The US Commitment to Global Health Innovation Working Group Meeting ehealth for Resource Poor Environments

Transcription

1 The US Commitment to Global Health Innovation Working Group Meeting ehealth for Resource Poor Environments 3 April 29

2 Focus of health investment should be on improving sector productivity Level of HC spending directly proportional to GDP/capita regardless of external funding Healthcare is an inefficient sector, can improve productivity through technology Log of health spend per capita (25) 4 R 2 = Log of GDP PPP per capita (25) Baumol's cost disease: Labor intensive services, such as health care, face productivity lag - cannot substitute capital for labor as efficiently as the general economy, so the cost of producing them goes up faster than general inflation 5 ways to improve productivity: 1) Increase capital per worker 2) Improved technology 3) Increased labor skill 4) Better management 5) Economies of scale as output rises The most effective way to improve productivity is to improve health systems Source: Nicholas C. Petris Center on Health Care Markets & Consumer Welfare (UC Berkeley), WHO 1

3 Effectiveness of health spending widely variable Health outcomes not tightly linked to income level Log GDP/Capita (PPP) vs Childhood (<5) Mortality Childhood (<5) Mortality (per 1) Kenya Rwanda Cambodia Countries with similar profiles with very different health outcomes 5 R 2 =.61 Vietnam Log of GDP PPP per capita (25) Variation in health outcomes highlights considerable room for improvement of inefficient and ineffective health systems Source: WHO 2

4 Effective health care delivery captures the value of integration Health care delivery system Public health organizations, governments, R&D, donors Prevention Access Diagnosis Delivery Monitoring Reduce need to access health care providers Support PH underlying prioritization and policy setting Patient ability to enter healthcare system once intervention needed (financial means, logistical access) Identifying underlying condition and needed intervention Catering diagnostics for regional needs Administration of medical care Reduction of health care expense for populations Tracking health of patients, populations and compliance with treatment regimens Tracking efficacy of new treatments Rockefeller criteria Efficiency Relative population health improvement for each dollar invested Equity Ensure good health outcomes are shared by entire population regardless of income or education Quality Relative effectiveness of healthcare system and medical interventions Source: WHO 3

5 ehealth can optimize improvement of efficiency, equity, and quality easing troublesome tradeoffs Equity ehealth provides greater access through broader reach, so underserved populations gain access Telemedicine provides access to experts in underserved populations Ability to track health outcomes allows donor orgs to make informed funding decisions HC information provided through alternate channels (kiosks, druggists) to reach additional populations Efficiency ehealth leverages scarce expertise and technology, automates manual tasks, measures outcomes so system can be continuously improved Online training for practitioners trains more at lower cost Electronic inventory tracking can increase availability of preventative care (e.g. treated bed nets) Telemedicine lets fewer experts serve larger populations ehealth Quality ehealth improves quality of care, adherence to standards SMS reminders shown to improve drug regimen compliance Best practice HC information available to practitioners online Universal access to patient info facilitates more effective treatment Practitioners have improved access to technology, research, support 4

6 Necessary ICT infrastructure for ehealth growing quickly in Global South... Internet users (per 1 inhabitants) Internet users in Africa Users per 1 inhabitants CAGR ( - 6) = 42% No data Annual growth 38% 64% 47% 49% 49% 31% Mobile phone subscribers (per 1 inhabitants) Mobile phone subscribers in Africa Subscribers per 1 inhabitants CAGR ( - 6) = 48% No data Annual growth 6% 43% 4% 47% 65% 36% Source: International Telecommunication Union, World Bank WDI, WHO 5

7 ...and 1, flowers blooming from local to global levels Broad range of initiatives, but few EHR-type interventions at scale of Northern implementations Global / Regional Health Metrics Network WHO GoE GOARN Weekly EPI Record (WHO) NEDSS (CDC) Antimicrobial inform. bank FluNetand RABNET APEC EINET Health InterNetwork (US) Roland Koch Institute Country / local Prevention Access Diagnosis Delivery Monitoring Source: BCG research Web based clinical information system for researchers PIH-EMR electronic medicalrecord supports TB and HIV Regional HIV data center SICLOM delivery ARV treatment elearning to train nurses HIV-EMR system HAN (CDC) HealthNet info network (8) Patient vaccination records HealthNet info network (6) EMR for AIDs and TB care (2) Uganda Health Information Network (UHIN) EMR for AIDs and TB care (2) HealthNet info network Teledermatology District public health tracker GENNET forum for gender issues On Cue SMS drug reminders for TB patients... and many more HealthNet Eritrea for health information HealthNet info network Telemedicine diagnosis Assess availability of HIV/AIDSrelated services Careware medical record system for HIV treatment AMREF remote clinical diagnosis by specialists EMR for AIDs and TB care Mosoriot medical record system HealthNet information network (2) EMR for AIDs and TB care (2) HealthNet information network (3) EMR for AIDs and TB care Cell-Life clinic workers remotely monitor health patient problems HealthNet information network Antiretroviral Therapy Information System (ARTIS) Monitor Vitamin A distribution Voxiva disease survelliance system in Tamil Nadu Remote eye diagnostics East Bhutan Tele-ECG Telediagnostics AMREF remote clinical diagnosis by specialists Sample demonstrates wonderful progress, but significant fragmentation HealthNet info network Register for immununization tracking HealthNet info network Hospital Management Software for rural hospitals HealthNet info network (2) Telepathology 6

8 Selected initiatives offer proof of unique ehealth value in strengthening Global South health systems Initiative type Implementation Impact 1 Point of care support Remote eye clinics, Aravind Eye Hospital, India Increased equity eye care is typically too far for those in rural villages to access, but made available via remote eye clinics connected via wi-fi and webcam 2 elearning for medical providers elearning program to train nurses, Kenya Improve efficiency in training process, >2x faster and 2x cheaper than traditional methods Improved equity in healthcare access: more health workers in remote, rural, marginalized areas Improved quality of overall care by increasing quantity of skilled providers in HR-constrained Kenya 3 Patient support On Cue: SMS reminders for TB patients, South Africa Improved quality: near-perfect compliance on drug regimen Improved efficiency: SMS reminders cheaper than DOTS method, with higher compliance rates 4 EMR, EHR, PHR Mosoriot Medical Record System (MMRS), Kenya Improved efficiency in clinical operations Higher quality care: Increased ability to provide relationshipand patient-based care More equitable care: Ability to proactively vaccinate those with low access to care 5 Inventory management Supply information system, South Africa Increased quality in treatment 39 percent reduction in stockouts of essential drugs 6 Disease and intervention surveillance Uganda HealthNet: data collection on bednet usage via PDAs Improved efficiency of data collection faster via PDAs Improved quality of data due to reduction in errors 7

9 2 elearning easing healthcare HR crisis in Kenya Similar results from PROFAE initiative in Brazil In Kenya, chronic shortage of highly skilled nurses Promising progress since start of program in Sep. 25 elearning can reach goal w/in next decade versus >2 years w/ traditional classroom methods Enrolled Nurses (ENs) comprise 7% of nursing and 45% of the health workforce in Kenya First point of contact for communities, but are inadequately skilled to manage new and re-emerging diseases like HIV/AIDS (K) 25 2 elearning vs. traditional methods for upgrading ENs 22, ENs to upgrade ~2,8 ENs upgraded/yr., cost ~ $2.5M PPP led by the Nursing Council of Kenya (NCK), the African Medical and Research Foundation (AMREF) and Accenture to upgrade 22, ENs from enrolled to registered level within 5 years via elearning (distance education through ICT) methods As of Nov. 26, 3,265 nurses upgraded 27 colleges and schools participating including AMREF s Virtual Nursing School Over 1 computer-equipped training centers set up in 8 provinces, including remote and marginalized districts elearning Traditional classroom method ~1 ENs upgraded/yr., cost > $5M 2225 Source: Source: WHO, AMREF website Results do not just represent dramatic cost and time improvements over status quo, they are nearly impossible without use of ICT 8

10 3 On Cue SMS reminders for TB patients in South Africa illustrates potential improvement in compliance... On Cue : 22 project in South Africa sending SMS reminders to TB patients for drug regimen compliance Evidence suggested that TB patients often do not take their medication simply because they forget Most widely used treatment method Directly Observed Treatment, Shortcourse (DOTS), involved direct observation of patient taking medicine to ensure compliance an expensive and resource-intensive method that is not 1% successful On Cue Compliance Service designed to improve compliance at lower cost: database of 138 patients taken at pilot clinic, SMS messages sent out every half hour to remind patients to take medicine As of Jan. 23, the city of Cape Town paid $16/patient/yr for SMS reminders In pilot, only 1 patient out of 138 was non-compliant (99.3% compliance rate) % Potential impact of SMS reminders for TB patients Died Unable to be evaluated Non-compliant Compliant Assuming 99% 7.4 compliance rate with SMS Do not have reminders cell phones DOTS Treatment Outcomes Have cell phones Non-compliant patients with cell phones Non-compliant "converted" to compliant with SMS 78.9 DOTS treatment outcomes with SMS reminders Source: Bridges.org, WHOSIS, WHO Global Tuberculosis Control report Status quo Potential impact 9

11 3...which could result in significant TB mortality reduction over time in South Africa One benefit: Potentially significant TB mortality reduction Cost is low, costeffectiveness ratio favorable # people 12, 1, 8, 6, 1,673 5% of untreated patients eventually die from TB 5,337 72% of South Africans have cell phones 99% compliance rate with SMS reminders in pilot ~242, DOTS patients/year ~$16 per patient per year for SMS messages Country cost of ~$3.9M per year for South Africa 4, 3,842 3,84 This equates to ~$1 per death averted 2, Non-compliant DOTS patients Deaths due to noncompliance Patient cell phone coverage Deaths averted In steady state, this represents an 11% decrease in annual mortality due to TB in South Africa (currently ~34,/year) One TB death equates to ~2 DALYs Thus, cost-effectiveness ratio of the intervention, without considering other benefits, is ~$5/DALY Other benefits include increased efficiency due to lower cost of treatment, reduced morbidity and building of capacity and infrastructure for other SMS-based interventions Source: Bridges.org, WHOSIS, WHO Global Tuberculosis Control report, Disease Control Priorities Project, Journal of Epidemiology and Community Health 1

12 4 MMRS improving healthcare personnel capacity in Kenya... MMRS, electronic HIV/AIDS medical records for rural clinics in Kenya, has improved efficiency of clinical care Patient visit time reduced by 22% Patient waiting time reduced by 38% Provider-patient time reduced by 58% Clinical personnel-patient time reduced by 5% Clinical personnel interactions with each other reduced by 66% Monthly reports for the Kenyan MoH, which previously took 2 weeks to prepare are now routinely prepared in an hour MoH now ranks Mosoriot center first among all Kenyan health centers in terms of speed, accuracy and completeness of monthly reports Cost per MMRS HIV/AIDS patient = $25/yr, vs. Cost per PEPFAR HIV/AIDS patient = $15/yr Source: Informatics in Primary Care(25), WHO In resource-constrained Kenya, these improvements could translate to dramatic benefits for HR capacity Physicians and Nurses per 1, Nurses Physicians Potential total with ehealth Kenya 1.5 Low income 3.1 Lower mid income 4.5 Upper mid income 11.2 High income Assuming similar results at all other healthcare facilities in Kenya, transitioning from paper to electronic medical records could effectively double healthcare HR capacity 11

13 4...and allowing transformation to evidence-based management of health MMRS EHR data allowed for proactive care delivery Kenya lags others in vital childhood immunizations Kenyan vaccine coverage has declined and stagnated Two patterns of care noticed on MMRS reports: Cluster of STDs in one village team of nurses dispatched to investigate Team was able to identify and treat individual that was responsible for spreading disease Lack of child immunizations in another village nurses dispatched to village, 6 children immunized Potential for broader implications % % % DTP3 vaccine coverage (25) Kenya Low Lower middle Upper middle High Measles vaccine coverage (25) Kenya Low Lower middle Upper middle High Income level averages Income level averages HepB3 vaccine coverage (25) 94 9 Kenya Low Lower middle Upper middle High Income level averages % Historical vaccine coverage, Kenya 1987 DTP3 Measles HepB Potential for EHR system to catalyze increase in vital childhood immunizations? 12