ICT and Health:

Telemedicine in Rural Philippines

PORTIA FERNANDEZ MARCELO, MD MPH

Director, National Telehealth Center

UNIVERSITY OF THE PHILIPPINES

*based from previous slide

• The Philippine Health Situation• Finding Solutions through eHealth:

– The National Telehealth Center– ONeHealth

• e-Medicine (telemedicine)

4

The Philippine Health Situation• Lower Middle Income

Country (LMIC)• 94Million, 63% live in urban

centers• Country of youths: 50%

population < age 21• Double disease burden:

infectious + lifestyle and chronic diseases

• Modest improvement in health indicators vs SEA nations- – 4th highest:

• IMR = 32/1000LB,– 2nd highest:

• MMR= 162/1000000LB

5

• Accessibility– Remote areas,

difficult to reach• Affordability

– High Out-of-Pocket expenses

– Universal Health Care → still to happen

Health Human Resource: Maldistribution of health professionals�$ *2'��-0)%-0"$��$,1(26�.$0��������.-.3* 2(-, (WHO, 2010)

MD: Philippines=12 World=14Nurses: Philippines =61 World =28But where are they?

Migration and brain drain inevitableSeek greener pastures

The Philippine Health Situation

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The Philippine Health SituationWidening inequity in healthDisparity in health service

delivery and utilization�--0�/3 *(26�-%�# 2 � ,#�(,%-0+ 2(-,Maldistribution of skilled health workersHigh out-of-pocket payment

payment (including drugs), low health expenditure by government

Food security & safety riskDual burden of diseasesDisasters, and chronic emergency in MindanaoSlow progress in maternal and child health and nutritionHigh population growth

-DOH, 2010 presented during the WHO-PHL Consultative Meeting

*based from previous slide

�(,#(,&��-*32(-,1

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Opportunities: ICT and HealthInformation and communications technology (ICT): essential infrastructure and tools, great enabler to people • for knowledge creation, sharing and dissemination.• boost the innovative capacity of all sectors and

contributes to more than 40% of overall productivity growth (EU KLEMS, 2007 in EC, 2009).

• by facilitating greater access to health and education services, and creating economic opportunities for disadvantaged groups (Daly, 2003, K. Chen, 2004, Jensen, 2007; Mercer, 2001; Oberski, 2004; Reisman, Roger, & Edge, 2001; UNDP, 2001; The World Bank, 2001 in Fong, 2009: 471-472.)

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Opportunities• Broadband infrastructure continuously

improving• Open source software becoming more

popular• Computerization is ubiquitous in all

institutions but security is certainly a valid concern– Free email groups vs. institution-based

• Increasing public awareness on the benefits of ICT

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Opportunities• According to International

Telecommunications Union 2010 Report– Mobile Phone Users per 100 population

• PHILIPPINES 100.5/100 • WORLD 49/100

– Internet Users per 100 population• PHILIPPINES 9/110• WORLD 22/100

• Philippines is the Texting Capital of the world

The National Telehealth Center

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Asia - Pacific

Philippines

Department of HealthDept. of Science

& TechnologyDept. of Interior & Local Government

National Computer CenterNational Economic

Development AuthorityNational Statistics Office

PhilHEALTHUP- National

Telehealth Center

9 Countries

LaosCambodia

FijiBangladeshIndonesiaMongoliaVietnamThailand

Philippines

�,(4$01(26�-%�2'$��'(*(..(,$1���

To improve the health of Filipinos through the optimal use of ICT

The National Telehealth Center

1* Target: strengthen the PUBLIC sector – where most of poor seek care

18

20

21

*based from previous slide

$�$#("(,$Telemedicine in the Philippines

Telemedicine in the Philippines

CICT 2004

SERVICERESEARCH

6 years of experience and collaborations with DOH-DTTBswith research support from DOST

DOST, 2008 DTTBs 2007-2011

UP Manila and UP Diliman

BUDDYWORKSProject

Telemedicine in the Philippines

CICT 2004

SERVICERESEARCH

6 years of experience and collaborations with DOH-DTTBswith research support from DOST

DOST, 2008 DTTBs 2007-2011

UP Manila and UP Diliman

BUDDYWORKSProject

GOVERNMENTleadership

ICT HealthScience

Academe

How do we do Telemedicine?

We train health workers how to use the cellphone to effectively collaborate with doctors and specialists (in their regional network).

RXBOX: undergoing field testing

UP Diliman VC Research Eng. Luis Sison PhD

& the RxBox

2006mHealth

University of the Philippines – Philippine General Hospital

27%

20%

11%

10%

9%

7%

6%

3%3% 3% 1% 1%

MEDPEDIAOBRADIO QTNDERMASURGECGMEDICO-LEGALOPTHAORLPSYCH

Total Referrals per Domain: Oct. 15, 2007 – Sept. 3, 2011

Adult medicine

Pediatrics

ObstetricsRadiology

Referrals: January – August 2011

Jan Feb Mar Apr May June July Aug0

20

40

60

80

100

120

140

Month

Num

ber o

f Ref

erra

ls

Certificate Course in eHealth & Telemedicine:

June 1-2, 2011

80% increase in useof system

Referrals: January – August 2011

● Line graph● Pie chart

Jan Feb Mar Apr May June July Aug0

20

40

60

80

100

120

140

Month

Num

ber o

f Ref

erra

ls

Sustained referrals of80 - 100+ per month

Stories of TELEMEDICINE

Teleradiology, teleorthopedics

Ortho: wash-out the antibiotic for one week then CS/debridement

Batanes: 23/M Post Traumatic Osteomyelitis

Batanes: 23/M Post Traumatic Osteomyelitis

Saved patient P8400 for one week “unnecessary” stay in Manila

Saved PGH P10,500 by asking antibiotic wash-out to be done in Batanes General Hospital instead of the PGH surgical bed

Sarangani (teledermatology): Tinea imbricata among an Indigenous People Community

Sarangani: Tinea imbricata among IP Community (teledermatology)

Message of dermatologist:

...It appears to be a lovely case of Tinea imbricata or Tokelau ringworm caused by the dermatophyte Trichophyton concentricum. This is a relatively rare dermatophytosis but is found among Filipinos in Mindanao or other rural areas. The first reported case was in 1789 by Williams Dampier-- of a Filipino from Mindanao. One early case report was on a Filipino from Mindoro (1962 MC Fernandez of PGH). A co-resident of mine CTan reported one case in the 1990s, a Badjao patient from MIndanao if I recall. You really should make a case report of your patient, and try to document any other cases existing in her community...

Batanes: 55/F sudden onset of blindness

suddenly lost sight after 'hitting a spider' she felt on her eye.

Tele-Ophthalmology

Saved patient Php 36600 in Travel/Accommodations

55/F Acute Angle Closure Glaucoma

Ophthalmologist:

Passed prescription to Batanes MHOPatient was managed conservatively in the island

Monitored remotely

Tele-Ophthalmology

MANILA (Domain Expert)

MED lm/51/f. Bp 200/110,nifedipine given 170/100, (+) chest pain, isoket given, bp 170/110..

Irregularly iregural heart rate. Whats d next

thing to do.. Thanks

11/23/2010 21:56:25 LANGIDEN,

11/23/2010 22:06:17

DB51 Ok. Could be HPNsive emergency. Just give Sublingual nitrates every 5-10

mins to relieve chest pain. Ok to give

atenolol, start with 25 mg now. Let pt rest

and observe for signs of improvement or

progresion of symptoms. WOF

neurologic signs. Tnx.

51/F Hypertensive Emergency

MED lm/51/f. Bp 200/110,nifedipine given

170/100, (+) chest pain, isoket given, bp 170/110.. Irregularly

iregural heart rate. Clear breath sounds, no neck vein distention.

Only available med here is nifedipine and atenolol, we

have to cross d abra river and travel by 30 to 1 hr b4 reaching

d hospital..noride available yet.. Hr is 59..

11/23/2010 22:15:57

11/23/2010 22:22:28

DB51 Is she congested now? Are her lungs clear

and neck veins flat?�-,2(,3$�5(2'�,(20 2$1��!$12�(%����(1-)$2�#0(..

Avoid nifedipine as it may precipitate ischemia/AMI

from reflex tachycardia. Do ECG if available.�0$ 2� 1�HPNsive emergency or

AcuteMI��#$.$,#(,&�-,�30� 11$11+$,2. May use

betablockers and Amlodipine to control HR

and chest pain if no signs of failure. Update w/ new

findings as needed. Tnx.

51/F Hypertensive Emergency

LANGIDEN,

MANILA (Domain Expert)

MANILA (Domain Expert)

Thank you po. BP is 160/80, hr is 60, hr is

still iregular. Decreased chest

pain, with generalized body weakness but no

paralysis or numbness. Thank

you po

11/23/2010 22:27:04

LANGIDEN,

40

ENT

Telemedicine Services

Feedback from DTTBs & MHOs

Very Useful Useful Not Useful0

5

10

15

20

25

DTTB/MHO Rating of DE's Response

Num

ber o

f Tel

eref

erra

ls

17

0

21

“Very useful to us dttbs esp those in remote areas where net access aren’t that gud. Responses r

readily sent so mgmt is not compromised. Very helpful since its jst a txt away and pxs are then

quickly managed.” -DTTB, Agutaya, Palawan

109 Currently Enrolled, Actively Referring Doctors

● 37 Municipal Health Officers (MHOs)

● 72 Doctors to the Barrios (DTTBs)

1,939 telereferrals

for a period of 46 months (October 2007 –

September 3, 2011)

109 Currently Enrolled, Actively Referring Doctors

234 Total Remote Doctors Served in 6 years

Where we are right now?

�(&'������0$ 1 ������(&'��-4$026���0$ 1�������������

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5 years of Telemedicine in the Philippines

• Telemedicine is possible in geographically isolated and disadvantaged areas (GIDA)

• Telemedicine is fraught with ethical, social, and legal challenges (read: should only be done by trained health professionals and certified personnel). Protocols are important.

• Telemedicine is expensive for few sites, but costs go down with more sites

National Telehealth Service Program

����������(,���������������proposed to the Ministry /��$. 02+$,2�-%��$ *2'

�$*$+$#("(,$�for 606 poor towns

��� – regular routine reports of selected indicators via cell phone from 1010 CCT (poor) towns Fresh data for DOH >>> decision making

�- "-++$,"$������ �������

National Telehealth Service ProgramFor 1st year funding: �$*$+$#("(,$�(,�����2-5,1

����%0-+�����2-5,1

Health indicators% CCT beneficiaries enrolled in PhilHealth, every month

# infants immunized (Fully Immunized Child rate) every quarter

# births attended to by skilled health professionals every month

# facility-based delivery every month

# current contraceptive users (Contraceptive Prevalence Rate) every quarter

# maternal deaths every month

# neonatal deaths every month

availability of medications from RHU and/or BnB

telehealth.phportiamarcelo@telehealth.ph