Draft Abstract for the BMJ Case Reports Elective presentation in CMC Vellore (Cognitio 2014)

Abstract:

The current paradigm of doctors solving clinical problems using their personal experiences and memorized knowledge is rapidly changing with advances in information and communication technology. The BMJ Case Reports Medical Elective (details here:
http://journals.bmj.com/site/marketing/landing-pages/Indian_Caseelectives.xhtml) is a blended learning program that allows every human including patients, medical students and health professionals alike to gain proficiency in gathering and understanding medical knowledge from internet resources while helping solve real-life clinical problems. This activity is already active, hands on, 'offline' in People's College of Medical Sciences, Bhopal and online in http://www.udhc.co.in with further conversational processing in an online forum called 'tabula rasa' where de-identified patient information is shared after informed consent from patients. This process democratizes medical knowledge and also identifies areas where more research is necessary. A few students from the BMJ blended learning program shall present their experiences in http://cognitio2014.com/#!/page_Schedule (18th July) through a few cases to create an appropriate stimulus for more and more interested students globally toward attending this program.

Body of the presentation:

Case study 1:

A lady with abdominal pain and abnormal behavior followed by seizures

Presenter: Surya Jain and Shrutika Singh (Access the case based conversations in the website here:http://www.udhc.co.in/INPUT/displayIssueGraphically.jsp?topic_id=1210)

Case study 2

Two patients: A patient with a blackening toe and a patient with abdominal pain and a past amputated toe (Access one of the raw case-data based in the website here:http://www.udhc.co.in/INPUT/displayIssueGraphically.jsp?topic_id=1236)

Presenter: Sumit Giri, Archit Jain and Ayush Gupta

Case Study 3

A child with a disabling abnormal posture

Presenter: Ayush Gupta and Sumit Giri (Access the case based conversations in the website here: http://www.udhc.co.in/INPUT/displayIssueGraphically.jsp?topic_id=1108

Case Study 4

A young man with Fever, Pain in Abdomen and Vomiting since 15 days

Presenter: Shrutika Singh and Sumit Giri (Access the case based conversations in the website here:http://www.udhc.co.in/INPUT/displayIssueGraphically.jsp?topic_id=1016)

Disclaimer policy of ArogyaUDHC

Question from Shrikant Sawant: Can you elaborate the disclaimer policy of this model. For example: God forbid, but if a patient dies in this process, and because all the data is electronic, it is easily provable who had given the opinion and prescription, is there even a vague possibility that, we as technology providers or the doctors, be prosecuted?

Answer: The disclaimer is displayed once the patient hits on the 'add a health case' button (this button can be found anywhere on most of the website pages as well as on the home page). This is the page that opens up here:http://www.udhc.co.in/INPUT/care-seeker-input.jsp
(Scroll down to the bottom to see the disclaimer which is essentially the same information content on our informed consent form here:http://www.udhc.co.in/STATICS/docs/udhc-english.pdf)
However more than the above your point hints at deeper issues of medical cognition, medical uncertainty, evidence gaps and their challenges to having a completely transparent clinical workflow. Our patients die everyday (as in most places in the globe) and all of these dead patient-records are still open in our website and anyone (patient relatives and kin) can easily scrutinize and audit whatever went wrong. In most instances we are confident of the fact that we did our best and acted free of errors (as much as is expected from current humans). A transparent clinical workflow could even reduce the amount of law-suits to doctors as most problems (in mutual understanding that lead to lawsuits in the first place) happen due to information gaps that often go unaddressed and we believe these gaps can be addressed by information technology.

Coming to the other important issue of if our outputs to the patient can be misinterpreted (by patients and TCHEs) leading to fatal errors we make it a point to direct all our online outputs and communication to the primary physician in-charge of the patient (click here:http://www.udhc.co.in/SOLUTION/solutionList.jsp). In many instances when we are ourselves the primary physician to the patient our outputs are mostly in the form of paper based prescriptions (or paper notes from the file) which are simply uploaded by the TCHE to maintain informational continuity in the patient's journey(to help their health professionals understand how to better solve their problems).

Does the current UDHC website also maintain patient history?

Question from Shrikant Sawant: Does the current website also maintain patient history? For example: a patient comes in the next time with a different ailment, does he have to input his details again, along with all reports etc..?

Answer:Here's an illustration from a real patient upload onto our website where every entry has talked about a different problem (in the same patient named 'Nymphoides736Hydrophylla') and yet all the information is manageable from a single window that you can access in this link here:http://www.udhc.co.in/PROFILE/PATIENT/profile.jsp?patient_name=Nymphoides736Hydrophylla
(you may have to scroll down a bit).

Scaling UDHC in your town: a sketchy business model and role of the 'Clinical Information communications manager' CICM

We are trying to implement the UDHC business model in our town and would like to learn more from your inputs on this brief and sketchy model (cash-flow and workflow) narrated below:

a) Clinical encounter fee from patient (100/-): Health professional sees patient in his clinic for a fee and asks his 'trained clinical information communications manager CICM or trained clinical health educator/entrepreneur' TCHE (more details on TCHE here:http://userdrivenhealthcare.blogspot.in/2014_01_01_archive.html) to prepare an online record in UDHC (which is more like an evolving case report of the patient with various bits and pieces of available information around the patient strewn coherently for meaningful use). This is done after obtaining informed consent from the patient from the form downloadable here:http://www.udhc.co.in/STATICS/docs/udhc-english.pdf

b)) Fee division (figures in %): Physician 70/- and CICM (20/-) for the first and subsequent visits (10/- could go to the online as well as offline managers/developers of this entire workflow).

Workflow: Physician primarily writes on the prescription slips (as per common-current workflow with minimal change pressures for the physician) and this is promptly uploaded on the site (after patient de-identification) by the CICM who also types out a proper history of the patient in the narrative space on the web based record. See this illustrative example from our functioning website here:http://www.udhc.co.in/INPUT/displayIssueGraphically.jsp?topic_id=1066

The CICM here in the above linked record is our medicine office clerk who is trained to take a clinical history (using the Hindi language and her common sense). She has input the data (again in Hindi using English fonts) to the site along with the uploaded prescriptions that i wrote for the patient and in the same narrative space we have pasted the subsequent conversations around this patient in our online processing forum (tabula rasa) with multiple inputs from global experts.

We could further train the CICM (particularly if the candidate has a nursing or pharmacy background) to become a complete physician's assistant (also well trained in medical information processing aka clinical problem solving). You may ask what would distinguish a fully trained CICM from a very good primary care physician then? Well the CICM can nurture the information workflow but may not still be able to take the final decision and make the prescription orders. But yes if the same training was given to an MBBS s/he may become a very good primary care physician.

The other important workflow of the CICM would be to take all the phone calls from the patients for the physician and if indicated enter those conversations into the patient's web based record to keep the physician asynchronously in the loop.In fact this model can be fast tracked with more and more patient users being generated through a telephonic introduction to the physician's and CICM's practice, following which (if the patient is satisfied after the first phone call and a phone call generated web record) the patient could decide to come and meet the physician and CICM for the first face to face clinical encounter.

The success of the model (as in most health care delivery models) would be heavily dependent on the level of training and learning-sustenance achieved in both the actors (physician as well as TCHEs) and the UDHC website is perhaps in some ways functioning as a differently structured 'web based learning management tool' for these actors (as well as the patient) and the entire information that may rapidly accumulate in this open database can again be 'mined' to gain further insights in health-cognition. In future we can develop this into a sustainable 'home-care' model integrating pharma and nursing trained CICMs/TCHEs (but that is for later and currently we just need to focus on the information communication part and i am willing to pilot this here in our town if i can begin with a few trainees and if we have nursing or pharma trainees we could even fast track the home-care model).

Will be looking forward to keep learning from all of your thoughts and inputs on the above.

Scaling UDHC through a mobile-phone-web based interface for interacting and communicating with our patients

Brief Background (to this current need):

We already have an active website for interacting with our patients here:http://www.udhc.co.in/ and the village representative working for us 2000 kms away from our institute in Bhopal, India charges money from patients to upload their history-data (after de-identification and signed informed consent) to the website and to his credit he has a long line of villagers queuing up regularly to provide their health inputs. More (wishful bloggy) details here:http://userdrivenhealthcare.blogspot.in/2013/10/reaching-out-hospital-services-to.html

Can we digitally overcome our rural patient's need to always interact with us through an intermediary who charges money?

We are looking forward to our developers helping us overcome this current rural digital divide (to E health) by designing a mobile phone interactive platform where patients could simply dial a number and provide the necessary details of their illness/problems through an IVR and a solution could be voice-mailed to them after appropriate processing through our website based online network of global health professionals. In effect the current website processing workflow would very much remain the same but our patients would have much better access to it? It may not altogether eliminate the need for an intermediary though.

Questions from Shrikant Sawant (13 May 2014):

With IVR you can possibly achieve direct contact with the patient, but the process of uploading the vital signs/ reports/ history cannot be achieved by that. I don’t know how effective this would be as a solution. Moreover even if we think of a smartphone app, the patient (without an intermediary like the TCHE) needs to have the know-how of operating the same, which we think is a rare possibility. Please correct me if I am wrong.

Answer:
I agree the IVR is more of an initiation interface into our UDHC website and does not altogether eliminate the need for an intermediary like the TCHE (currently labeled 'information communication manager ICM). After the first voice mail is analyzed (mostly the history without any reports) the ICM can ask the patient to meet for guiding the first upload of detailed reports and vital signs to the website (for which service the ICM can charge a fee...so very much the current existing 'fee for service' model but with more outreach to potential customers?).

 

Extending the scope of a Medical Elective blended learning program toward scaling and replication of 'user driven healthcare UDHC.'

Our current UDHC passion is spent in trying to develop a unique CA firm (CA as in clinical audit) where Indian health care activists/enthusiasts/entrepreneurs can interface with patient information requirements to audit the information (in the prescriptions provided by the direct agents of the patients aka clinicians) and you will find a lot of such information in the prescriptions available at the individual patient records here:http://www.udhc.co.in/INPUT/input_directory.jsp

In our work with 'patient centered learning' we have felt this need for training in EBM and we have designed an elective curriculum in 'blended learning' in our institute here: http://journals.bmj.com/site/marketing/landing-pages/Indian_Caseelectives.xhtml which is attended by students globally.
  

We can extend this and train any health entrepreneur who wishes to make a difference here in our institute/practice area (completely hands on) and completely free of cost.These activists/entrepreneurs can then utilize the training to open their own UDHC clinics in their chosen locations on a fee for service model (preferably in collaboration with an medical practitioner).

Patient centred online learning has so much to give to our patients and health professional trainees that it is a pity we are currently not utilizing a fraction of it! I am even thinking of expanding our practice area beyond the confines of our PCMS institute (which mostly functions from 9 AM to 4 PM) and extending it to a private practice community clinic setting where these clinical entrepreneurs are likely to practice in their own future.

The selected graduates need to be savvy in computer mediated communication and learning and we could also have a run in period of 1-4 weeks to decide their suitability for the program.

 

We shall soon post the complete details of our 'blended learning' training program (a small summary of which is already shared  in the BMJ medical elective link here:http://journals.bmj.com/site/marketing/landing-pages/Indian_Caseelectives.xhtml and here is a blog post feedback on the training by one trainee:http://likethechickenscratch.blogspot.in/?m=1. Here's an earlier version of the above Clinical entrepreneur proposal where we had named it differently:https://globalhealthtrials.tghn.org/community/blogs/post/6765/2013/07/a-learning-ecosystem-for-case-based-health-inf/. These trained activists/entrepreneurs can also work with govt bodies to perform large scale clinical audit surveys in hospitals and large group practices where clinicians (unwittingly?)engage in non-evidence based practices (unknowingly working in collusion with the drug industry?

Hoping we can collaborate with more and more interested stakeholders in a 'Patient centered Clinical Audit and Research Entrepreneurship' development program for currently unemployed/employed Indian graduates looking for clinical-entrepreneurship-career options (and we can help to provide free training). Can this can help pave the way forward to a 'transparent and evidence based healthcare ecosystem' in India?