September 2007

Pocket Electronic Health Diary (PeHD) : Dr Shabbir Syed Abdul

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PeHD is a pocket electronic health diary system created on patients’ own interest and managed by hospitals who offer it. The main aim of a PeHD for developing countries is to introduce an electronic health record where there is no centralized health care system and governments cannot maintain database of citizen’s health records. This will be an initial step not only towards paperless health care systems, but also to empower patients through access to their medical information.

In this era of ICT (Information and Communication Technology) when no sector has been left untouched, recent advancements in ICT have changed health care systems. The use of ICT through Telemedicine and e-Health tools has created bridges between space and time, this has been reflected on a “better access to health care and access to better health care, cost effectiveness, equity and efficiency of health care” [11]. These qualities of Telemedicine and e-Health services are attracting policy makers on health care from developing countries where there is a boom of health crises and lack of infrastructures, human resources, and of course funding [2].

PeHD is a decentralized, patient centric, health record which provides an organised summary of personal medical information for presentation to health care providers [3]. It is multifunctional and multipurpose, includes text, images, sounds, and other multimedia content. It not only supports doctors to have access to the patients’ medical records, but also for Hospital treatment purposes, Government bodies for statistical purposes, and research purposes.

The Health information is not only stored in a server but also stored in a USB drive for quick accessing of essential medical information where internet is not available [4]. And patients have to carry this USB drive along with him/her as an ATM card or credit card. As PeHD is used by different users (stakeholders), different interfaces are made so that only information required for that user can be accessed from patient’s health information data.

PeHD’s main goal is to help patients to become active participants in their own care, empowering them to acquire awareness of their own,or their family members’, health status. The available literature does not yet seem to adequately describe the potential capabilities and utility of these systems in developing countries – “Unfortunately few systems have been described in the literature and fewer evaluated” [10] and “In addition, the lack of a proven business case for widespread deployment hinders Personal Health Records adoption” [3].

Most consumers and patients receive care from many health care providers, and consequently their health data are dispersed over much paper record of many hospitals. A fragmented system of storing and retrieving essential patients’ data impedes optimal care.

Present Scenario

It is common to have patients visiting the hospital or GP without any previous medical reports, incomplete, or very old and half torn reports. Sometimes reports are in good shape but we aren’t able to read due to the doctor’s illegible handwriting [5]. Patients often arrive in casualty with serious illnesses, but don’t know anything about their previous treatment,  even what operation they had undergoneor what medication they might be on, the only thing they would recall is that they are on anti hypertensive medicine or anti diabetes and the colour of the tablets (red or white). It is common for patients not to carry medical records.  Thus one can imagine in this situation how difficult it will be to manage the case. In t an emergency, there’s no room for errors. However if anything goes wrong, Doctors are  blamed.

It is now time to provide our doctors a little help with a system which gives them complete access to  their patient’s medical history. We have found that PeHD is what we need to achieve our aim.

The Proposed Solution

The proposed solution is called PeHD � Pocket electronic Health Diary � and its internal structure is shown in fig1. PeHD is a decentralized, patient centric, health record supported by a simple device such as a pen drive (common designation for a solid state memory device with a USB interface) [6]. It is able to store not only the person’s own health information (a database), but also the technical means to read it (a computer application), and the necessary security mechanisms to protect it (encryption tools); making it a fully autonomous system. In fact this is now possible with the given capabilities of such devices which are able to store over 1 GB of data.  This could only be achieved, some years ago, with a non portable sized hard disk.

The information inside the pen drive is organized according to 2 security levels: public and protected (private).  An application is stored inside the pen drive, allowing the interaction with a PC without any additional software. While the public data is accessible by everyone, the protected (private) data is only accessible by the authorized. Public data includes, for instance, blood type and allergies. The protected data is accessible by a login/password combination, and includes past medical history, medication, exams, vaccination, etc. Any telemedicine application, to be successful, must be economically feasible. Excellent ideas have never left the pages of scientific journals or conference proceedings due to this problem. The low cost of this solution allows for an easy dissemination through both a public healthcare system and private companies.

This work is currently under development. Requirements have been completely identified, the system specification has been produced and its implementation is under way, with the aim of using Open Source technology and platforms. A prototype of a working product is expected in September 2007 (current year).

Benefits to Users

Patients:

1. They can access their own medical record for rechecking medication schedules (Usually patients get confused when they have more then 4 medicines with different times to take them); for confirming review date, investigation date and vaccination date [7].

2. If they are elderly or unable to use the computer they can permit someone taking care of them by giving the token (flash memory pen drive ) to them.

3. They can be reassured about medication schedule in case of confusion by sending email (if and when available) to their doctor, communication barriers are responsible for many adverse effects of drugs in out patient setting. [8] [9]

4. They can send and receive email from their family doctor.

5. They don’t need to go to diagnostic centres just for collecting results, they will receive them directly on their PeHD via internet. In addition, doctors can also check these results from their own office, and contact patients for further treatment or instruction if needed.

Health Care Professionals (Doctors / Nurses / Lab Technecians):

1. Doctors can access the PeHD to get complete medical history, investigation reports, present medications, allergies to drugs etc. There by tsaving lots of time and getting the correct information about the patient. Moreover, this will be of great help for diagnosing present illness.

2. Previous Investigation record prevents repeating of same investigation, saves  time for diagnosis,  patient’s money, and lab technicians’ workload.

3. Doctors can contact their supervisors / professors and colleagues for case discussion or for second opinion.

4. Nurses can access the PeHD if the patient is admitted in the hospital and can order lab tests, check lab results, check medication schedules; this can help in starting medicine which was effective in previous treatments.

Hospitals which can offer PeHD

1. These Hospitals can rope in new clients: once people obtain a PeHD from a hospital they will continue to revisit it for future treatment (though it may not be obligatory,)

2. Clients may also be assigned to a Medical Officer from the same hospital who could help the patient maintain his/ her PeHD, thus adding to the clinician’s list.

3. These hospitals can approach new patient markets. i.e. they can collaborate with nursing homes in other towns and villages, they can facilitate telemedicine consultation if needed, and subsequently get patients from those hospitals (Nursing homes) if future treatment is required.

4. They can use this PeHD integrated with the hospital’s EPR (patient record) whenever this patient is admitted to the hospital.

5. Hospital can make a deal with a Health Insurance company and can offer free treatment for patients with PeHD by taking premium amount which was mutually agreed between the Hospital and the Insurance Company.

6. The PeHD can help maintaining up to date statistic databases with births, deaths, diseases, diagnosis, treatments, etc.

Government bodies:

Can maintain accurate and up to date records of diseases in the given region. Especially of infectious diseases which are diseases that require  adequate steps for their prophylactics and prevention, and in this way epidemics can be predicted at the earliest possible time.

Ownership and flow of the information

When this USB is plugged in only strictly necessary information will appear on the screen. Like chronic diseases, allergies and blood type. The rest is password protected. Different information will be available for different parts of the health service. For instance the pharmacy can access only information about the medication. They do not need to know name or what health problem the patients are suffering from. The same applies for a laboratory.

This technology makes the patient the owner of the information, and gives him or her more control over the record.

Patients cannot change what the doctor has written, but they own the information. The information is encrypted, and one will not have access without knowing the password to the detailed medical data. If the patient is not able to communicate the password, you could call the hospital and provide a number given on the memory-stick in
addition to a description of the patient. Among other things one could use special features like scars and other skin lesions.

Conclusions

This paper proposesa solution for the introduction of personal health diaries in developing countries, namely in regions where there is no centralized system for EPR (Electronic Patient Records) and internet access is limited . In these scenarios patients do not have a single point-of-care and are approaching different health care providers. With PeHD the patient is given both,  access to his/her own health information and the responsibility for it and in this way empowers the patient and encourages him/her to actively participate in maintaining his/her own health. For doctors this technology facilitates the access to their patients’ health record. Most of the information is immediately obtained, and the larger files, like MRI images or echocardiogram, is stored in the hospital server. In the PeHD links to the hospital’s EPR can be stored. The PeHD  also includes URLs of publicly accessible health information on the internet.

Acknowledgment

We acknowledge the support from NST “Norwegian Centre for Telemedicine” and the University of Troms�.

References

[1] M. Savard. “The Savard Health Record: A Six-Step System
for Managing Your Healthcare”, Alexandria, Va.:Time �
Life, 2000

[2] M.A.Ryan.”Maintain your medical records. Today’s Chemist at Work”.  Vol. 8(8) pp. 49-50,52-53. 1999

[3] E. Spragins. “Get it writing”, Newsweek Aug 24, pp. 62, 1998

[4] Tang et al. “PHRs: Definitions to Adoption Strategies”, JAMA Vol 13 Number 2 Mar/April 2006

[5] P. C. Tang, E. H. Shortliffe.”Traditional hospital records as a source of clinical data in the outpatient settings”, proceedings of the symposium on computer application in medical care, Philadelphia:Hanley & Belfus, pp. 575-579, 1994

[6] Paul et al. “Personal health records: Definitions, Benefits, and Strategies for Overcoming Barriers for Adoption”, JAMA Vol 13 Number 2, Mar/April, 2006

[7] D. L. Hunt, R. B. Haynes, S. Hanna and K. Smith. “Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review”, JAMA, num. 280, pp. 1339-1346, 1998

[8] T. Delbanco, D. Z. Sands. “Electrons in flight � e-mail between doctors and patients”, N Engl J Med, num. 350, pp. 1705-1707, 2004

[9] T. K. Gandhi, S. N. Weingart, J. Borus, et al. “Adverse drug  events in ambulatory care” N Engl J Med, num. 348, pp. 1556-15, 2003

[10] H. S. F. Fraser et al “Implementing electronic medial record systems in developing countries”, Informatics in primary care, num. 13, pp. 85-95, 2005

[11] A.C. Norris. “Essentials of Telemedicine and Telecare”,
pp. 30-32, 2001

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