November 2006

GIS AND TELEMEDICINE: TOOLS FOR PUBLIC HEALTHCARE

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Recent IT innovations worldwide have been so impactful that they have been able to bring about paradigm shifts in almost all realms ranging from education, banking, governance to healthcare. Public health administrators across the globe today are putting in efforts to come up with a common agenda for using upcoming ICT applications to transform the domain of epidemiology.


e-Health : Matrix of Stakeholders, tools, ICT and Citizen

One of the key objectives of e-Health is to enhance efficiency of current healthcare delivery system including, sharing of information and engaging citizens for an advantageous arrangement, both between the government and the citizens. This is illustrated with the e-Health Matrix that comprises of stakeholders, e-Health tools, and ICT applications, all centered on the citizen.

The actors involved in the implementation of e-Health are healthcare organisations, physicians, policy makers, health management personnel, clinicians, paramedical personnel, pharmacists, application developers and citizens. These actors use the WHO identified tools  identified by the World Health Organisation (WHO) such as GIS, Telemedicine, Patient’s Information System, Decision Support System, Electronic Health Records, etc. to form the basis of their public healthcare setup. These e-Health tools further use existing ICT applications such as kiosks, Internet, email and video conferencing services as a backbone infrastructure to reach to the healthcare requiring public.

Why e-Health?
Of all the services that government engages itself in, public healthcare is the most sensitive domain as its quality and access has always been a major concern. The main reason for such a concern is that in case of public healthcare delivery, if right information is not delivered to the right people at the right place and at the right time, many lives would be lost.

So far the Indian healthcare scenario presents a gloomy picture. Life expectancy hovers 4 years below the global average.  India is one such country where eradication of polio is still awaited despite the best efforts and numerous polio eradication drives. India ranks number one to home 5.7 million HIV AIDS patients, as per the UNAIDS Report on the global AIDS epidemic, 2006.  Tuberculosis and malaria also take a high toll on health. These grim statistics expose a yawning gap that needs to be plugged by Indian healthcare delivery system in India. Ironically, on the other side, the next big Indian success story in the making is medical tourism. As per McKinsey & Company and Confederation of Indian Industries, healthcare tourism in India can rake over USD 2 billion annually by 2012. But these strides cannot compensate for intransigent healthcare issues those are afflicting Indian public health.

Owing to the emergence of new global epidemics and unexpected spurt of natural disasters, these issues are attaining new levels of complexities. Counteracting to the complexities of epidemiological world, ICTs today are offering solutions that enable access to knowledge warehouse in the least time possible and dynamic communication networks, surpassing national and international limits.  Even more, efficient healthcare delivery to citizens has always been underpinned by various processes that enable exchange and sharing of information. Therefore, the following may be cited as some of the goals for e-Health tools to tackle healthcare:

a) Identification of gaps between the healthcare delivery set ups and the vulnerable population with the help of information superhighways.
b) Availability of information systems which nurture knowledge.


Geospatial technologies for public healthcare

Linkages and or access pertaining to healthcare has already been enabled with the help of telemedicine technologies and the factors pertaining to availability of information systems with respect to public health (catering to various activities like reporting, surveillance, etc.) can be achieved with the implementation of geospatial technologies.

Geospatial, telemedicine and public health
Geospatial, telemedicine and internet technologies form the components of public health informatics that have the potential to resolve some of the challenges affecting public health care. Geospatial Solutions comprising of GIS, remote sensing and spatial modeling; generally refer to a description of the characteristics and tools used in the organization and management of geographical data. Spatial data are commonly in the form of layers that may depict topography, healthcare statistics, healthcare demographics or environmental elements. Geospatial technologies have recently become an essential tool for combining various map and satellite information sources in models that simulate the interactions of complex natural systems.

Telemedicine on the other hand is defined as the use of communication networks to exchange healthcare information to enable clinical care and medical education.

Geo-spatial technologies can be instrumental in more than one ways to help public healthcare activities throughout their life-cycle. As shown in the figure, GIS systems allow development of various health related maps, undertake spatial analysis on health data, create simulation models for various disease spreads and increasingly provide ‘up to date’event information right on the user’s mobile. Applications like disease surveillance systems, emergency planning systems and real-time response monitoring systems are transforming the way public healthcare systems used to operate traditionally. Remote Sensing technologies, an aspect of GIS, can help model spread of diseases through satellite imagery by isolating areas that are more susceptible to the disease spread. Studies have also brought in a complete new paradigm linking meteorology – climate change studies – GIS, remote sensing and disease spread monitoring.

On the other hand, with advancement in telecommunication mechanisms, the public health systems have become direct beneficiaries; owing to their large informa-tion exchange requirements. Telemedicine – a direct offshoot of this advancement in communication technologies, is emerging as very effective in the domain of public health.


Public Health Activities and Informatics

In many ways, both these technologies complement each other. While GIS helps analysing health related events in a wider perspective, telemedicine helps in capturing the information and providing appropriate health advice immediately. Communication technologies form the enabling platform for both the systems to operate effectively.

Mentioned below are some of the key applications of GIS and telemedicine technologies in each of the five activities of public health:

a. Event surveillance
b. Event assessment
c. Event verification
d. Event information dissemination
e. Event response

a) Event surveillance

Epidemiological surveillance enables health care administrators to gather information that leads to the prevention or control or a better understanding of an outbreak, emerging infections and bioterrorism. The following information is extracted during the course of this activity:

i) Where could be a possible event outbreak?
ii) Is a particular health care set up equipped to handle a potential  disaster?
iii) Which location is most vulnerable to a particular type of outbreak?
iv) Do we have adequate resources (infrastructural and human) to tackle the outbreak?
v) What is the risk attached with the spread of an epidemic?
vi) Where should we have effective health campaigns?

If we notice carefully, a lot of relevant health related questions either point towards getting spatial intelligence or ask for core health domain information.

Conventional public health surveillance systems rely on manual operations and off-line analysis and are smitten with limited effectiveness. Tabular information sometimes overlooks certain important dependencies and trends that are crucial to analyse and monitor an outbreak. However, the mapping and analysing techniques based on geo-spatial technologies promise to enhance quality of epidemiological surveillance in terms of their (i) sensitivity, (ii) specificity, (iii) representativeness, (iv) timeliness, (v) simplicity, (vi) flexibility and (vii) acceptability. GIS uses map overlay techniques which view data pertaining to demographics, social infrastructure, healthcare institutions and patient’s geo-positioned points – all in one view. This enables the user to have the ‘big picture’ of the outbreak scenario, while also having complete details of micro events.

One such surveillance system is Real-time Outbreak and Disease Surveillance (RODS) system, which incorporates GIS and telemedicine.

b) Event assessment
Once an event is identified by a local health authority or people suffering from the ailment, event assessment is carried out by public health officials. It is done in order to plan out the epidemic or disease eradication strategy, calculation of the risk attached with the outbreak or visualising the impact that the event may have on the society. Assessment of a particular epidemic enables healthcare administrators to get answers for the following queries:

i) How would an event spread across geographies?

ii) Which is the nearest hospital to cater to particular emergencies?

iii) What could be the impact of the outbreak?

iv)  On spreading further, who would be at high risk?

v) How does the event outbreak affect the existing healthcare system?

GIS brings the capability to analyse data, using both the statistics and the spatial element, thereby giving a user-friendly output that defines the whole problem. Geo-statistical techniques like choropleth maps and spatial patterns produce results which allow the user to understand how the disease has travelled historically, across other geographies. The result is extrapolated with an extra usage of risk factors. One such geosta-tistical modeling technique, ‘kriging’, takes into account the existing underlying spatial structure of geo-referenced information (distances among samples or observations). This technique is used for visualising the spatial pattern of the disease. Spread of the outbreak of severe acute respiratory syndrome (SARS) was analysed using GIS techniques.


Public Health Informatics and its Architectural Components

c) Event verification

Event verification follows event assessment to display its potential importance based on the available background information, endemicity levels, and details of previous outbreaks. Verification mechanisms aim to improve epidemic disease control by informing key public health professionals about confirmed and unconfirmed outbreaks of international public health importance. Active response action has to be taken if the danger and sensitivity of the outbreak is large, and corresponding to that adequate preparation is done. Owing to introduction of ICT in public health domain, these days event verifi-cation converts large amounts of data into accurate information for suitable action and throws light on the following:

i) Sensitivity/urgency of outbreak response
ii) Population affected by the outbreak event
iii) Planning for public alarm and resources

Linkages and or access pertaining to healthcare has already been enabled with the help of telemedicine technologies and the factors pertaining to availability of information systems with respect to public health can be achieved with the implementation of geospatial technologies..


WHO has established an innovative outbreak verification system that employs web-based telemedicine concept where the information is shared through emails for the needy.

d) Information dissemination

The damages of a potentially dangerous outbreak can be minimised if the disease is subdued as early as possible. Therefore, for a timely and efficient response, the information about the disease and its extent must be reached and shared among healthcare institutions, medical bodies, NGOs and the government. The primary task of event information dissemination is to share the knowledge about the epidemic with the decision makers to help develop programs and policies for prevention and control activities.

Epidemic information dissemination activities answers queries like:

i) Where has the event occurred or spread?
ii) What is responsible for the event?
iii) What is the status of current resources available at the disaster location?
iv) Where are the experts located?

Geospatial intelligence, embedded in hospital information systems (HIS), provides a framework for managing, integrating, analysing, and communi-cating volumes of data. This enables hospitals to respond quickly to disease outbreaks.

Satellife [www.healthnet.org] is a pioneering project implemented in Ghana, Uganda, and Kenya in 2002. Satellife uses e-Health / telemedicine concepts for information, dissemination. Satellife is now working towards building a nationwide handheld computer network that will bring the power of email to health facilities in the periphery. It will also increase both their access to up-to-date information on HIV/AIDS, malaria, child and maternal health, and their ability to collect, analyse, and utilise data for decision making and resource allocation.

e) Event response
Event response is the most crucial action for public health authorities because response at the wrong time, sent to the wrong person, with incomplete or untrue information can cost a number of lives. Therefore, external expertise and help is required in order to mellow down the crisis. Each response activity answers the following queries:

i) Measuring accessibility to the deceased
ii) Resource allocation as per geography (recorded history)
iii) Visualising progress in damaged scenarios
iv) Time stamping events in various locations
v) Saturation capacity reports at hospitals
vi) Options for utilisation of hospital space
vii) Health information through the use of telemedicine
viii) Assessing the aftermaths of the outbreak event

Resource allocation is the primary step that any government takes in case of an outbreak. Therefore, allocation of teams with respect to their expertise, nearest areas to reach the needy, information on the existing social infrastructure such as roads, administration buildings, military camps, etc. are easily accomplished using geospatial technologies. Once the response teams reach the site of the event, mobile GIS gives an opportunity to record and send real-time data. Way back in September 2001, Mobile GIS was used for recording the symptom information of the residents of Pennathur Village (India), to know the extent of damage being done by the dengue outbreak.

In case of emergency, hospital space management becomes a bottleneck in providing better response to the affected. Geospatial technologies not only help in the visual representation of hospitals down to the bed level, but also provide information such as hospital capacity, staff on call, number of patients enrolled, etc.

Analysis of the response action after the event has been curbed is important to the government officials for purposes such as auditing, planning for better future response, etc.

GIS – Telemedicine : The synergy
As explained earlier, geospatial techno-logies used in combination with remote field data collection tools, connectivity to information highways, wireless application and satellite systems; hold a new promise for addressing infectious disease threats rapidly and effectively at local and global levels, even in countries with poor infrastructures.

Lot of time, energy and money is being spent on implementation of geospatial technology based applications in various municipalities and government departments. Telemedicine tools also are steadily seeping into healthcare delivery systems laterally at various levels and there are already some stories echoing success. Combining simultaneous implementation and use of these two e-Health tools can lead to cost optimisation, add more value, and highlight an integrated view of health information to the policy level user as well as to others in the field.

In summary the benefits of a ‘packaged’ GIS-Telemedicine solution for public healthcare include:

• Better visualisation to public health experts.
• Remote sensing techniques (sub-group of geospatial technologies) help in the real-time monitoring of the epidemics/outbreaks and facilitate in the formation of early warning systems. Those could be reinforced with efficient telemedicine systems.
• Adequate guidelines about any emerging epidemic can be provided only if complete information of the geogra-phy, socio-economic and other data is available. Geospatial technologies can thus add another dimension to telemedicine by providing additional demographic information to the clinicians.
• On one side telemedicine links a medical consumer with the medical service supplier and on the other side  geospatial technologies provide collective information on the epidemic and demographics. By utilising both these technologies, healthcare administrators can develop a realistic response and approach towards the epidemic.

Conclusion
Owing high social relevance public health calls for special concern as far as e-Health is concerned. With rapid advances in technology today, investors in systems development need to step back and see how convergence in different technology streams could open up new possibilities.

Time is not far when technologies like distributed spatial data portals, geospatial libraries, etc. would transform traditional public healthcare into a form of ubiquitous healthcare. This transformation will come about with health grid and high bandwidth linkages, which those will enable delivery of vital information across the length and breadth of countries, and continents. Keeping in mind the exploding ICT scene, despite changing health needs, building and integrating comprehensive and responsive domain of public health informatics is very clearly a challenging but an attainable ideal.

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