Sunday, January 24, 2016

Project detail: Achieving Swa-astha by putting patient at the center of the health-system


"The Sanskrit word for the healthy is swa-astha, one who is not dependent on others. This term denotes autonomy and freedom." Quoted from  Bang A, Health insurance, assurance, and empowerment in India.The Lancet , Volume 386 , Issue 10011 , 2372 - 2373. 

One way to achieve Swa-astha is through 'Patient-centred or people-centred care' which conveys "the idea that the patient should be at the centre of the health system so that care “is respectful of and responsive to individual patient preferences, needs, and values”. 
Our goal is to achieve Patient centred care delivery through empowerment of patients and local caregivers connected through a global information network.

Key objective:

Management of chronic disease patients (Non communicable diseases NCDs with co-exsistent communicable diseases CDs) through trained Tele-health workers THWs working with local and global doctors toward best quality evidence based information communication for patients

Population served:

Chronic disease patients around 500,000-to 1 million in 2 years will be followed up by the THWs in their communities

People Needed:
Trained THWs, Local and Global doctors to care locally and learn globally

What do we offer?

A seed PPP funded project for two years to impact a sample local population served by THWs and local doctors through global networking establishing a monitoring and screening each person and address their needs accordingly with prevention and information. For example, a healthy man may have a routine check up every 1- 2 years; an iron deficient girl every 6 months, a diabetic once or more every month.

The cost of each check up should not be much- perhaps 100 INR. If a THW (perhaps a science grad from the same locality) can get 30 such checkups done a day- he stands to earn 3000 INR a day or 75,000 INR in a month.

The role of a doctor comes in checking the information upload and correcting the THW-s as and when alarms due to remarkable situations come up. This also connects patients to medical college hospitals (only if necessary) for further rigorous tests and treatments.

Operational Plan:

How many districts, blocks, families and individual consumers/ users will be under this project by the end of this seed-project i.e., 2017?

40 Tele-health workers THWs shall be recruited by our medical  college hospital to cover 800 patients/persons per day and these will comprise of 1) complex cases such as complicated diabetes, cancers and mental health problems from those who visit our medical  college hospital from 5-10 districts of Central India, and 2) simple cases such as uncomplicated diabetes, hypertension, obesity, mental-health-addictions (like smoking, chewing tobacco that can lead to cancer) from the communities our THWs will visit and follow up in the community monthly, weekly or daily as per need using project supported information communication technology ICT tools. At the end of two years this may generate nearly 500,000 patient records and if we include each of their families it will likely touch 1000,000 lives. Scaling on the number of THWs in subsequent years will further expand the reach of our project.

Key health parameters and improvements: 

Detection and screening:

An open case-record of patients integrated into a mobile health database can be accessed from anywhere, anytime by both patients and care-providers.

E-rounds: significantly reduces time/effort for busy consultant-doctors

Home-healthcare: better coverage and assessment of chronic disease patients at their home settings.

Follow ups: Patients in remote locations can be accessed and helped further through high-definition video calling systems.

Economic impact (reduction in lost wages, travel costs etc)

Project will not only significantly reduce travelling cost for multiple follow-ups but also reduce lost daily wages often suffered by patients who have to sacrifice their workdays to attend hospital OPDs

- Possible reduction in tertiary care load but bigger coverage

The project will reduce number of visits to tertiary hospital based care and add more value to better monitoring and evaluation in community based home-healthcare settings

Possible reduction of cost of care per patient
Travel cost, physician time, better co-ordination, improved care delivery, quicker diagnosis and referral system with increased patient involvement in care. 

Time Line:

Recruitment of THWs (1 week to 1 month)

Interviews and trial run for a month to assess training feasibility in individuals to be selected

Training of THWs (3 months)

Hands on training in identification of disease from patient’s history and clinical findings and investigations and creation of open-case-records (PHRs) for each of their patients

Classifying disease into NCD and CD

Apply information driven evidence based clinical problem solving

Learn various protocols guided by online evidence toward management of NCDs and CDs

Training to care for the whole patient and be driven by patient requirements rather than solely by disease requirements

Learn to communicate information obtained by them from the patients (as well as online-resources -validated by Global online experts) to the local physicians in the patient’s village

Learn to collaborate with the local physicians to develop a collaborative approach to patient care

Formative assessment through regular online interactions and documentations

THW workflow: (2 years)

THWs Screen individual rural and urban patients from different districts for NCDs and CDs.

THWs create detailed electronic health records of identified patients (after signed informed consent and HIPAA de-identification)

THWs share the records across a global participatory tele-healthcare learning ecosystem 

THWs contact the ’local-doctors’ in their area and share inputs from the Global doctors on each patient and invite inputs and queries from the local-doctor and feed-back those to the global doctors

Obtain conversational and evidence based clinical decision support input to benefit those patients with the records

Study design and Outcomes assessment (over 2 years)

This project will employ a case-study-design, integrating units of single-patient-case-studies that will be guided chiefly by the M-health specialist, doctors and research analysts covered by the project budget. They will thematically analyze individual patient records created by the THWs including their updates and prepare situational, problem-based, patient-case-studies based on the SOARC model linked here: 

They shall integrate similar single-patient-case-studies to achieve insights into suitable scale-able strategies that can best prevent and optimally manage such cases in future.

Situation (S of SOARC)
·         What was the background to the current state?
·         What was happening?
·         What was the problem?
·         How was this identified?

Sample illustration (from our current patient-records):

Simple Case-scenario (Trunkal Obesity with Diabetes):

A 35 year old man with trunkal obesity (abdominal circumference of 130 cm) and a strong family history of diabetes and heart attack is interviewed by our THW in the community and an electronic Personal health record PHR is created along with screening for diabetes and hypertension which are absent. He is found to have fasting blood glucose of 130 mg% and post prandial blood glucose of 200 mg% which establishes the diagnosis of diabetes for the first time. He is found to have a BP of 130/82 mm Hg. On ophthalmological examination he doesn’t have any evidence of diabetic retinopathy. His PHR created and updated by the THW serves as a platform to follow him up with 3 monthly preventive advice regarding diet and exercise to reduce his abdominal circumference and record his repeat weekly blood glucose for monitoring his diabetes and his weekly BP to detect the development of hypertension.

Complex Case-scenario (Diabetes with pain abdomen and diarrhoea and Paralysis of one leg)

A 35-year-old man was recently interviewed by our THW in LNMCH for registering into the PHR. This patient had previously presented to a community hospital with eighteen months of chronic abdominal pain. The pain was epigastric, mild, and associated with occasional diarrhoea. After being admitted to the hospital, the patient was diagnosed with Insulin-Dependent Diabetes Mellitus (IDDM) and was started on subcutaneous insulin injections. His condition improved and he was discharged. After a brief respite, he suffered from severe abdominal pain for which he returned to the Primary Health Centre nearest to his village. He was given an intramuscular injection of an unknown substance into the left gluteal region to relieve his pain.

After receiving the intramuscular injection, the patient was unable to rise from a supine position. He discovered that he was unable to move his left leg. The patient returned to the same PHC two days later, where nothing was done for his left leg weakness, but instead he was given another intramuscular injection in the contra-lateral gluteal region. The patient was later admitted to the PHC for thirty days, but no therapeutic steps were taken to resolve the loss of mobility and the patient noticed no improvement in his condition. The patient returned to his home for two weeks, hoping for an improvement in his condition, but there was no change. Six weeks after the injury, the patient presented to a tertiary care hospital with foot drop, mild paraesthesia and tingling sensations in the left leg.

Situation/ Problems Bottom-line: Injection nerve palsy, Insulin dependent Diabetes, chronic abdominal pain and diarrhoea

Objective (
·         What were the aims of the project?
·         What was hoped to be achieved?

Sample illustration (from one of our current patient-records): For all our single-patient-case-study projects the broad research questions are: What is this patient’s situation/problem and how can we help find better options for him/her and others like him/her?
Simple Case-Objective: Once we identified the above mentioned patient with a definite problem of significant trunkal obesity with strong family history of diabetes making him high risk for heart and brain attacks our primary objective was to reduce his trunkal obesity as that would not only significantly reduce his chances of hypertension and heart or brain attack but also contribute to controlling his diabetes. Our secondary objective was to follow him up with intermittent screening for any further complications such as weekly for BP and annually for retinopathy.
Complex Case-objective: Through the above mentioned patient with paralysis of one leg following an injection, we found that ‘injection nerve palsy’ was a significant problem in Central India not just for the particular patient who presented to us but also in a few more similar patients we came across and we realized that a fresh approach was necessary to prevent this problem from recurring. Our objective was to reduce this problem by identifying training lacunae in injection practices and instituting training beginning with our own nursing staff and publicize our actions through appropriate channels to scale our action. We also needed to take care of his insulin dependent diabetes by optimizing the dose and frequency of his insulin injections as well as his diarrhoea and pain abdomen by investigating it further. We also needed to follow him up with intermittent screening for any further complications such as weekly for BP and annually for retinopathy.

Action (
·         What action was taken?
·         What were the implemented improvements (tools/techniques)?

Simple Case-Objective: For the problem of ‘trunkal obesity’ on reviewing the literature, we found that informational interventions that re-iterate the optimization of diet and exercise in individuals with target to reduce the abdominal circumference can be effective and we instituted the same in our patient through weekly follow ups over mobile phone and SMS reminders about diet and exercise and also collected the information on his weekly fasting and post-prandial blood glucose values and his Home BP recordings that was entered into his PHR. The THW was provided with a portable blood glucose monitor and portable BP monitoring standard oscillometric device for initially training the patient on its use as the patient was also expected to buy the same device and learn to operate it on his own at the end of one to two years. Annual Fundoscopy screening was planned to be done through tele-ophthalmology techniques as previously described from India here:
Complex Case-objective: For the problem of ‘injection nerve palsy’ on reviewing the literature, we found that informational interventions that disseminated proper training to develop an anatomical understanding of the sciatic nerve can be effective and we took the nursing staff of our hospital to the dissection room and demonstrated the anatomy of the sciatic nerve along with the measures to prevent such injuries by demonstrating proper techniques (ventro-gluteal in supine position instead of the currently prevalent practice of dorso-gluteal in lateral position) and monitoring the staff as they practised on cadavers. For the patient, an ankle-foot orthosis (AFO) was used to provide foot dorsiflexion during the swing phase and lateral stability at the ankle during stance.  Since the patient also complained of paraesthesia, pregabalin was prescribed to manage this symptom. Unfortunately, because of the patient’s poor socioeconomic condition, he was not in a position where he could afford these medicines. Hence, to alleviate his pain, less expensive medications, paracetamol and diclofenac were prescribed. Along with these treatments, the patient was put on regular insulin for his IDDM and the dose and frequency was optimized. His diarrhoea was further investigated and basic stool examination did not reveal any abnormality and he was managed as autonomic diarrhoea and pain. Once discharged from our hospital he was followed up by our THW, who collected information not only about his afore mentioned problems but also on his weekly fasting and post-prandial blood glucose values as well as his Home BP recordings using a portable blood glucose monitor and portable BP monitoring standard oscillometric device. Annual Fundoscopy screening was planned to be done through tele-ophthalmology techniques.

·         What is the situation now?
·         What was achieved through the action(s) and were objectives met?

Simple Case-Result: The patient with trunkal obesity has made good progress over two years and his current abdominal circumference is 95 cm and his blood glucose normalized over 6 months. He hasn’t developed hypertension and his annual fundoscopy results obtained through tele-ophthalmology are normal.
Complex Case-Result: The patient with injection nerve palsy is still living with his gait disturbance due to the nerve palsy and is still using a posterior AFO although he finds it uncomfortable while walking. The fit of his AFO is less than ideal, and the authors are searching for financial resources to supply this patient with a model that will fit. His diabetes is well controlled. He still continues to have episodes of abdominal pain and diarrhoea although the duration and frequency is less than before. After training our own nurses in using a ventro-gluteal-supine approach we are trying to scale to propagate this safer injection approach to other nurses and any practitioner who administers injections to patients. We still need to gather more robust evidence through a funded RCT where one can compare the two approaches and establish the superiority of the ventro-gluteal-supine approach as a fool-proof and consequently safer method.

·         How is the change sustainable

Simple Case intervention sustainability and scaling: In two years our THWs are expected to identify more than 100,000 patients with trunkal obesity and with their information based intervention to reduce trunkal circumference, they are expected to contribute a substantial impact in reducing the population of people with diabetes and hypertension in central India.
Complex Case intervention sustainability and scaling: In two years our THWs and doctors are expected to scale their informational intervention to promote safe injection practices to not just hospital based nursing staff such as in LNMCH but also similar staff and rural practitioners who regularly inject patients and may not be aware of the fallacies.

Overall Project sustainability and scaling:

The most significant contribution of our project we believe is the creation of a usage model for ICT in healthcare that has the promise of generating a patient-centred learning ecosystem comprising of multiple stakeholders such as patients, their primary care-providers ranging from THWs, medical students, local doctors and global online doctors. We already have a working prototype of this ecosystem that has its epicentre at LNMCH along with a strong online presence and our current funded project will scale it further such that we shall be able to attract a lot many new learners into this system who would not have otherwise been made aware of its existence and usefulness. 

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