regions. Patients suffering from tuberculosis,malaria etc. who need regular monitoring, expecting womenwho dont have access to facilities like pre and post natal care

are major sufferers because of the unavailability of relevanthealth information. Also, many people suffering from thesediseases are not even properly diagnosed due to lack offacilities and consequently dont get a chance to get proper

treatment. Research on patients in rural regions have ledresearchers and social work participants to state that ruralpeople should be considered an at-risk or diverse group basedon their high rates of poverty, lower life opportunities, andstigmatized social status. (Riebschleger, 2007). Aside fromthese attributes, the geographical location of these people is

often considered to be without the facilities required for afunctioning health care system.

Paper submission date: 10/01/2013 -This work was supported in part byIEEE & U.S. AID

Z.S Author was with \ Northwestern University Evanston, IL 60201 USA(e-mail: [email protected]).

S. B. Author, Jr., was with Rice University, Houston, TX 77005 USA. Heis now with the Department of Physics, Colorado State University, FortCollins, CO 80523 USA (e-mail: [email protected]).

T. C. Author is with the Electrical Engineering Department, University ofColorado, Boulder, CO 80309 USA, on leave from the National ResearchInstitute for Metals, Tsukuba, Japan (e-mail: [email protected]).

One cannot fill the void created because of the unavailabilityof doctors but recent advancement in technology can act as amediator and thus can help in building a bridge between thepatients and the limited trained medical staff. Here, theunprecedented deep penetration of mobile phones provides usa viable communication medium to develop somethingsubstantial solution. As studies have also shown that mobiletechnology has the potential to convene healthcare delivery indeveloping regions therefore a better communication systemcan act as a bridge between the patients at remote and ruralareas and the health workers.People living in remote and rural areas are illiterate or semi-literate therefore a platform which they can use should be easyto understand so that it can be used with very minimaltraining. Automated Interactive Voice Response System(IVRS) & Short Message Service (SMS) have been found tobe very useful and beneficial especially for low income groupsand populations in rural & remote areas. Many applications indifferent domains have been successfully built and deployedusing IVRs & SMS. In the healthcare sector, people have alsostarted exploring IVRs to alarm patients about their medicines,to provide post hospitalization care etc. in many regionsThe geo-distribution of health centers in rural areas is one of

the reasons for low collaboration between healthprofessionals. There is little standardization of data-sets andprocesses in these areas. Social collaboration between healthprofessionals may provide an early indicator of a developingepidemic. It would also present a more coordinated process ofdelivering rural healthcare.Power generation and sustainability is another key issuerelated to providing an information system for rural areas.Portable solar kits and alternatives such as infrastructuresharing have been discussed as a possible solution.

II. SOLUTION PROPOSALMobile technology has the potential to vastly improve

healthcare delivery in developing regions. In this proposal weaim to provide a low cost and low power solution for problemslike these. A system is envisaged where each patient andcentral unit are connected via a central hub. To realize this, weneed to partner with Organizations, NGOs and SHGs workingin the domain of healthcare at different levels. We stronglybelieve that communication technologies that exist today havethe power to improve society and can play a significant role inimproving the healthcare for underprivileged people. Todaythere are more than 6 billion mobile phones in the world,creating unprecedented opportunities to connect and engage

Proposal for Rural District Health Data Connectivity & eHealth

Record System(September 2013)Piyush Aggarwal, Matthew Imhoff, Ray Gorman, Vincent Mosoti, Chandramouli Sharma, Prabhav Nr, Nitu

Jangir and Zeeshan Shah


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with just about anyone on the planet. The ability to connect tomost of the world via mobile opens up new potential to putpeople and their needs at the heart of our decision-making andservice design using the power of Information andCommunication Technology which has changed the life inpast few years enormously.

Here, we assume that each family has a mobile phone asstudies have revealed that there exist a vast penetration of

mobile phones even in remote and rural areas of anydeveloping nation as compared to the usage of Internet whichis yet a far cry for many as compared to cell phones which aregenerally available to and all sundry.Each person will be registered when they visit the

Community Health Centers (CHC) with their basicdemographic information along with their Mobile Number.CHC will be provided with basic applications to felicitate theregistration process. Applications could be MobileApplications, Desktop Applications or Web-BasedApplication, depending on the location of the CHC. It can beeither cloud based service or locally hosted service.In case of cloud based service all this data thus collected can

be uploaded to a central place. We can use a Delay TolerantNetwork in places where internet connectivity is poor andSMS platforms for this purpose. These are different use casescenarios where this platform can be used 1) Normal andRoutine 2) Emergency Situations 3) Follow Up 4) Pre & PostNatal Care.Normal and Routine: Here, if the person i.e. patient wantsany medical related information, he/she can call or send SMSto a specific number from his/her registered mobile numberwith the description of the problem.The system will recognize the person with his/her mobilenumber. This will be completely automated IVR (InteractiveVoice response) System or SMS System where patient canrecord his problem and other related symptoms. This call willbe recorded at the CHC with Patient ID. Community HealthWorker (CHW) will be able to see on his/her system all thecalls received with their details.If the CHW knows the answer of the problem, he/she canreply to call or SMS. If the patient has called then he/she willreceive the SMS that his query has been answered and he cancall back to listen to the response, otherwise he will receivethe response as SMS. Also, patient can also listen to theresponse by calling at the same number.Emergency Situations: In case of emergency situations forinstance sudden outbreak of some disease, the system can alertlocal residents with suggestion/precautions which can bebroadcasted on registered numbers as SMS or IVR Calls to

safeguard and protect them. Patients can also call the IVRNumber or send SMS to retrieve such information. Here eachPhone Call & SMS will be automated but monitored so thatthe human intervention can be minimized and help can beprovided 24x7.Also, if there is an emergency at patients end, the n the patientcan call or send SMS to the number which can be directlymonitored by CHWs to take proper action in such situation.It can help CHWs and patient to seek timely, appropriatemedical help by reducing the time that elapses between ahealth crisis and care.

Natural Disaster: As mentioned with the use case foremergency situations, users registered with the service can besent a text or voice message to alert them to developingdisasters. The application hosted on the IVR can be integratedwith the national disaster system to generate alerts for theregistered users. This setup can also be used to get an initialassessment of the affected populace, when used in conjunctionwith the GIS mapping being proposed, interactive heat maps

would be producible. Businesses have been reported to showan uptime of 99.99% of IVR systems during disasters, USairlines fielded 350,000 more calls than usual a day beforeHurricane Sandy. Such usage by businesses serves as avalidation for the effect of IVR systems for disasters.Political/Strife relocation: In the case of relocation ofexisting users, the mobile system would allow uniqueidentification. The mobile number registered in the IVRapplication should be able to recognize the number andretrieve the previous history of the patient.Follow-up: Automated IVR Calls and SMSs can be sent asreminders to the patients to inform them about their upcomingappointments. Patients can also be notified about the health

camps or workshops if and when they are organized.Maternal & Child Health: SMS/IVRS platforms can be usedto promote maternal and child health. Regular relevant healthinformation can be sent to expecting women (they need topreregister with their details) for pre & post natal care fromlocal facilities. Information can include common questionsabout new-born care, vaccinations etc. We believe skilled carebefore, during and after childbirth can save the lives of womenand new-born babies.In order to provide useful information, a woman can registerherself or someone on her behalf with a Call or SMS withtheir expected date of delivery. Regular and automatic SMS orCalls addressing topics like labour signs, prenatal care,nutrition, diet, various milestones etc. can be sent which canhelp a lot of women to get timely information.Tuberculosis and Other Related Diseases:One of the majorproblems in case of TB & other related diseases are adherenceto medications which if not followed can lead to Multi DrugResistance which is more fatal.Similarly, different IVRS/SMS based systems can be used tomonitor other diseases like Malaria, HIV etc. Follow upapplications and Buddy Systems can be used to monitorsituations.Data-Sets:For a higher level of collaboration between districthealth centers, it is recommended to have a standardized dataset for information. According to the health officials we got intouch with, there is a large amount of variation among the

district health center. The mobile IVR system would allow afirst level of data-set standardization upon which analytics canbe run.IVR Interfaces: The modern IVR systems are often builtupon a digital document standard for interactive media andvoice dialogs such as VoiceXML, Call Control XML, speechrecognition grammar specification and speech synthesismarkup language. Instead of custom languages which wereused for building traditional IVR systems, these standards areopen standards and work like web pages through the usage of


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voice browsers. The usage of open-standards allows cheaperdevelopment with allowance for flexibility.Interface development brings up a challenge due to the dataset variation between locations. IVRs require customapplications because of the specific medical informationrequired as well as because of information security. Withrespect to the use case scenarios defined, it is important tohave the IVR interface navigation available in multiple

languages. It is recommended to keep navigation menus to 5,to anticipate the use of colloquialismsData Sizes: There are two types of data to consider for thissolution. A text message and a voice call. SMS data packetsusually have a payload length of 1120 bit on the networkwhile telephony uses 8 KHz sampling. Digital standards suchas VoiceXML can handle 8 to 16 bit (8 KHz) audio formats.IVR Deployment: There are two options which can beconsidered for deployment. We have proposed these twooptions in order to be flexible to the geographical limitations.The IVR system can be hosted through a vendor or can beplaced at a district health center. We recommend that thedistrict health center would be a regional headquarter with full

infrastructure support. Due to the type of solution beingproposed, there is little need to deploy in a remote locationwith infrastructure issues such as electricity. A hosted IVR ispreferable since it offers a lower TCO in remote locations. Thechallenge here becomes the availability of publictelecommunication networksIVR Data Security:Medical information is legally protectedby governments. The hosted IVR applications will need anauthorization role system in order to restrict informationaccess. This regulation can be different as per geographicallocation.

III. COLLABORATIONRural healthcare providers are known to have heterogeneous

medical quality standards and clinical practices in differentregions of the world. This is a result of practices evolving outof healthcare systems specific to those regions. Providers usedifferent data sets for their record keeping; some use a paperbased system while others use some form of electronic Recordsystem. The results of studies show that inequalities inhealthcare provision are apparent within and across cities, andbetween rural and urban regions. The range and scope of thesestudies suggests that healthcare inequality is an issue of globalconcern. (Gallego, 2010)Clinicians take up new practices at different rates (Coleman etal. 1957,1966;Menzel 1960). Studies in both primary (general

practice) and acute care (inside hospitals) provide detailedsamples of how doctors decide to adopt new medicationpractices and the ways in which they receive information.(Gallego, 2010).In this paper we discuss the potential effect of social

networking within community health centers and specialists.To support this social networking, it is important to have anestablished map to identify which areas can be connectedbetter. (Jul, Kirkpatrick, Kleinberg, Israelski, & Rasmussen,2008).Our hypothesis is that an area which has an established

spatial map, which shows CHCs for regions in a location. It

will provide a platform where social networking can takeeffect. Healthcare providers working at these CHCs can seewhich other CHCs are most relevant or interconnected, thusallowing greater diffusion of information. Social networking isa form of a network based diffusion model. We believethrough this network diffusion model, it will easier andquicker to alert institutions of possible epidemic spreads.Diffusion Model: The diffusion mechanism is a model of the

individual decision-making process enacted by individualsduring an interaction with a neighbor. Clinicians decide on theadoption of a new practice using one or more sources ofinformation and based on perceived benefits versus risks, theability to try without commitment or cost, and the capacity toobserve and measure results. A change in practice takes placeonly through influence from a peer or an exogenous event. Westate that a collaborative framework is needed in whichautonomous agents facilitate introductions between users andalso facilitate the sharing of sensitive yet critical informationbetween groups without breaking the circle of trust.Establishing the effectiveness of this mobile system can bemade possible through the steps mentioned above. There are

existing studies made on diffusion models which are providedin the references.Spatial Mapping GIS: GIS mapping of CHCs is an importantaspect of rural healthcare which has been undertaken by manyorganizations globally. It is one of the most affordablemethods of generating actionable information on ruralhealthcare. The solution proposes to integrate GIS mappingdata with the social collaboration element and generate smartinformation. Smart information includes a map for thenetwork model, the interconnected CHCs which have socialcollaboration in place. There are different methods ofimplementing this model, one of the common one is the usageof national census to breakdown regional areas into portrayalsof measures or intensity or concentration. Popular softwaresuch as ArcMap can be used to generate the elements. Thegoal being able to create a) quantitative measure of medicalresources (doctors/ bed capacity) versus households per acreb) being able to see a social collaboration network within theCHCs c) integrate with the IVR system to quickly analyze thehighest category of reported diseases.

IV. IMPLEMENTATION CONSIDERATIONS This project assumes that CHC and telecom infrastructure

exist in the regions. There are three scenarios which candictate the cost of such rural healthcare projects1) Scenario A: No CHCs or telecom infrastructure exists inthe region2) Scenario B: CHCs exist whereas telecom infrastructuredoes not exist / and vice versa

3) Scenario C: CHCs and telecom infrastructure both existOur focus is on the delivery of our project proposal thereforewe will be focusing on the costs of implementing the system.Additional costs related to the creation of a rural healthcarecenter or telecom infrastructure are not covered in ourproposal. Division of implementation costs display a variancedepending on the configuration of hardware and softwareconfigurations adopted. A breakdown of the potential costareas are as follows
http://jasss.soc.surrey.ac.uk/13/4/8.html#coleman1957http://jasss.soc.surrey.ac.uk/13/4/8.html#coleman1957http://jasss.soc.surrey.ac.uk/13/4/8.html#coleman1957http://jasss.soc.surrey.ac.uk/13/4/8.html#coleman1957http://jasss.soc.surrey.ac.uk/13/4/8.html#coleman1966http://jasss.soc.surrey.ac.uk/13/4/8.html#coleman1966http://jasss.soc.surrey.ac.uk/13/4/8.html#menzel1960http://jasss.soc.surrey.ac.uk/13/4/8.html#menzel1960http://jasss.soc.surrey.ac.uk/13/4/8.html#menzel1960http://jasss.soc.surrey.ac.uk/13/4/8.html#menzel1960http://jasss.soc.surrey.ac.uk/13/4/8.html#coleman1966http://jasss.soc.surrey.ac.uk/13/4/8.html#coleman1957http://jasss.soc.surrey.ac.uk/13/4/8.html#coleman1957


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Economic considerations: The traditional model ofinfrastructure is being challenged in developing nations.Increased competition, commoditization of telecommunicationhardware and stricter regulatory actions has ledtelecommunication companies to adopting the practice ofinfrastructure sharing. Mobile infrastructure sharing intelecom is an important measure to reduce costs. It is useful ina start-up phase to build coverage quickly and in the longer

term scenario to build more cost effective coverage, especiallyin rural and less populated or marginalized areas. The sharingof sites and antennas, a combination of level one and level twosharing, can reduce on an average 2030% of CAPEX costs.(Meddoura, Gourhanta, & Rasheed, 2011)We believe this is an indicator of increased mobile telecompenetration in rural areas. Lower operational costs wouldallow a greater spread of our proposed mobile solution.Regulation in health sciences is an important aspect toconsider. India and Africa are developing areas for health

sciences. India has a more advanced setup for regulation thanAfrica. There are regulations to consider: a) informationsecurity for patients data b) registration with governmental

.

The above images show common call rate charges and

TCOs listed by established IVR (traditional and VXML)

systemsTarget segments & Stakeholders:Identified stakeholders are

the communities in the rural areas, the personnel involved in

the operations of the CHCs (doctors, nurses & operational

staff), district health centers & other national healthcare

institutions, government ministries for healthcare,

telecommunication companies and donation/charity

organizations (NGOs). Other stakeholders include the

software development and maintenance vendor, the

investor/funding institution for the system (USAID), the

entrepreneurial community for software (social collaboration,

networking) and institutions setting standards for medical

data-sets and procedures There are different categories within

stakeholders including end users, government and providers.All of the mentioned stakeholders above can be placed in a

category. The communities in the rural area can be considered

the end users whereas the medical personal which will be

responsible for setting up the initial data setup with the

developers can be considered as the subject matter experts.

Government and funding institutions can be considered the

regulatory bodies which can set down direction, goals and

rules for the implementation. Medical institutions and

development vendors can be considered as the facilitators who

will support the system.

Power Generation: It is expected that the IVR system be

deployed at a location which has access to the requiredinfrastructure. The location is not a constraint for this type of

system therefore power generation has not been considered as

an essential discussion point. There was a review of portable

power generation methods such as solar powered kits and

diesel generators. The mobile infrastructure is generally

powered through generators or a dedicated power line setup by

the telecommunications company.

Maintenance Plans: It is suggested that IVR system bedeployed as a hosted system through a vendor. VoiceXMLand other such technologies allow cheaper maintenance than

TABLEIINFRASTRUCTURE COSTS

Type Product Cost

CAPEX hardware 1 phone line $3000 - $3500softwarelicensing

$2000 - $14000 /

regulation Dependent on regional governmentregulation costs

OPEX calling costs $0.11 to $0.16 per minutemaintenance & support Costs are 15-22% of the total cost

Applicationmodification

$60 -$110 per hour

Partner fees Telecom infrastructure usage fees/infrastructure sharing

A typical 24 Port IVR with speech recognition and advanced text tospeech is estimated to cost between the ranges of $24,000 to $90,000.

The above is based upon the costs advertised by the vendors Voxeo,PlumVoice and inContact. The above costs are an estimate based on the IVR.A typical social networking model can be developed using outsourced/opensource platforms for an estimated cost of under $25,000.


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traditional IVR systems. India & Africa have recently seen anumber of companies offering their services by the hour.Contracts should be reviewed and handled on a case to casebasis. One option could be to request maintenance funding asa corporate social responsibility act from companies.Insurance for the hardware can also be considered at a lowercost. A combination maintenance plan is advised since thecomplete proposed solution mentions an IVR system and a

social network system.Training Plan: A skills gap analysis would need to beperformed for the stakeholders. Vocal help can be providedthrough the IVR system in the language of choice. Weestimate that the primary end user would need to be trained.The best method would be to include a help option on the IVRnavigation menu which describes the options as easily aspossible. Due to the distributed nature of the communities, it isnot feasible to have regular training sessions at CHCs althoughwe do recommend passing out pamphlets or posting banners invillages with simple instructions. The medical personnel needto be trained on the value this solution will provide. Anawareness and value realization session would be necessary

for the operations staff. Governmental or medical agenciesanalyzing diseases trends need to be involved in the sametraining plan as well.Staging:The steps for rolling out this solution are a) identifyand select metrics for success b) selection of rural areas forimplementation and assess challenges in region c) creation ofcontrol group of end-users and medical personnel d) involvingrelevant stakeholders for region e) conduct hypothesis tests. Astage-gate implementation is suggested for this solution.Based on the amount of funding available for the project, it isfeasible to select a small geographical area with access tomobile infrastructure and conduct the test over a period oftime. The technology within the IVR system allows immediatescaling for more users and it does not have geographicalrestraints within a country. The social collaboration element isconsidered to be highly scalable as well.Hypothesis Tests: The team carried out interviews withhealthcare professionals and NGOs in the field with thissolution in mind. The existing challenges faced by these twostakeholders were discussed. The results from the interviewsshowed that the medical personal did not feel strongly aboutthe medical data-set and procedure standardization for thedifferent use cases. They realized there was significant value ifthe system could be implemented properly.

V. CONCLUSIONThe rural healthcare system can stand to benefit fromtechnologies which are emerging to be low-cost with a wideacceptance rate among populations. The proposed system isdesigned to be a low cost solution which can be scaled todifferent geographical locations and adapt to different use casescenarios.

REFERENCES

[1] Abhinav Anand, Veljko Pejovic, David L. Johnson, Elizabeth M.Belding, VillageCell: Cost effective Cellular Connectivity in Rural

Areas, ICTD2012, University of California, Santa Barbera[Online]

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[3] Susanne Jul, Robert Kirkpatrick, Judith Kleinberg, Dennis Israelski, EricRasmussen, Emerging Methods in Public Health Informatics:Addressing the Collaboration Gap, /making the eHealth connection,Bellagio, Italy, July 13-August 8, 2008 [Online]

[4] Joanne Riebschleger. (2007). Title. Families in Society: The Journal ofContemporary Social Services. [Online] Available:

www.ce4alliance.com/articles/101109/riebschleger.pdf

[5] J. Hammer, W. Jack. (2001, Nov). Title. Journal of DevelopmentEconomics. 69 (2002) 297 303. [Online] Available:www9.georgetown.edu/faculty/wgj/papers/hammer-jack.pdf

[6] J Goldenberg, Oded Lowengart, Daniel Shapira. [Online]. Availablehttp://www.complexmarkets.com/files/GoldenbergLowengratShapira_Hubs_2010.pdf

[7] Ceren Budak, Divyakant Agrawal, Amr El Abbadi. Diffusion ofInformation in Social Networks: Is It All Local? [Online]. Availablewww.cs.ucsb.edu/~cbudak/ICDM2012.pdf

ieee report forma rural district health office data connectivity and ehealth record system version 2

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