If there is one growth indicator in India rising faster than the stock market Sensex in India, it is the ballistic rise in chronic lifestyle diseases. Amongst these killer diseases, cardiac diseases have taken the leading position. More than 8% of India’s population i.e. a whopping 80 million are estimated to suffer from cardiac diseases. Genetic predisposition compounded by rapid urbanisation, economic prosperity, changes in diet and lifestyle amongst Indians is expected to further aggravate this situation.
It is a well-known fact that there is a major shortage of healthcare facilities, clinical skills and other resources to contain this national level crisis. New innovative treatments such as genetic and stem cell therapy are still in their infancy. Prevention and Chronic Disease Management programs to fight these diseases have a long way to go before they can make any impact – hence we have to depend on conventional cardiac care treatment.
If we just focus on ‘coronary vascular diseases,’ which cause a heart attack, the figures will speak for themselves. Angioplasty is a minimally invasive procedure that clears the cholesterol block in the arteries supplying blood to the heart, while open heart surgery (CABG or OHS) bypasses the block by grafting some other healthy blood vessel. The estimated number of angioplasties per year is set to cross 50,000 whereas the figures for CABG are 32000+ in India.
It is obvious from the above that, it is not possible to meet the humongous demand-supply gap of over 95% of the cases going untreated, just by increasing the number of cardiac hospitals, cardiologists and cardiac surgeons or by simply working longer hours. Add to this, the factors of affordability and availability of these expensive surgeries.
New hospitals with cardiac speciality are sprouting up all over the country. Skilled surgeons and cardiologists are burning out trying to cope up with the ever-burgeoning patient load. This though, is not enough to meet the huge gap between demand and supply.
Information & Communication Technologies (ICT) have transformed our lives in every conceivable area from banking to stock markets and from travel to entertainment, not to mention mobile communication. What is stopping ICT technologies from being used extensively in sophisticated knowledge-based clinical applications like Laboratory Systems, Imaging Systems, Electronic Medical Records and Telemedicine?
Important Issues to be addressed by ICT solutions for clinical applications:
They must deliver critical information in a manner that simplifies the job of overworked clinicians and paramedics. This is possible only if these applications are designed and validated by healthcare domain experts and not IT experts.
They must be first implemented, incorporating innovative and improved processes by champions willing to change conventional mindsets. This is a big change management exercise and unless this is handled effectively, no improvement is possible.
They must be a seamlessly integrated with all the other relevant systems like HIS and not behave like islands of super-efficiency.
They must be cost effective and improve quality of patient care.
They must help to improve the productivity of scarce & expensive resources like Cathlabs, Cardiac OTs and cardiac surgeons and cardiologists.
To illustrate these facts it will be appropriate to study the impact of innovative use of ICT in Cardiology Information Systems with Advanced Imaging & iEMR. This clinical information system touches all information related to the patient and the episode. Demographics and administrative data is captured mostly in the hospital information system and is linked to the clinical system of CIS. Specific clinical history and subsequent OP encounter details such as examination, medication, prescription, diagnostics etc. get appended in the course of time. Finally, inpatient treatment details such as coronary intervention / surgery is added to the patient record.
It is a reliable and structured way to store and retrieve clinical and patient information in a structured manner in a very short time. Faster data access can reduce wait and search time, which is an obstacle in quality healthcare in India. Early diagnosis with fast and accurate treatment can save a huge cost that our country cannot afford today. Needless to talk of benefits when this saves lives.
It is a powerful tool to analyze the information for Education, Academics, Quality initiatives, Research and Performance measurement.
It is integrated with administrative processes to improve overall patient management and satisfaction.
Indians suffering form cardiac diseases: 8 crore
Newborns with cardiac diseases: 2.25lacs/yr
Average age of Indians suffering heart attacks: 45 years
Average age of people suffering heart attacks in Western countries: 65 years
Heart attacks in those under 40 years: 25%
Innovation is the Key
All these benefits are not possible without innovative use of technology, which support Commonsensical requirements. Let us see how all these points apply to applications in a typical cardiac care. Three pillars of innovative use of technology on which such a system rests:
Flexible EMR engine
Electronic Medical Records present an unprecedented challenge to the software professional.
On the one hand is the need to provide a system that is rule driven, structured and with a need for outputs and Management Information System that is fairly standardised, while on the other hand is the need for flexibility dictated by the esoteric body of knowledge and a structure that does not fit any precise standard. All this at the lowest possible prices! It therefore makes no sense to develop and design a system that fits the requirements of each doctor separately and individually.
The way out of this complicated problem is to have an EMR engine which can empower the doctor to define his own inputs with validations and outputs and statistical reports. The EMR engine design therefore puts into the hands of the end-user a powerful tool, which he can use to customize the input mechanisms, the output formats and a methodology to be able to extract information into standardised reports.
Such engines should integrate with popularly used technologies such as software like Microsoft Word, Microsoft Excel, that require little or no training, have clinical standards based on texts such as Lowe and Bailey Surgical Notes etc. So that, while the users have an option to choose, it should not be ‘a start from scratch’ approach. It should also follow integrated health standards and talk to other systems through HL7 messages.
Innovative approach to image distribution
Conventional approach of PACS will not work in the Indian context. In case of cardiac diagnostics and procedures, we typically do not deal with films. Naturally, we cannot talk of benefits of film-less environment from a radiology perspective. Most of the viewers that are available as satellite console, provided by modality vendors, confine the focus on specific modalities where commercial interest lies and do not easily integrate the information as needed ideally by the clinicians across the hospital.
A cardiologist has to deal with diversified clinical data such as OP consultation, ECG strips, 2D echo / angiography loops, procedure plan etc. Clinically, every data is important as it collectively impacts the decision making. However, the records are all scattered. OP consultations are usually handwritten paper records and quite often, no system can interpret or classify the contents. ECG strips are added to paper records. 2D echo loops most of the time are trapped in the machine itself and are rarely available as records in the form of videocassette or a CD. Angiography loops are typically provided in what is called as DICOM CD, which needs its own specific viewer software. No one can blame a cardiologist for interpretation based on limited data available in the middle of a huge OP wait list.
All these details need to be digitized and united under one roof to demolish barriers for communication. Advanced image archival that integrates ECG waveforms, 2D echo and angiography images. The imaging viewers need to be specially designed from integrated access to address holistic healthcare.Build clinical intelligence into the system. Archival without planning storage and addressing efficient retrieval will create more problems that it aims to resolve. If one has to include the imaging records, clinically intelligent storage needs to be planned.
Intelligent storage policies
It is easy to understand clinically important imaging data is very little as compared to the total data produced. For example, a normal chest X-ray has very limited or no clinical value after 30 days from the interpretation. A chest X-ray of the patient in cardiac ICU if normal loses value may be in 2 days. On the other hand a chest X-ray of a VIP or medico-legal case, even if normal, may have to be preserved for long.
The system has to incorporate clinical intelligence to plan the lifespan of the imaging data. In fact, without such intelligent storage planning, 2D echo tests are often repeated in most of the hospitals. Just before a procedure (Angioplasty or Surgery) review of 2D echo is highly necessary. 2D echo test is always done on a patient during OPD before the procedure takes place and it is just 2 -3 months old data. Unfortunately, lack of intelligent storage results in repeated 2D echo test. It has been observed that in a 500+ bedded cardiac super specialty hospital this could mean saving of up to 3 hours of a senior cardiologist and the machine for repeated procedure.
Clinical intelligence can be extended further to extract clinically important portion from the imaging data. This automatically highlights pathology for the consultants viewing summary. It also reduces the size of the data without losing any clinical information. Thus, iEMR reduces traffic on the data network and improves efficiency! A huge Angio loop of 250MB containing only one block reduces to 1MB as the cardiologist can store only the details about block and ignore other details which has little or no clinical significance.
The bottom line is that appropriate use of ICT technology can dramatically improve patient management and enhance the efficiency of utilization of the scarce / expensive resources through a properly structured Cardiology Information System that integrates with the Imaging Electronic Medical Records system.
All this is meaningless if it is not made affordable for the masses. While the innovations typically are aimed to bring down the cost of the solution, it is important for the healthcare sector in India to realise that the outlook towards ICT also needs reforms. We do not have to burden the treasury by putting 4-6% of the top-line on ICT budgeting like developed countries do, but we must take a call on at least allocating a modest 2-3% for ICT in India. The healthcare sector is at the point of exponential growth as discussed in most of the health conclaves today, but this transformation rests on ICT. So lets start looking at ICT as a strategic investment rather that an overhead to mainstream healthcare.