In Sri Lanka, to overcome this problem of accessibility to specialized healthcare, a patient centric eHealth initiative  ‘Vidusuwa’ was carried out by conducting eConsultations and eClinics to help the patients in remote locations to meet consultants based in cities making available specialized healthcare to many.

Significance of Strategic eHealth Transformation

One of the main objectives of the Sri Lankan healthcare system is to improve health services delivery & health actions. In compliance with the health policy of Sri Lanka, the main emphasis of Vidusuwa is on setting up of eConsultation centers and eClinics to link the specialist in a general hospital in a city with a patient in a peripheral setting. The Vidusuwa process starts in a non-complicated environment which is easy to use by the patients, doctors and other healthcare workers. Therefore, the concept as well as the product is fundamentally based on the following principals –

• Keep the technology simple/local

• Build on existing technology used by all

• Involve users to feel ownership

  
  

• Use a participatory approach to introduce ICT

• Use a strategy that is relatively resilient in the face of developing-world conditions.

• Strengthen ICT infrastructure and create a conducive environment to develop healthcare

• Interoperability, flexibility and adaptability should be key enabling features.

The main eHealth deployment areas identified were electronic health records, patient identifiers, health portals for informing patients and professionals on health issues and disease prevention, citizen card activities and telemedicine. With regard to electronic health records, there is substantial variability in development priorities between countries. The main emphasis of Vidusuwa is on setting up of an eConsultation Clinic to link the specialist in a general hospital in a city with a patient in a peripheral setting. This will consist of a peripheral eClinic, a web-based EMR, m-Communication system (Vatsalan et al, 2009) and an e-Consultation centre with a medical specialist. Sri Lanka has a total teledensity (fixed and cellular phones) of 78.6% by the end of the 2nd quarter of 2009 which is high as compared with other developing countries (TRC, 2009). In order to extend the usage of eClinics across the country using existing infrastructure, a proper strategy of deployment need to be adopted. The eTransformation process needs careful attention as it is essential to get the support of patients, healthcare professionals, healthcare institutions, health-related businesses, governments, international donor agencies, private and public sector ICT and telecom service providers who are the main stakeholders (ICT and Health Vision 2025).

Seven E’s in eTransformation

The 7Es in eTransformation is a methodology that has been developed to strategically and successfully transform Small and Medium Enterprises (SMEs) in the business sector. It has been tried and tested in the manufacturing sector with success (Arunatileka & Ginige, 2003b). However, in this paper, the 7E Model has been adopted for public sector transformation. This will be the first time the model is applied for eHealth transformation. The paper explains the suitability of the 7E Model and how it will be modified to eTransform the health sector.

The following description briefly explains the 7E Model (Figure 1) and how it is modified to effectively eTransform the health sector.

Stage 1: Environmental Analysis

The environmental analysis takes in to consideration, the global as well as the local environment with regard to the healthcare institution. The strategy would be to ‘Think Globally and Act Locally’. The characteristics studied under four main areas are – Global trends in eHealth, National State of Affairs, Institutional situation and Patient related aspects.

Under Global eHealth trends, the main activities are identifying specific successes, failures, and lessons learned from existing applications and technologies and studying eHealth policies, frameworks, new technologies, practices related to developed and developing countries. National eHealth policies and initiatives are analyzed as it is important to understand the government instigated health initiatives and policies as well as eHealth initiatives to have an idea about how to develop strategies to facilitate deployment of eClinics across the country. Studying the institutional environment is of utmost importance for the development of specific strategies for each healthcare provider. The information related to the patients who attending the healthcare institution are studied in terms of Patient population & distribution (areas as well as numbers), demographics, disease spectrum, Cost and difficulties, pre-assessment surveys, privacy and legal issues, cultural and ethnic peculiarities as well as language issues.

Stage 2: eHealth Goals and Strategies

Using the information gathered in the first stage, eHealth goals and strategies are developed for the healthcare institution. This will decide which eClinics are needed by the health care provider in the periphery and which peripheral units need to be linked. At this stage it is very important to follow an evolutionary and participatory approach of healthcare providers to transform and decide on strategies. There are four main strategies to decide, such as – Single Specialty Point to point locations; Single specialty to multiple peripheral locations; Multiple specialties to Single peripheral location; Highly Specialized clinic (centre of excellence) � peripheral institution or eClinic location (Eg. Neuro surgical clinic, endocrinology clinic); International consultancy link- Global eClinics; Expandability and innovation � linking ITU net, Hospital net, epidemiology unit or poison information centre etc.

Stage 3: eReadiness

Infrastructure development for an eHealth process will require key enablers like interoperability, secure ID controls and common platforms for data exchange such as open source. Professor Herbert Kubicek and Ralph Cimander (2009) present a useful model that suggests that each of these dimensions of interoperability must be addressed from three perspectives simultaneously � (i) politically, to negotiate among institutional actors (ii) functionally, to align data, information and workflows effectively (iii) and as a service to govern and regulate directories, formats, and message routing. Government should put effort into inclusion, building trust in the new technologies and the promotion of, at least, basic IT skills. eReadiness of hospitals as well as patients should be ensured to identify major barriers and issues related to change management.

eReadiness of Institutions is measured through following parameters – Infrastructure (Hardware & Software); Connectivity (ADSL, DSL, Broadband, VPN); Funding (Government, Private sector, NGO etc); Support of Senior management (Regional heads, Ministry level, Influential personalities, Hospital administrators, Consultants, Doctors, etc.); Identifying champions for the cause within institutions; IT literacy and IT Training needs of the healthcare provider. eReadiness of patients is measured through parameters such as – economic status and concerns; psychological preparedness to participate in an eClinic; disease peculiarities that may have an impact on the clinic; psychological and physical disabilities that may have an influence on the clinic.

Stage 4: The eTeleconsultation Roadmap

The current position identified by the eReadiness stage is mapped in the eTransformation roadmap to develop a specific step-by-step path to proceed with the transformation process. It is important to note that there is an internal process as well as an external process of transformation to achieve the ideal state of convergence (Figure 2).

Points to point clinics are easier to establish as a starting point to sense the local IT environment and introduce users to the eClinic system. A micro analysis and feedback can be arranged to overcome connectivity problems and technicalities. During this time efforts should be made to improve the confidence of staff in using the system, workout maneuvers to shorten the actual consultancy times, improve familiarity of staff with the EMR. This is the stage where champions in the cause can influence their peers to conduct clinics in other specialties. This will lead to multiple specialties being linked to a single peripheral hospital. Administrators can encourage other hospitals in their region to embark on eClinics if a specific need exists by sharing the successes of the system with counterparts. Finally single specialties can be joined to multiple peripheral eClinics and also multiple specialties to multiple eClinics. This would happen when the regional awareness and the need for eClinics reaches its optimum. Key players such as service providers, health officials, specialists, health media personnel and key enablers are deployed to the maximum.

When multiple hospitals are communicating with each other using the eClinic systems a platform is created for effective integration of data networks between these institutions and their support services like labs and radiology departments. Thus a peripheral eClinic can be linked to a Peripheral eConsultation clinic, to a Central eClinic or to a Highly Specialized eConsultation Centre. It would also be possible in the future to establish links with global eConsultation Centres across borders. Patient smart cards using digital signatures and access ID can enable health information and patient data to be securely transferred to relevant institutions around the world to deliver quality healthcare to a given patient.

Stage 5: The eTransformation Methodology

In order to eTransform an organisation in an iterative manner, a step-by-step approach is used in modeling, re-engineering, implementing and training on business processes. The Evolutionary eTransformation methodology is used for this stage as the iterative technique. It has been proven beyond doubt that the most successful projects always had the secret of integrating people, process and technology successfully. The following illustration (Figure 4) shows the importance of the integration between the 3 aspects as well as when it is linked with other processes.

Performance attributes such as technical feasibility, diagnostic accuracy, sensitivity, specificity, clinical outcome, and cost effectiveness have to be taken into consideration when setting up a telemedicine project. In setting up of eClinics in Sri Lanka during the pilot project, concerns were expressed regarding technical aspects of the consultation itself. Past experience in limited telemedicine projects had problems with connectivity line efficiency, lighting illusions making difficult accurate diagnoses, delay in uploading data and some hassle in transferring of data to health officials via e-mails. But promising data emerged from these studies showing a seventy five percent accuracy rate in diagnoses (when a TMVC camera was used) and a twelve percent inaccuracy of diagnoses (Oakley et al 1997). However, the study (Oakley et al., 1997) concluded that TMVC could be used with a reasonable degree of accuracy. An asynchronous software application can provide levels of diagnostic accuracy and concordance equivalent to those reported using live teleconsultation. The concordance between the in-person and teleconsultant diagnoses was in agreement 77% of the time (90% if differential diagnoses were included).

The ViduSuwa project was able to overcome most of these barriers by paying attention to the room environment that eClinics are conducted in, using pretested webcams which could give clear images of the patient, using dedicated broadband connection, uploading digital images of lesions captured with a 10 megapixel camera and incorporating these into to the ViduSuwa EMR prior to starting the actual eConsultation. This allows more time for the specialist to communicate with the patient.

Stage 6: eSystems

This stage deals with three main components in the post implementation stage which are management controls, Security measures and IT Management & support. The main activities in this stage involves development of IT policies, standards, guidelines to users, user manuals, support and maintenance procedures for the new systems, ensuring security measures to deal with sabotage, hacking and privacy, assuring support and maintenance for ICT infrastructure, upgrading, backing up etc. A contingency plan and a disaster recovery plan also need to be in place for sustainability of the project.

Health standards apply as in industry models but with some peculiarities specific to healthcare. The Vidusuwa EMR meets the standard requirement of patient notes or medical record with all aspects represented in a concise way but maintaining simplicity of use and a user friendly interface. As time is of utmost importance in running an eClinic the number of clicks necessary and the number of windows or folders to be opened are kept at a minimum. Doctors and other staff adhere to procedures and practices carried out at normal clinics. Availability of a disclaimer and a ViduSuwa user manual guide users on the proper usage of the system effectively.

At every step of developing the ViduSuwa EMR, security and non loyal user abuse and access have been looked into and possible safeguards added to ensure patient data protection. Data backup is done at the moment by service providers. The authors propose to use local backup facilities to be totally independent in management. The EMR is constantly being upgraded to improve features as well as expand the system making it a dynamic and flexible entity according to the evolutionary approach. Many issues have been looked into with regard to access rights, the role of each user category (consultants, hospital administrators, junior doctors, nurses etc.), hierarchy in the healthcare setup and administrative procedures related to the system itself.

Stage 7: Evolution � Change Management

This is the most important stage that runs across all other stages managing the changes in an evolutionary manner. The methodology is needed in change management of health sector initiatives still in its infancy in the developing world as well as some developed countries. The seven main aspects to be addressed at this stage are the changes in Structure, Systems, Style, Strategies, Shared values, Staff & Skills as described by McKensey’s 7S (Waterman, 1980).
Understanding the healthcare system as a whole and its rural infrastructure was crucial to identifying and deploying eClinics in Sri lanka. Healthcare institutions in Sri Lanka have their own peculiarities with regard to patient management chain and arranging follow up care. These issues need to be addressed when locating eClinics. Strategic marketing of the concept has to be done carefully as many key players have their own sensitivities and concerns. A participatory approach helped to overcome skepticism unfounded fears among healthcare staff. Setting up the ViduSuwa eClinic system was challenging as participants from many sectors were contributing their expertise and interacting to meet requirements across different specialties. Therefore, a common ground had to be found to integrate technical capabilities, IT infrastructure development and healthcare needs of the patient.

The real problem, as experienced in the above study and applicable to Vidusuwa is to integrate electronic flows between pre-existing obsolete proprietary systems and to entice clinicians to use technology for their daily activities (e.g. medical reports issuing, referral notes etc;). What are the effects of this mode of healthcare delivery on the doctor-patient relationship? Examining patient perceptions would help to address the reasons why patients liked or disliked a service and help healthcare providers to better understand patients’ subjective definitions of acceptability and utility. Cadre training in basic IT related applications, attitude changing brainstorming sessions and dedicated healthcare workers and administrators can contribute to overcome obstacles in eTransformation. In the process of change management, Governments should put efforts into inclusion, building trust in the new technologies and the promotion of, at least, basic eSkills. “Key enablers are the glue that binds eGovernment together” (European Commission, 2007). Therefore, the experiences between different stakeholders, whether from the public or the private sector, and members of research centres and academia should be encouraged in order to enhance collaboration and better cooperation for interoperability (Archmann & Iglesias, 2009)

Conclusion

Telehealth’s successful implementation in communities and in links to remote providers, as well as its acceptance by patients and families, depends to a very large extent on the commitment and capacity of individual people in the community to make it happen, in service to the community.

The Vidusuwa approach has a firm foundation as all its key players have one common shared value � well being of the patient. This evolutionary approach using the 7E model for eHealth transformation takes into consideration cultural and other factors specific to a country to systematically and successfully eTransform the Health sector.

This ensures sustainable and quality healthcare to all citizens making a patient-centric approach more acceptable to quality healthcare in Sri Lanka as well as in other developing countries.

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