Proposal: Implementing a Telemedicine Program for Rural Areas in Saudi Arabia

Prepared by Mohamed AlkherbFor any questions, please email: arealeader@gmail.com

OutlinesI. BackgroundII. Benefits of TelemedicineIII. Barriers to Health Care Access:A. TransportationB. DistanceC. Regional variations & Rural and urban areas inequalitiesD. Other barriers in rural areasIV. The Proposed Program:A. Step 1: Defining the proposalB. Step 2: Identifying the causesC. Step 3: Prioritizing the causesD. Step 4: Deciding the program servicesE. Step 5: Designing the programF. Step 6: Implementing Security and Privacy measurementsG. Step 7: Program MaintenanceV. Challenges and Solutions of the ProgramVI. RecommendationVII. Conclusion

Background:The use of telemedicine was facilitated when the telephone was invented in the nineteenth century. In 1906, Einthoven transmitted electrocardiogram (ECG) tracing via telephone lines, which is one of the earliest recorded utilization of information communication technology in telemedicine (Hjelm & Julius, 2005). By the 1930s, specialist medical centers received medical information that were transmitted from remote regions of Australia and Alaska. Advances in television and video conferencing resulted in the adoption of telemedicine in consultations and patient monitoring with the invention of the television in the 1950s (Murphy & Bird, 1974). In 1960s, National Aeronautics and Space Administration (NASA) implemented and used modern telemedicine during manned space flights for remote physiological monitoring of astronauts, which is perhaps the earliest utilization of modern telemedicine (Zundel, 1996). NASA continued to develop telemedicine solutions with the development of the Space Technology Applied to Rural Papago Advanced Health Care (SARPAHC) project conducted in Arizona, USA, in 1972. This STARPAHC project used a van that is equipped with an X-ray machine and other medical devices as well as two employed paramedics. This van was connected by two-way microwave transmission to the Public Health Service Hospital that is linked by a clinic in a different area, which has a physician assistant linked to the control center in the hospital (Freiburger, Holcomb, & Piper, 2007). NASA also established the first international program to use telemedicine after the 1988 earthquake disaster in Armenia, which is known as the Spacebridge to Armenia that enabled interactive telemedicine consultation between healthcare centers in the United States and Armenia (Doarn & Merrell, 2011). By the 1970s, a research studying the reliability of telemedicine via satellite communication to 26 sites in Alaska, USA was funded by the National library of Medicine. With the continuous improvements in telecommunications technology, there were advances in network infrastructure that contributed to enable the development of high-definition real-time interactive video-conferencing networks such as LiveCity project. These resulted to increased research since the 1990s and increased use in telemedicine during the past 40 to 50 years (Mencl et al., 2013).It is not surprising that interest in the utilization of telemedicine is growing with increasing access to high-speed technology and a vast number of reports of success with different models ("Canadian Telehealth Report," 2013; Rada, 2015). However, for over 40 years being around, the making use of telemedicine has been slow. The major barriers to its implementation have included issues regarding privacy, logistics, cost, reimbursement, and insufficient evidence supporting its use (Rada, 2015; Sikka N, 2014).Benefits of Telemedicine:Telemedicine can be divided into three main categories for application. The first category concerns patient monitoring or home care that allows healthcare providers to remotely monitor patients by utilizing several technological devices, such as heart rate monitors. It is mainly used to manage chronic diseases such as diabetes and heart diseases. The second one consists of applications that allow interactive or real-time communication technologies delivered using internet between users. This includes teleconsultation, video-conferencing, telerehabilitation, and similar applications. The third category consists of store-and-forward applications that may not include real-time interaction. This allows health care providers use technologies such as teleradiology or telepathology to remotely receive medical data such as medical images and lab results for assessment ("American Telemedicine Association. Telemedicine/Telehealth Terminology.," ; Sachpazidis, 2008).The importance of telemedicine is increasing, whether for distance diagnosis or intervention. There are many advantages in the diagnostic use of telemedicine. It offers the expertise and specialized care to remote population, it reduces overcall costs and waiting times of preclinical and clinical examination, and it enables the performance of accurate screening. Diagnostic telemedicine is heavily relied on in some clinical specialties such as cardiology (Postuma & Loewen, 2005). In addition, other applications are used. For example, telemedicine can be used to accurately diagnose and treat skin diseases occurring at sea and needs immediate care (Lucas, Boniface, & Hite, 2010).In rural areas, telemedicine has many potential applications. One way is that it provides the ability to access a healthcare provider remotely, and this improves access to health care for patients who have difficulties to travel long distances to receive the same care. In addition, it delivers care to patients who would forego care because of some reasons such as lack of transportation resources. Furthermore, telemedicine can provide an effective alternative for appointments that do not require physical presence. If the quality of provided care is the same as the quality of services provided in cities, cost and burden are saved for patients (HRSA, 2015).Barriers to Health Care Access:Even though access to healthcare is known internationally as a major human right (Grad, 2003), many areas still experience inadequate population access to health care services (Armstrong, Gillespie, Leeder, Rubin, & Russell, 2007; Joyce, McNeil, & Stoelwinder, 2006). Globally, rural areas and remote communities are usually known to be the most highlighted groups who need health care because of their usual poor health status (Saihw, 2015), face many access obstacles to health care services. For many rural and remote populations around the world, the most critical issue is access to health care due to several barriers (Strasser, 2003). In Saudi Arabia, geographical barriers to access health care services may include three identified aspects: transportation, regional variations, and inequalities between rural and urban areas. Several actions should be made to mitigate the costs, reduce/eliminate travel burden, or ensure the availability of healthcare facilities (Kronfol, 2015).Transportation:Transportation can be an important issue for people who rely on public transportation, such as the Saudi bus network, to access healthcare. In particular, this is a major issue in rural areas. Furthermore, people with disabilities need more assistance to arrive at health care centers (Manfred Huber & Elisabeth Jelfs, 2008). Costs of transportations, availability of buses, and the ease of boarding in some areas can be a concern for some people. This is an issue especially for the older population (Foster, Dale, & Jessopp, 2001; Stark, Reay, & Shiroyama, 2002).Distance:Another barrier to access health care is distance (Smith & Peter, 1998). This is an issue including transportation arrangement, and if the health care clinic have early closing hours, which may be a barrier for people (Dixon-Woods et al., 2006; Smith & Peter, 1998). Distance have an impact on preventive services such as screening, which appears to greater issue than curative treatments, particularly where follow-up treatments are needed (Haynes, 2003; Smith & Peter, 1998). In the more disadvantaged groups, it should be noted that car ownership is limited.People with disability have very specific needs to access health care facilities and access to information (Dixon-Woods et al., 2006). For example, in some scenarios it is important to guarantee that health care facilities are easily accessible for patients on wheelchairs, or that leaflets or other sources of information are available in convenient formats for people with visual impairments (Kronfol, 2015).Regional variations & Rural and urban areas inequalities:Rural and urban areas inequalities in access to health care facilities are an imperative issue. This is especially because rural areas often have a more fragile economic and demographic situation compared to urban areas, with more poverty and social isolation risks for people living in rural areas (Boutayeb & Helmert, 2011). Furthermore, it has been shown that some people who live in rural areas may have health beliefs that may result in late appearance and delay early treatments with health care facilities (Boutayeb & Serghini, 2006).Other barriers in rural areas:Other small research have studied patient satisfaction with health care facilities and services in Saudi Arabia. These studies were mainly focused on the primary healthcare centers of the Saudi Ministry of Health. Among those studies, most of them concluded a high percent of patient dissatisfaction. The main negative factors that mostly impacting patients satisfaction were regarding facility characteristics, including distance travelled, lack of specialty clinics, confidentiality measures, facility working hours, waiting time, and waiting area structure. As for staff characteristics, most issues include surgeons services, language barriers and communication about health status with physicians. As of patients characteristics, females and the educated patients appear to be more satisfied than males and more educated users, respectively (Al-Doghaither, 2005; Ali & Mahmoud, 1993; Haran, 1999).

Step 1: Define stage:Domain:The total population of Saudi Arabia is over 30 million, with around 5 million of them living in rural areas (Geohive, 2015). There are 270 hospitals; most of them resides in the large cities such as Riyadh (MOH, 2014).Problem statement:In the past years, many patients in rural areas in Saudi Arabia are facing increasing need for quality healthcare at a time when access is difficult. In addition, physicians and other healthcare providers who work in rural areas are not qualified enough to properly diagnose some advance illnesses. As a result, the patients satisfaction rate has been significantly declined (Al-Doghaither, 2005; Ali & Mahmoud, 1993; Haran, 1999).Goal statement:Provides a solution to enable patients who live in rural areas in Saudi Arabia to easily access healthcare services, receive accurate diagnosis, and high-quality health care services. The objective is to increase patients satisfaction rate by eliminating or mitigating the problem.Step 2: Identifying the causes:Figure 1 is a visualization tool was used to identify the root causes that led to high patients dissatisfaction rate. This tool is typically used in Six Sigma methodology to summarize the potential causes for a problem and make it easy to brainstorm or organize the reasons that led to an effect. Although this project is not directly related to Six Sigma, it is utilized here to analyze and find out the possible root causes of the patients dissatisfaction and put them into categories. Figure 1 shows the brainstormed factors and barriers that led to patients dissatisfaction rate in rural areas in Saudi Arabia. The main skeleton consists of four major categories 1) human (such as service provider and patients), 2) organization (such as clinic or hospital), 3) material (such as cars, equipment and supplies), and environment (such as nature and weather). Each one of these categories has the causes that is can be listed under this category.Figure 1: Developed Fishbone diagram:

Category: Human Lack of specialty: some physicians and other healthcare providers are not specialized in in an area of care or are not board certificated. Limited experience: some physicians may lack the necessary work experience. Limited education: some physicians and other healthcare providers may not be qualified enough to treat advanced illnesses. Language barriers: patients may be unable to express their health status clearly or do not understand physicians due to accents or languages.Category: Organization Lack of clinics: some rural areas do not have healthcare centers or very limited clinics. Limited working hours: healthcare providers may not be available in both shifts. Workforce shortages: most healthcare facilities are understaffed. Long schedule time: patients wait for unreasonable time to see their physicians.Category: Material: Limited medical equipment: physicians need advanced equipment to analyze data. Limited IT equipment: there may be a lack of computers. Absence of EHR: patients may find difficulties to share their health records due to missing papers or not implementation of electronic health records system. Lack of transportations: patients may be unable to transport to clinic.Category: Environment Distance: clinics may not be available to travel within a reasonable distance. Rough roads: the roads in rural areas may not be suitable for patients to travel. Extreme weather: summer can be a barrier due to extreme hot weather in Saudi ArabiaStep 3: Prioritizing the causes:After identifying the potential causes of the high patients dissatisfaction rate, the next step is to prioritize the causes of the problem. Because each cause may not be as important as others, it is important to conduct an assessment for the causes to know the importance of each one. This will allow us to focus the majority of time and effort on the most important issues.A methodology that is typically used to conduct Risk Assessment in organizations is utilized here to prioritize the causes. This methodology considers two factors to determine the priority rating: impact level and probability (or likelihood). In this assessment, numbers are used to express the level of each factor. Figure 2 shows the meaning of each number that will be used in the assessment:Figure 2: Impact level and probability rates explanation:Impact level (Consequences)Probability (Likelihood)

3. Highly prevents access to healthcare3. Very Likely

2. Somehow prevents access healthcare2. Likely

1. Do not prevent access healthcare1. Unlikely

To determine the priority rate, a formula will be used:Impact level x Probability = Priority rateFigure 3 shows the priority rate descriptions after applying the formula:Figure 3: Priority rate explanation:Priority rateDescription

6 to 9 (High)Solving the cause is very important.

3 to 5 (Medium)Solving the cause is important.

1 to 2 (Low)Solving the cause is preferred.

In figure 4, the identified causes will be filled in a table and analyze each cause individually to rate the priority. In addition, it will be organized based on the calculated priority rate. This table is based on research and literature. The impact of each issue has been analyzed individually with two questions. What is the impact this issue has done to the patients based on the research and literature? Is it possible that it could prevent them from accessing health care? If yes, to what extent? These questions led to the impact score. To analyze the probability, a question has been asked. What is the likelihood of this impact to occur? Does it happen frequently, occasionally, or rarely? Answering this question led to the probability scores. Both impact level scores and probability scores have been distributed in Figure 4 based on research and literature.Figure 4: Developed Impact level, probability, and calculated priority rates based on research and literature:IssueImpact level (1-3)Probability(1-3)Priority Rating(Impact x Probability)

Human:

Lack of specialty339 (High)

Limited experience236 (High)

Limited education236 (High)

Language barriers122 (Low)

Organization:

Lack of clinics339 (High)

Limited working hours224 (Medium)

Long schedule time122 (Low)

Workforce shortages122 (Low)

Material:

Lack of transportation339 (High)

Absence of EHR339 (High)

Limited medical equipment224 (Medium)

Limited IT equipment224 (Medium)

Environment:

Long distance339 (High)

Rough roads122 (Low)

Extreme weather122 (Low)

Step 4: Deciding the program services:Based on the found priority rates in Figure 4, a telemedicine program will be developed to be used in rural areas in Saudi Arabia and to addresses the identified causes accordingly in order to provide better healthcare and receive improved patient satisfactions in these areas.The proposed telemedicine program will deliver health care service at home. An ambulatory car will be equipped with IT and network equipment. This car will use a Satellite connection because even if the area does not have broadband internet, the healthcare provider will still be able to connect via satellite, regardless if there are implemented cables or not. This car will reach patients in need to these services at home and deliver them. A trained healthcare provider will assist the patient, gather the data, and connect the patient to the proper physician. The physician will remotely provide treatment and/or consultations to the patient and document the visit. The benefits of the proposed program include:Offered services: Provides healthcare in rural areas even if clinics may not be available. Access to specialized healthcare services and consultations to patients. Patients will not travel, and will receive healthcare services at home. If needed, translator will be available for communication with physician. Data will be analyzed with advanced medical equipment in a timely manner. Access to national Electronic Health Record system will be available. The program will use interactive video-conferencing technology to deliver healthcare services. The program will provide training skills for maintenance. The program is reliable, secure and deliver a user-friendly experience.Impact: Improved access to healthcare & specialists. Increased patient satisfaction with care Improved health status of the population in rural areas. Improved health related quality of life. Reduction in emergency room utilization. Improved clinical outcomes Reduction in workload for healthcare centers in the surrounding areas. Cost savings.Step 5: Designing the program:After deciding the services the program will offer and providing the impact of these services, the next step is to identify the project cycle, including requirements, activities, and the outcomes. Again, a tool called SIPOC is adopted from Six Sigma methodology and adjusted for this program and used here to design the process map. A SIPOC diagram is a tool used to identify all relevant elements of a process development project before work begins. Figure 5 shows the developed SIPOC diagram for this proposed telemedicine program. The input represents the requirements that is used before the process starts. The activities briefly show the process of this project. The output shows what are the products of this process Finally, the outcome shows what are effects of these products.Figure 5: Developed SIPOC Tool:

After identifying all the relevant elements for this telemedicine program and developing the SIPOC diagram (Figure 5), a detailed technical workflow diagram is needed. This detailed workflow diagram is needed to show the internal process of the proposed telemedicine program. Therefore, Figure 6 has been developed to provide this technical map.Figure 6 shows the developed internal workflow of this proposed telemedicine program. The following steps are shown: Level 1 care: The ambulatory car uses satellite network to connect. It is equipped with IT infrastructure & network, medical equipment, a healthcare provider and patient. This ambulatory car is linked to the closest primary care facility, which includes a physician and equipped with IT infrastructure & network. Both of the car and primary care facility are connected to the same network and Electronic Health Records system. Level 2 care: If the physician was unable to diagnose the patient due to limited qualifications, the primary care facility will proceed to level 2 care, which transfers the connection to a regional hospital, which has several physicians and healthcare providers. Level 3 care: If the regional hospital was unable to diagnose the patient and required specialized care, then the hospital will proceed to level 3 care, which transfers the patient to a specialty hospital. This specialty hospital is also connected to several other specialty hospitals in order to continue the cycle until a qualified physician virtually meets the patient. All the linked hospitals in this program are connected to the same satellite network and Electronic Health Records system. Figure 6: Developed internal workflow for the proposed telemedicine program for rural areas in Saudi Arabia:

Step 6: Implementing Security and Privacy measurements:The proposed telemedicine program is HIPAA compliance:Although Saudi Arabia does not have security and privacy law for health information (at least for now), the proposed program is in compliance with HIPAA law in order to demonstrate a high privacy and security level for this program. Patients privacy is in top priorities and all the conversations are fully secured and confidential. The highlighted areas in the Privacy Policy of the proposed program could be summarized as following: A detailed consent will be provided prior conversations. No other entity will be able to access the conversation between patient and therapist. The conversation will not be recorded or retained. The conversation will not be shared with non-covered entities. Stored ePHI will not be shared with non-covered entities. The conversation and ePHI are fully encrypted at-rest and in-transit with strong encryption algorithm. More detailed policies are included as well to protect patients security and privacy.Step 7: Program Maintenance:In order to ensure program usability, a training program will be developed for the health care professional. This training program will provide healthcare providers who work in the ambulatory cars with the necessary skills to operate, maintain, and troubleshoot the system. If the interactive video-conferencing between the patient and physician interrupted for some reason, the healthcare provider will be able to fix the issue. In addition, the program will include basic troubleshooting help, answers to frequently asked questions, and a phone number for technical support department in case if any additional help is needed.To evaluate usability, a basic survey will completed by both the patients and the discharging healthcare providers. This survey will evaluate patients satisfaction rate and evaluate whether it meets the causes assessment and goal statement provided in the previous steps of this project.If the survey result did not meet the desired objectives, the product will be sent to the quality management department where they can start the refinement process. They will identify, measure, analyze, improve, and control the products process and generate a report to apply their work. This report will be passed to several departments for approval and make sure that it addressed the issues facing the patients.Challenges and Solutions of the Program:Despite the advantages of the proposed telemedicine program, it does have some limitations. The healthcare provider will not be able to conduct a physical exam on the patient. Therefore, it limits the ability to assess the patients health status. In addition, the satellite internet may not be perfect for use all the time. Some areas may experience interruptions due some factors such as conflicted signals with other devices or inappropriate weather. Finally, the patient may not be used to this technology and may not accept a treatment from distance.As stated in the previous steps, the program will provide solutions to mitigate these issues. The proposed telemedicine system is extensible. The ambulatory car has medical equipment connected in it. Some medical equipment will be connected to the computer via USB or Bluetooth, others will be used by the healthcare provider in car to assist the patient. In addition, the gathered data will be shared with the physician for assessment.Furthermore, if the internet connection is interrupted, the healthcare provider in the car is trained to provide troubleshooting and fix the problems. If this issue was not fixed, then the healthcare provider can contact the technical support department for further assistance. This will provide the best possible solutions to maintain a stable connection between the physician and the patient.Finally, if the patient is not used to telemedicine systems, the healthcare provider will be there to guide him/her. From the time the provider arrives at patients home to discharge, the patient will be with the healthcare provider and be carefully guided. This will enable the patient to accept this system and improve overall patients satisfaction rate.Recommendation:In my view, I find telemedicine is a necessary method of care that the Ministry of Health in Saudi Arabia should consider. This is because the access of health care in some rural areas in Saudi Arabia is not sufficient. This is because, in my opinion, most physicians and healthcare providers do not want to live in rural areas. Perhaps this may not only apply to Saudi Arabia, but many other countries too. This led to the discussed issues such as lack of clinics and specialties. In order to solve this issue, I recommend that the ministry of health to implement my proposed program to expand the healthcare access in these areas. This program will utilize the current technologies and use effective alternatives for healthcare and ensures that everyone will have access to healthcare. All the requirements and resources of this project are available, so at least they should consider trying it for few rural areas at first, for a short period of time to evaluate its effectiveness. If it met the desired results, which I am sure it will, then they should officially implement it in the other areas. In short, this program will take the access of healthcare to a greater level.Conclusion:Telemedicine is useful to deliver healthcare to rural areas. It uses technology to provide virtual visits between two different areas. It can be utilized in a wide variety of settings and can treat several illnesses from distance. 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