September 2009

Enhancing e-Health using m-Communication in Developing Countries : V Dinusha, Dr. SMKD Arunatileka, Dr. KRP Chapman, GP Seneviratne, S Saatviga, D Wijethilake and SYYD Wickramasinghe Hospital, Ahmedabad

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Co-Authors

Dr. S.M.K.D. Arunatileka
Senior Lecturer,
University of Colombo School of Computing, Colombo, Sri Lanka

Dr. K.R.P. Chapman
Consultant Surgeon,
Base Hospital Marawila, Sri Lanka

G.P. Seneviratne
University of Colombo School of Computing, Colombo, Sri Lanka

S. Saatviga
University of Colombo School of Computing, Colombo, Sri Lanka

D. Wijethilake
University of Colombo School of Computing, Colombo, Sri Lanka

S.Y.Y.D. Wickramasinghe
University of Colombo School of Computing, Colombo, Sri Lanka

This paper investigates the applicability of existing mobile technologies in the health sector and proposes an effective M-Communication (Mobile Communication) module to suit the Sri Lankan setting.


 

Introduction
Mobile technologies are increasingly growing in developing countries. There have been several new researches and developments in this space. Now-a-days, mobile phones are becoming an important ICT tool not only in urban regions, but also in remote and rural areas. M-technology is increasingly being used in the health care field.

Mobile health involves using wireless technologies such as Bluetooth, GSM/ GPRS/3G, WiFi, WiMAX, and so on to transmit and enable various eHealth data contents and services.

mHealth and eHealth are inextricably linked�both are used to improve health outcomes and their technologies work in conjunction. For example, many eHealth initiatives involve digitizing patient records and creating an electronic ‘backbone’ that ideally will standardize access to patient data within a system. MHealth programs can serve as the access point for entering patient data into health information systems, and as remote information tools that provide information to patients, healthcare clinics, home providers, and health workers in the field. While there are many stand-alone mHealth programs, the main idea is the opportunity mHealth presents for strengthening broader eHealth initiatives.

Already, mobile technology is providing and augmenting healthcare initiatives throughout the world. The Opportunity of Mobile Technology for Healthcare in the Developing World is most widely recognised and over 50 of these types of initiatives have been undertaken throughout 26 countries. According to Terry Kramer, the strategy director at British operator Vodafone, there are 2.2 billion mobile phones in the developing world, 305 million computers but only 11 million hospital beds. This clearly reveals that we can harness the power of mobile technology as a high-impact, low-cost tool in order to compensate the scarcity of resources problem in the health field in developing countries.

MOBILE HEALTH IN DEVELOPING COUNTRIES
According to the United Nations Foundation’s report on mHealth for development, it is summarized that the biggest adopters of mobile technology were India with 11 projects and South Africa and Uganda with 6 each.

Examples of such mobile projects include:

  • Sending mobile phone owners updates on diseases via SMS.
  • Letting health workers in Uganda log data on mobile devices from the field.
  • In South Africa, the SIMpill is a sensor-equipped pill bottle with a SIM card that informs doctors whether patients are taking their tuberculosis medicine.
  • In Uganda, a multiple-choice quiz about HIV/AIDS was sent to 15,000 subscribers inviting them to answer questions and seek tests. Those who completed the quiz were given free airtime minutes. At the end of the quiz, a final SMS encouraged participants to go for voluntary testing. The number of people, who did so, increased from 1000 to 1400 over a 6-week period.
  • In the Amazonas state of Brazil, health workers filled in surveys on their phones about the incidences of mosquito-borne dengue fever.
  • In Mexico, a medical hotline called MedicallHome lets patients send medical questions via SMS.

Though the mHealth field is still in its early stages, it has already begun to transform health delivery. Projects throughout the developing world are demonstrating concrete benefits, including:

  • Increased access to healthcare and health-related information, particularly for hard-to-reach populations.
  • Improved ability to diagnose and track diseases.
  • Timelier, more actionable public health information.
  • Improved compliance with treatment regimes: A 2007 Thai study showed that TB patients who received daily text message medication reminders jumped to over 90% adherence. A device called SIMpill is used that uses mobile technology to monitor and direct medication adherence. In the United States, a study found improved drug adherence rates among HIV SMS reminders to take daily medication compared to patients who did not.
  • Improved public awareness outcomes: In South Africa, project Masiluleke, which promotes an AIDS hotline through SMS messages, resulted in a 350% increase in phone calls to the hotline.

Mobile communication offers an effective means of bringing healthcare services to developing-country citizens. With low-cost handsets and promotion of mobile phone networks globally, tens of millions of citizens that never had regular access to a fixed telephone or computer now use mobile devices as daily tools for transfer. A full 64% of all mobile phone users can now be found in the developing world.

Furthermore, estimates show that by 2012, half of all individuals in remote areas of the world will have mobile phones. This growing ubiquity of mobile phones is a central element in the promise of mobile technologies for health.

As illustrated in figure 1, developing world citizens have plentiful access to mobile phones, even while other technologies and health in phone usage has the potential to improve health service delivery on a massive scale. For example, mobile technology can support increasingly inclusive health systems by enabling health workers to provide re-marginalized areas where health services are often scarce or absent altogether.

THE PILOT PROJECT
The pilot project being carried out by the authors in Sri Lanka is a mobile health solution to use Electronic Medical Record System and video conferencing to link the specialist in a general hospital in a city with a patient in a peripheral setting and to use m-Communication system to effectively and economically communicate with the patients. This makes the health service accessible as a mobile solution from anywhere. An Electronic Medical Record System (EMR) is used to transfer the information and a doctor is assisting the patient using easily acquirable relatively inexpensive technology that is currently being used. And as an enhancement, mobile communication system is used for sending important information such as the Clinic date, Operation date, appointment cancellation, investigations to be done, vaccination dates, etc. This project is designed to be implemented using an evolutionary approach in order to have a smooth eTransformation. The pilot project is named as ‘ViduSuwa’ and is presently implemented in two hospitals in Sri Lanka, a base hospital which will be the specialist e-consultation centre in collaboration with a peripheral hospital which will act as an e-care clinic. (www.vidusuwa.com).

This simple mobile health concept is implemented with a very little extension to the existing technology. The EMR system is developed using open source technologies and the pilot project used an open source conferencing tool to carry out the e-Consultation. To enhance this setting by making use of highly available mobile technologies a research is carried out to incorporate an m-Communication system that would improve the patients’ communication with the healthcare expert in an effective and efficient manner utilizing the existing mobile technologies and infrastructure. The m-Communication system is implemented making use of existing infrastructure and open source technologies. The paper further discusses about the m-Communication system model, architecture, technologies and it’s applicability in the context.

M-COMMUNICATION SYSTEM
According to Sri Lankan Tele-Communications Regulatory Commission, out of 21 Million populations over 10 million people are subscribed to cellular mobile services. At the diagnosis stage a preliminary survey was done in a base hospital at Marawila, Sri Lanka, and the results show that over 51% of the patients have access to their own personal mobile phone, out of which 50% use SMS tool for communication. Nearly 80% of patients have access to mobile phones through an immediate family member. These results depict a high penetration of mobile phones in the peripheral sector which can be used very effectively for communication.

Therefore, a two way m-Communication model as conceptualized in figure 2 is introduced as an mHealth initiative with the existing mobile technologies for sending important information (appointment dates, vaccination dates, operation dates, medical tests, postponement or cancellation of appointments due to various reasons, checkup dates, etc) to patients and for the patients to communicate effectively with the hospital.

Integrating the hospital’s EMR System, SMS reminders will be sent to the patients’ mobile phones on clinic appointments, operation dates, vaccination dates and other important tests dates. If an appointment is cancelled or postponed also the message will be sent to the patients’ mobile which cuts the unwanted travelling of patients. The mobile communication system will also receive SMS messages from the patients and forward to the administrator or consultant as an email and SMS. The model enhances the mobile health solution, provides a form of transparency between patients and healthcare by utilizing the existing telecommunications infrastructure in Sri Lanka, and ultimately supports a patient centric mobile health initiative which would be an effective and economic model for Sri Lanka. The paper focuses on the ongoing research on the applicability and development of the model in the Sri Lankan settings.

M-COMMUNICATION SYSTEM COMPONENTS
For the pilot project carried out by the authors, the following components were modeled in the m-Communication system (figure 3).

  • Sending Scheduled SMS: This component deals with sending automated scheduled SMS messages to the patients’ mobile phones as reminders on the clinical dates, operation dates, vaccination dates and other important tests dates. It also sends message postponements of appointments. When an appointment is booked an entry is made in the hospital’s Electronic Medical Record (EMR) system. Soon after the entry is saved in the database a SMS message is scheduled to be sent before the appointment time.
  • Receiving SMS: The model supports two way communication through the ‘receiving SMS’ component.
  • Auto Replying/ Auto Forwarding: This component makes it possible to reply to incoming messages and to forward these messages to administrator’s phone number. A function will be triggered by the system to send a pre-defined message to the patient as a response and also it will forward the message to the administrator.
  • SMSToE-Mail: This component converts the messages to email and forwards them.

THE ARCHITECTURE AND TECHNICAL SOLUTION
If we plan to send/receive less than 15,000 SMS messages per day a good option may be to attach a GSM phone or GSM modem to the PC. The GSM phone/ modem must be equipped with a SIM card that has good tariff for SMS messages. The GSM phone/ modem can be attached with a data cable, with an InfraRed port (IR) or with a BlueTooth (BT) connection.

With this setup we can use a computer program that can send/receive SMS messages. The computer program in this case uses the attached device to communicate with the GSM network.

If a message is sent by the application running on the computer it is first sent to the attached GSM phone/ modem, and as a second step the GSM phone transmits the messages to the SMSC of the GSM service provider through a wireless link.

In order to come up with an economically feasible model, the existing technologies were analyzed and a technical solution that is simple and economical is chosen. Sending an SMS message using a GSM phone/ modem takes about 5-6 seconds. Receiving takes about the same time. The connection methods are analyzed and justified that the best option to connect a phone to the PC in our setting is to use a standard RS232 serial cable. USB cables, InfraRed and Bluetooth connections are not that reliable.

SMSLib is a Java Library for sending and receiving SMS messages via a GSM modem or mobile phone. It is free, open source and easy to integrate in an independent module manner (An Object- Oriented feature). It supports all the object orientation features and makes it possible to benefit from reusability and maintainability.

The pilot project carried out by the author uses SMSLib Java library and a GSM modem connected using RS232 cables with the server to implement the m-Communication system.

The SMS reminding component is running as a java thread daemon service in the server. In the EMR database, we have another table namely ‘SMSReminders’. This table gets updated whenever an eClinic appointment or theatre operation is scheduled, rescheduled, cancelled or an investigation to be done is recorded to insert a new row with the patient mobile number, date to send, time to send, and status. The status field is used to set the status of the message (send, transmitted, cancelled).Hence, when inserting a new row to this table in order to send the SMS on a particular time, the status value would be as ‘send’. Once the message is sent the status would be updated as ‘transmitted’.

The Schedular class in the component periodically gets the values from the SMSReminders table and checks whether the time to send is less than or equal to the current system time and the status is equal to ‘send’ and if these two conditions are met, a SMS message will be sent by invoking a sendMessage(String contactNo, String messge) method of the SendMessage class that is defined by the SMSLib Java framework. Once the message is send, the respective row in the SMSReminders table will get updated by setting the value of status to ‘transmitted’. This prevents sending duplicate messages. The gateway ID, Com Port, baud rate, manufacturer, and model should be passed as parameters so that the GSM modem can be detected by the application. The classes are written in java and thus object orientation functions are used to make the component totally independent of the EMR system.

AWARENESS AND EDUCATION
In the pilot project, the M-Communi-cation system is implemented only for the eClinic patients who will be treated through econsultation. The eClinic patients selected by the consultants are educated on how to read SMS reminders and how to respond to it. To make the SMS messages unambiguous and readable by patients, the SMS message format is defined in the most effective way. Once a patient is selected as an eClinic patient, he/she has to get registered him/herself to the system by giving all the details at the eclinical Management Centre (including the mobile number). When they get registered to the eClinic the instructions and information are given to the patients on m-Communication system to make them aware of the system and how to make use of it.

USER STUDY
A post implementation analysis is being carried out by the authors to evaluate the usage, effectiveness and applicability of the M-Communication model in the Sri Lankan settings.

This is being done through the means of survey studies. The survey focuses on the patients’ ease of access to the message, attitudes, accuracy, timeliness and effectiveness of the Mcommunication system.

CONCLUSIONS AND FUTURE WORK
This paper describes the ongoing research, proposes an effective two-way m- Communication model for developing countries and discusses the mCommunication model components, architecture and design, critical analysis and the applicability and effectiveness of the model.

Since this is a mobile health initiative in Sri Lanka, the research is limited to the mobile communication system in its first phase. As a future research, this can be extended to extensively use the existing mobile technologies and infrastructure in the healthcare filed.

To read the complete paper log on to the website:
www.eINDIA.net.in 

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