June 2007

Emerging Technologies for Sustainable Rural e-Health

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The issue of rural e-Health software is a complex one. There are hundreds of open source Electronic Medical Record (EMR) systems supporting different platforms available around the world. These range from full-fledged hospital management solutions to community EMRs, to personal health records. The advantage of open-source applications is reduced costs, flexibility to customize, and sharing of knowledge with developer community and users.

A number of technologies are now emerging, which can create a sustainable ecosystem for rural e-Health. The well-demonstrated evidence about the benefits of rural e-Health has been bolstered by the support for comprehensive surveillance after the SARS and bird flu outbreaks in the recent times. Given the resource constrained environment, any successful rural e-Health project has to bring together enablers at the right time and with right incentives for widespread adoption and sustainability. Such systems need to be low cost, rugged, portable, convenient and interoperable. The four vital components of e-Health are mobile hardware, which can be taken into patient’s dwellings and has support for network access, software for accessing records with some decision support built in, reliable network which is low cost and connects mobile workers to the central base or a national grid, and most importantly the power source, for providing electricity in remote areas.

Some of the promising technologies which can have tremendous impact on these four e-Health components have been discussed here. These are either in pilot stage or in early launch phase. Some are not being explicitly promoted for e-Health applications, but their specifications make them ideal candidates for e-Health adoption.

The ICT developments  in the hardware domain

Hardware is central to e-Health implementation. Over years, many large and small organizations have introduced mobile devices to enable their application in rural settings with varying degree of success. These devices can be used to access patient records at point of care, enter data during patient encounter and instantly make available to central databases.

One of the most visible educational technology projects in the world is the $100 usd laptop project. This project is aimed at creating a low-cost laptop that would be used as an educational aid in developing countries. Recently renamed as ‘One Laptop Per Child (OLPC) project’, this MIT Media Lab design is a Linux-based system, manufactured by a Taiwanese company.

The multiple features of the laptop � low cost, rugged design, longer battery life, multiple network connectivity options, human power source, make it ideal for use in any setting in rural areas. It is expected to cost about $150 at its launch, which is expected to take place in late 2007.

Intel, the world’s largest CPU maker, has come up with ‘Classmate PC’, which is targeted at children. It supports Windows XP and a 900 Mhz Celeron CPU. There is no hard drive and it uses 1GB flash memory for data storage. The product is priced substantially higher than OLPC at $400. The design is very rugged, has extremely low power requirements and is considered to be the better alternative to OLPC.

A couple of years back, an Indian company had launched ‘Simputer’, which was a Linux- based device and a cross between a PDA and a laptop. It failed to take off and was subsequently bought by a mobile application development company. Now another device called ‘Mobilis’ has seen the light of the day. It is a Linux- based tablet PC, and is one of the most advanced low-cost mobile computers from India. However, it is yet to be deployed in any large project.

Apart from these, there have been some attempts to build low-cost laptops in Brazil and China. AsiaTotal.net attempted to distribute free PCs by subsidizing the costs from the sponsors who could have hotlinks on the keyboards, directing to their webportals. In 2004, AMD introduced the Personal Internet Communicator as part of its 50×15 program, but abandoned the project in 2006.

HP also experimented with mobile computers, targeted at developing countries, before discontinuing any more investments in the project. However, these devices were too generic to address the requirements of any single sector comprehensively.

Rural e-Health Software

The issue of rural e-Health software is a complex one. There are hundreds of open source Electronic Medical Record (EMR) systems supporting different platforms available around the world. These range from full-fledged hospital management solutions to community EMRs, to personal health records. The advantage of open-source applications is reduced costs, flexibility to customize, and sharing of knowledge with developer community and users.

One of the oldest and most widely used open source EMR is VistA, which was developed by Veterans Affairs health system in the US. It includes more than 50 separate but integrated modules, and different development groups have added pediatric, obstetric and other hospital applications on to the base system. The system has a track record of supporting a large variety of clinical settings and medical delivery systems, and it can be customized for Indian deployment. VistA is developed in Mumps (M language) but some of the other available open source EMRs are developed on contemporary platforms, and  are easier to install and manage.

Challenges of Reliable Network Connectivity

The network connectivity is a major component of rural e-Health setup. So far it has been the most difficult and expensive to manage. In a sparsely populated area, it becomes very expensive to use wireline technologies, and cellular phone companies cannot recoup their investments. However, global R&D is producing some innovative technologies which can address these pressing issues.

The four vital components of e-Health are mobile hardware, which can be taken into patient’s dwellings and has support for network access, software for accessing records with some decision support built in, reliable network which is low cost and connects mobile workers to the central base or a national grid, and most importantly the power source, for providing electricity in remote areas.

Intel and University of California, Berkeley are working together to provide Internet access, using steerable antennas with range of hundreds of kilometers. These antennas with range of hundreds of kilometers are connected on the one end to the urban centers and are ‘daisy chained’ to each other. At the other end, they can be connected to a local wi-fi system. The antennas can auto-calibrate and can run on solar power or other conventional power source. They can be deployed in a mesh-network system and can provide variations of  802.11 and 802.16 wireless protocols; optimized for remote locations.

A tele-ophthalmology project is already being run with this system in South India. In test runs, up to 1 mbps bandwidth was obtained at a distance of 200 km. Drishtee, a social enterprise supported by Acumen Fund, is collaborating with rural entrepreneurs in India to set up e-kiosks that will provide a large variety of health-related services like preventive checkups, health information, hospitalization insurance and medicines.

There are more encouraging examples in the Indian context. Voxiva is piloting projects in India, after successful deployment in Peru and other developing countries. They are promoting the use of phones instead of PCs to enter healthcare information at remote rural sites. This system can be used to enter basic patient information or any disease outbreak warnings by just calling-in.

Researchers at IIT Chennai are working towards deploying Internet kiosks in villages. A  combination of wireline and wireless systems would enable connectivity with central servers and data storage. Using thin clients, users can access a central server and provide connectivity to business applications, Internet and e-mail. The project would involve local entrepreneurs to operate and manage these kiosks and earn profit over services delivered through them. A similar model has been successfully demonstrated by ITC’s e-choupal project.

International Telecommunication Union (ITU), which is a specialized agency of United Nations established to standardize and regulate international radio and telecommunications, has a number of projects to provide wireless network access to rural areas. One of these is UMTS Forum Project which aims to make lower frequencies available for mobile phone networks, based on open standards, harmonized frequency bands and global deployment.

In another ITU project, which is codenamed Enclusion, the GSM networks are extended to wider population, using VHF radio transmitters.  People can connect to this low bandwidth network using mobile phones, computers or special devices and access predominantly text only information.

A very innovative model is being promoted by a UK based organization named Aleutia, which markets hand-held devices with inbuilt wireless transmitters and receivers. Aleutia is piloting this technology in East Africa, starting with Rwanda. So far, they do not have any plans to launch it in Asia, but this novel idea can be easily implemented by interested agencies in India.

Each device has a range of about 7 km and can communicate with other devices and also with the base stations, within a range of 34 km. The interesting concept is that the local transport buses act as the data carriers. The mobile device closest to the bus stop is the last one in the mesh of mobile device network.

It aggregates all the outbound e-mails from mobile devices and exchanges e-mails with the mobile device in the buses, when the local buses passes through that village. As buses travel through remote areas, they exchange data with devices in their range and the devices subsequently share the data with others distributed. This mesh network is a self-contained solution and any node can be linked to a GPRS-based device or an Internet network.

However, all said and done, one of the most important initiatives to create an e-Health network in India is the Integrated Disease Surveillance Project, funded by World Bank. Currently in the process of roll out, it has a central disease surveillance unit linked with district hospitals, medical hospitals, community health centers and peripheral health centers. The local units monitor case reports, verify lab reports and report to district surveillance unit, which is connected to central database.

The aim is to generate warning signals for epidemics and monitor progress of ongoing disease control programs. The nodes across the nation are connected through 45 mbps satellite link, provided by ISRO.

Powering Change

Lack of reliable and quality electricity is an infrastructural bottleneck in rural areas of developing economies like India. Every technology deployment has to address the power requirements before it can be made sustainable. The problem is acute for mobile devices since they are unable to utilize many of the available alternative energy sources. Also, the options have to be cost effective to be successful. Both solar power and fuel cells could be ruled out for this reason. Some concepts that are available include:

Hand crank on the side of laptop: This was the original design of OLPC, but has been discontinued in favour of human-powered generator with string mechanism.

Potenco has designed a hand-pulled string powered model for OLPC. The string can be pulled by hand or leg to generate power. About one minute of pulling generates power for 10 minutes of use of OLPC. The target price for the generator is $10usd. A special kind of batteries in the OLPC keep the machine running for about eight hours on a single charge.

A foot-powered energy source is being sold by Freeplay. It is currently retailing for about $200usd per unit.

The Last Word

There are many technologies that are either in research stage or pilot testing phase, which can address any of the four components for rural e-Health in emerging economies. Any integrator who could bring these technologies together around an e-Health application would not only be able to provide quality healthcare delivery to millions of people, but would also lay the foundation of a medical communication network. This requires high initial capital investment, collaboration with multiple agencies, clear ROI assumptions and measurable project outcomes. It is right to assume that with the limited healthcare-IT deployment in urban centers, it is very difficult to push it in the rural centers. But the fact is the potential benefit of e-Health in a medically underserved area is much greater, so as to justify the investment.  

Helping Older People to Help Themselves

The number of elderly people is increasing significantly and rapidly in all EU countries, thereby creating substantial problems in terms of resources needed for assisting them. Specially their healthcare needs are a cause of concern in many EU states, as many of the old people live alone, with not enough money at their disposal to afford private carers. Thus with the increase in elderly population in EU, the relative public burden on healthcare in EU states is also rising. The OLDES project is an honest endeavour to address the healthcare needs of the elderly population of EU, through the help of ICT.

The OLDES project is aiming to offer new technological solutions for improving the quality of life of older people. To go into more detail, the project aims to plan and develop a technological, cheap and easy to use platform for tele-assistance and tele-company, thanks to the joint work of 11 EU partners.

OLDES project, which has a scheduled time-span of 36 months(from 1 January 2007- 31 December 2009),  is working to plan and implement an innovative low cost and easy to use technological platform,  which will be able to provide a wider range of health services to a higher number of elderly people. The platform will be tested by 100 elderly people in Italy (10 of them affected by heart disease) and a sample of diabetics in Prague. In a nutshell, OLDES’ objectives are  to develop a cost optimised technical solution; to define the profile of ‘elderly people’; to define a standardised procedure for tele-care interaction; and to develop a programme for results evaluation. The success of the OLDES project will make the older people in EU access to e-Healthcare services from their homes.

OLDES puts older people at the centre and makes their needs the main priority in all developments. This will be achieved through the use of modeling and animation tools to create scenarios designed to elicit responses from older people, their carers and service  providers. Animation and simulation will help to ensure that developments are, at all stages, grounded in the realities of social and healthcare, the cultures and economies of the specific pilot contexts, and has as wide a range as possible of other European public service contexts. 

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