Applications of Information Technology for Health Care

This speech was presented to the Caribbean Association of National Telecommunication Organizations (CANTO) in June 2003 at their annual meeting, by Ken Bleakley, President and CEO of FONEMED.  FONEMED operates nurse advice lines from its medical call center in North America and installs medical call centers internationally.  

Broader use of tele-health services in the Caribbean region would:

• Improve the health of the regional population;

• Provide new export opportunities for health information technology services;

• Create new markets for regional telephone companies and organizations.

Regional Health

The health sector in the Caribbean faces two core demands: (a) to provide expanded and equitable access to quality healthcare services and (b) to reduce or at least control the rising costs of healthcare services. Changing demographics (particularly age structures) and lifestyles (mainly due to epidemiological profiles, urbanization, and growing industrialization) highlight the need to reorient present care models. Significant opportunities do exist to improve health status but there are still a considerable number of preventable diseases and premature deaths, both in absolute and relative terms and there is great inequity of access to basic health services resulting in regions, communities, and social groups being left without access to the most basic healthcare.

Despite the fact that the health sector is key to the welfare of the population and the formation of human capital, the sector has not kept pace with the momentum of change that most Caribbean countries have experienced in recent years in the application of information and communication technologies to other areas. All countries have embarked in some form of health sector reform. Health reform processes in the Caribbean have many facets and there is no single model being adopted by all countries. Each country is moving at a different pace in the implementation of its own particular health system model but the economic and globalization changes of the last years have brought a new urgency to the reform processes.

Advances in computer/telephone integration and the dissemination of networked data processing created a new environment of universal access to information and the globalization of communications, businesses, and services. In the health sector, this trend is exemplified by the growing consolidation of “e-health” – an area distinguished by the combined utilization of electronic communication and information technology to transmit, store and retrieve digital data for clinical, educational, and administrative purposes, both at the local site and at distance. Among leading digital technologies, Internet-based solutions are rapidly changing the way health providers, health plans, organizations, payers, regulators, and consumers, access information, acquire health products and services, deliver care, and communicate with each other.

The essence of e-health is reliable transaction delivery in a fast-changing environment involving people, processes, and a health infrastructure focused on the ill or healthy citizen. Emerging e-health applications are oriented to professional networking, integration of the clinical care process management, and the provision of Web-based health information and patient care, including remote monitoring and health care.

The “Caribbean Regional Health Study,” prepared by the Inter-American Development Bank, Pan American Health Organization and World Health Organization for the 1996 Caribbean Group Cooperation in Economic Development Meeting, emphasizes that the Health Sector contributes directly to economic development and is dependent on the informatics sector.  It notes that a series of studies, such as that of the West Indian Commission (1993), recommendations, and the report of the high level Conference on the Prospects for Service Exports, focus on “niche” markets that require high technology activities such as health tourism where the Region has a comparative economic advantage.

Nonetheless, there is a continuing gap between the potential of information technology to improve health care in the Americas and the knowledge of such technology by the officials charged with implementing programs. Studies by the Pan American Health Organization and the broadly based public/private sector Americas Healthnet Committee found over $2 billion in funds from the international financial institutions that were going unused by Caribbean and Latin American governments. The projects for health sector reform, decentralization, accountability and coordination of public sector initiatives made scant mention of the contribution information technology could make to such initiatives.

In summary, the nations of the Region could benefit from:

• Providing greater access to health care for those in remote areas through use of remote monitoring devices, on-line and telephonic physician consultations and information services.
• Connecting health care facilities internally and improving access to international centers for second opinions, consultation and learning.

New Information Technology Exports

Ambitious national and regional plans exist to increase use and exports of information services. Nevertheless, a number of factors, particularly the lack of proactive programs in the telecommunications sector to stimulate growth in the informatics industry, concerns about intellectual property, and the need for advanced training to meet the needs of sophisticated end users delay implementation.

World expenditures for information services are over $500 billion and are grew at 13% annually over the last decade.  In the major economic powers, imports of such services are growing faster than exports at some 20% per year.  The Caribbean Region provides the ideal site for outsourcing such services because of its geographic location, language, and literacy base and infrastructure.  Other areas of the world, however, have outstripped the Region in seizing opportunities in one of the greatest areas for economic growth and job creation.

The Caribbean Call Center Report prepared by the Zagada Institute last year pointed out for example:

“While India is often seen as the developing world’s benefactor of the move to offshore - growing to $U.S. 18.6 billion by 2008-2009 from its $222 million figure for 1998-99, the Caribbean is emerging as a competitive force. Corporate decision makers are finding comparable and better value in the Caribbean based on proficiency, proximity and preparedness”

There are extensive lists of inter-related opportunities in the information-processing arena. To date regional; strategies have concentrated on commercial services over the Internet, tourism, call centers, broadcast content and satellite support, for agribusiness, and the facilitation of international trade.

Health information and medical call centers can be a strong niche market for which the Caribbean already has the right mix of human resources and telecommunications infrastructure. Shortages of trained medical and IT professionals in the United States create strong demand for medical transcript services, back- office administrative processing for health care facilities, and information and call center services for the public. Export areas include:

• Hospital administration
• Home health care monitoring
• Telemedicine and distributed consultation capabilities
• Medical call center services
• Medical procurement systems
• Internet health services

However, before Caribbean Health services can penetrate the lucrative international market, they must first demonstrate their ability to deliver e-health services in their own region. Organizations such as the American Healthcare Accreditation Commission / URAC base their accreditations that are critical to winning customers, on evaluation of existing medical services. It is necessary to build the client base in the countries of the Region before their services can be accredited for export.

Creating an e-health industry in the Caribbean, therefore, will require coordinated efforts by both the public and private sector based on the three factors. First, there is an extremely high demand for training and information in the particular field of healthcare technology, but limited resources available for this purpose.  Second, there is general awareness of tele-medicine capabilities, but much less information about cost effective technologies that can have immediate impact on the population as a whole in higher priority areas such as primary care, affordability and accessibility.  Finally, international development institutions would greatly improve the effectiveness of healthcare investments by using technology in several key areas of reform.

Priority Action areas are:

Provide Better Support for Rural Health Services

Several solutions exist to provide better links between rural clinics, patients, and healthcare facilities in major urban centers. Information kiosks in remote areas linked to centers of excellence can serve broad health needs as well as providing applications in education and agriculture. Likewise, a project initiated by the Americas Health Net Committee successfully demonstrated in Costa Rica how PAHO, the OAS and the private sector could work together to link rural clinics to national hospital centers using voice data and images over existing telephone lines store and forward technology now makes it possible to transmit these digital signals by any available media from Plain Old Telephone lines through advanced broadband Internet connections. 

Re-Orient Public Health Services to address Individual Needs more directly

Call center technologies have created an affordable way to strengthen public health information campaigns by orienting services more directly towards individual needs.  Approximately 40% of all healthcare services involves a simple exchange of information with clients.  This can be done most efficiently through information kiosks that offer telephone and computer based health information services.  Individuals in rural areas may receive information through public education and awareness campaigns, but have little recourse for further information regarding symptoms, treatments, prevention, etc.  Doctors and specialists working from call centers based in urban centers can now personalize public health services by responding directly to incoming toll-free telephone calls and to queries sent via e-mail. 

Develop Better Epidemiological Trending and Monitoring Systems

Most epidemiological statistics are based on annual figures such as morbidity rates.  Most countries have little or no capability for real-time monitoring of diseases.  Many existing technologies could be used to enable real time trending and monitoring based on instantaneous reporting of symptoms. This would enable a quicker response to outbreaks and encourage a more effective allocation of government resources. 

Electronic Health Information centers produce real-time statistics as they track the number of inquiries and nature of complaints coming from the general public.  Call centers use out-bound calling services for polling, and are able to quickly respond to problems by disseminating treatment and prevention information by telephone.  Wireless technologies and the evolution of laptops and PDA’s (Personal Digital Assistants) opens up another new approach to data collection.  By tying in these data collection methods with the advanced capabilities of call centers, health officials can create an extremely effective and efficient approach to trending and monitoring systems. 

Bring Efficiency and Transparency into Health Sector Procurement

A combination of Internet technologies and the recent development of specialized software now allows governments, hospitals and clinics to rationalize procurement systems and realize significant cost savings. Group purchasing organizations such as the Eastern Caribbean Regional Pharmaceuticals Management project coordinated by the Organization of Eastern Caribbean States with support from USAID and a private foundation resulted in an average price decrease of 44% in the procurement of medical consumables for the seven participating nations. Technologies now exists to expand such programs to cover all of the Americas and to enhance the cost effectiveness of the procurement process even further through regionally hosted web portals and sophisticated analytical programs.

Problems to be overcome include:

Slow Transition within Lending Institutions

Although international lending and donor institutions have started to introduce technology into certain high profile health reform initiatives, much more needs to be done in this area.  Technology has not been systematically integrated within all phases of health reform programs. 

Mistaken Priorities - Investments Limited to Telemedicine & Advanced Care

There is a high level of awareness of telemedicine advancements across both public and private sectors in participating countries.  However trainees had very little information about less costly technology applications that are easier to implement and more directly related to regional priorities.  The focus on telemedicine directs attention on advanced medicine and doctor-to-doctor consultations on individual cases, at the expense of higher priority issues of public health and basic access to primary and preventative care. 

Include Healthcare in Public Internet & Connectivity Initiatives

Ministries of Health should provide a major health component to broader government Internet and connectivity initiatives.  Many countries have major programs underway to deploy computers with Internet connectivity in schools and to construct information “kiosks” for public use in rural or underserved areas.  However connectivity is only as helpful as the content it provides.  Access to health information and services should be a major focus of such initiatives.  Internet portals should direct users to health information resources.  Portals should tie in directly to medical call center services so that individuals can supplement Internet resources with more direct advice and counsel provided by professional health practitioners via telephone. 

Regular Training & Information for Health Reform Officials

A formal, regularly scheduled program of information and training programs should be required for staff and senior directors at the various international lending institutions as well as for the senior and mid-level government officials involved in project development and implementation within the region.  The “private / public cooperation on training” initiative sponsored by the OAS/IACD is a good model and should be expanded to meet these objectives. 

Follow Up Training Programs with Pilot Projects

Training programs should lead into greater levels of public/private cooperation, such as the joint implementation of pilot projects and demonstration activities, and the cross-border exchange of expertise and experiences.  Program participants should be given support to initiate demonstrative and pilot projects.  Governments and international organizations should aggressively encourage private sector cooperation in such projects as a tool through which to jump-start further investments.  Pilot projects often lead to continued private sector investments as demand for certain technologies is revealed. 

In summary, the economies of the Region could benefit from:

• Provision of remote monitoring and trending services for devices installed by home health care agencies abroad.
• Offering transcription and other support services to medical practices abroad.
• Staffing health Information centers providing information and advice by telephone and Internet to international clients.

Opportunities for the Regional Telecommunications Industry

Along with the governments of the Caribbean, the members of CANTO and of the private technology sector need to be come more proactive in developing the information services technology industry in the Region.  We all know that, in addition to providing capital, private investment also stimulates development of new technologies, equipment, services, new sources of information, and managerial skills, which will expedite infrastructure growth and improvements, increase efficiency in the provision of services, and create greater responsiveness to customer needs.

A private sector plan of action prepared for the Senior Telecommunications Officials Meeting as part of the Summit of the Americas process includes the following:                 

“The private sector encourages the STOs to launch or expand pilot projects that can apply communications and information technologies to current problems.  This support starts by reaching out to other sectors to understand their needs and to adjust telecommunications strategies accordingly.  In addition to establishing a viable commercial and legal environment, the private sector believes that government must encourage the development of these technologies, not as ends in themselves, but as a means to demonstrate the ability of technology to deliver the Summit goals.”

The industry needs to take heed of that message. If the private sector does not take the lead in stimulating demand for its services, we can hardly expect government to do it alone. We can expect the continuing diversion of Information Technology telephone traffic to areas of the world that are providing a more hospitable environment for these lucrative services.

Telecommunications and Information Technology companies have much to contribute and much to gain by supporting tele-health initiatives.  These initiatives provide a new market for voice and data transmission and demonstrate the value of telecommunications to meeting national social and economic objectives.

For example, Eight Caribbean call centers, two technology providers and two integrators recently announced the launch of the Sphaero Alliance (sphaeroalliance.com).   The Sphaero Alliance seeks to meet the increasing demands by corporate decision makers in the United States who are finding significant value in the Caribbean in regards to call center requirements, based on level of proficiency, preparedness in its peoples and the added bonus of geographic proximity. The alliance plans to provide a reliable platform for managing RFP proposals and securing contracts.

Specific applications of higher- end call centers include Medical Call Centers that can serve as the focal point for useful applications of information technology to the telehealth sector. Effective personal health management relies on proven medicine, highly specialized technology, and synergistic expertise to improve health and sustain a competitive advantage.  All three can be provided efficiently and effectively though a Medical Call Center.

A Medical Call Center is an accessible, cost-effective resource center where trained medical professionals take calls from health plan members, patients, employees or citizens who want professional health care advice, information, and placement in the medical treatment system.  After talking together, a medical professional uses judgment and clinical algorithms to evaluate the caller’s needs. The professional then directs the caller to the right care resource or information This versatile telephone-based “triage” process may include directions for self-care at home or referral to a physician office, urgent care center or emergency room. Individuals may access large audio libraries of pre-recorded health information, or receive printed health information by mail or fax.

Call Center developers such as FONEMED Global Health Services are offering interested organizations in the Caribbean the opportunity to join with them in providing state-of-the-art medical centers to populations in the Region.  They provide turnkey packages and follow-on support needed to operate medical call centers and provide cost effective solutions to enhancing access to health care.  Potential clients include government agencies, hospitals, clinics, insurance companies, and health maintenance organizations, as well as companies and individuals wherever long distance telephone charges do not prove prohibitive.

Inaction on the part of Caribbean governments and companies to develop programs in the e-health area cannot be attributed to the oft-cited lack of financing. In addition to the traditional international financial institutions and regional organizations such as the OAS and Pan American Health Organization, foundations such as the SUMMA Foundation in Washington DC have expressed their interest in providing attractive financing for tele-health projects. 

In conclusion, health information technology provides a means to improve the well being of the citizens of the Caribbean and to create a new source of information technology exports for the Region and for the companies involved. The companies and government representatives present today need to seize the opportunity offered by international companies and financial institutions that want to partner with them in this endeavor.

About FONEMED

FONEMED® uses communications technology to provide individuals with round-the-clock, telephone or web-based access to medical advice, information, products, and services. It provides outsourced nurse triage services from its North American Medical Call Center. It also supplies qualified national and international partners with the tools, technology, and know-how to operate proprietary Health Information Centers as either installed systems or with concession agreements. For more information, visit www.fonemed.com or call 1-800-FONEMED.