48
ICT and Health: Telemedicine in Rural Philippines PORTIA FERNANDEZ MARCELO, MD MPH Director, National Telehealth Center UNIVERSITY OF THE PHILIPPINES
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
6
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
8
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.)
9
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
10
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
13
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�������������
45
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
