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Regional Consultation on Telemedicine: Sharing Experience and a way forward by: Dr. Mohamed Ali Dr.

Nusaiba Farouk Hassan

Overview
Demography
Evolution of E-Health and Telemedicine Current Scenario Strategic Direction Innovations and applications of eHealth and telemedicine Strength Weakness

Opportunity
Threats The way forward

Demography
An archipelago: 1192 Islands
Inhabited: 200 islands Population: 360,000

Distribution: Largest: Over 100,000 in Male City Area: 90,000 sq km ( sea)


Ethinicity - Asian

Background
In constitution: The right of every citizen to access

good quality health services is protected. The Government: Constitutionally mandated to realize this right for all.
Guiding Principles;

Recognizing Health as a human right and its universality Ensuring equitable access to affordable, quality health services based on primary health care approach Harnessing solidarity for health in all national policies Ensuring policy development based on facts and scientific evidence

Vision for Health: Improving the quality and affordability of health care with a focus on access for all. Goal for E- Health: Providing standardized high quality medical services, by using interoperable, compatible, reliable, and scalable E-Health solutions such as telemedicine, HIMS, whereby all residents of Maldives have equal access medical expertise available in the Maldives as well as internal medical care institutes.

Strengths:
ICT is one of the fastest growing areas in Health
Existing institution based programmes / databases National ID Nos are being entered to independent

systems, which can be used as a unique patient identifier Large potential for M-Health; extensive use of mobile phones and related devices

Major Healthcare initiatives in place:


Online Nutrition and Child Health Surveillance

System (ONCHSS) SEARO Integrated Data Analysis System (SIDAS) Hospital Information System (HIS) E-Government Portal for online birth and death registration Neonatal/Perinatal Database

E Health Objectives
Establish an integrated health information System
Improve access and quality of health care given to

general public using E-Health Strengthen the capacity to monitor health indicators and conduct system reviews in a timely manner Facilitate efficient emergency or disaster management and timely decision making in health emergency situations

Specific Strategies
Establishment of a governance structure to deliver the E-Health

Strategy Unique citizen identifiers for a common health services and health insurance Implementing Telemedicine Availability of needed health information at a national level in a timely manner Implement consumables management information system Begin introduction of more clinical information systems and EPRs Expand use of M-Health Invest in computing infrastructure Access to broad-band services Adequate communication of E-Health strategies

Current Investments, goals and plans:


Patient centered information systems
Electronic Health Record Systems Telemedicine

Information Databases
Preventive Health Services using Mobiles

Telemedicine in Maldives
Vision: Provide a telemedicine solution to Maldives

which is compatible, scalable, reliable and interoperable. The objective is to upgrade the quality of health care and minimize the cost of medical care through effective acquisition of relevant clinical information at remote sites. And also to ensure that all residents of Maldives have equal access to high quality health services regardless of their location.

Telemedicine in Maldives
Objective:

Enable people in islands to use tele-consultation and avoid travel and support continuing medical education:

Implemented in II Phases
Aiding agencies

Integrated Human Development Project; World Bank Khalifa Bin Al Nahyan Foundation; Abu Dhabi

Implementation:
Phase I: Integrated Human Development Project; World

Bank

Telemedicine: 4 Main hubs connected on 5th May 2010 Indhira Gandhi Memorial Hospital Central Kulhudhufushi Regional Hospital - North Thinadhoo Regional Hospital South B. Eydhafushi Hospital

Phase II
34 New Centres joined Telemedicine Network under

Khalifa Bin Zayed Al Nahyan Foundation; Abu Dhabi: 20th November 2011 Two components
Telemedicine Kiosk and Equipment Training Component

70 Nurses 10 Specialists; Biomedical Engineers, Obstetrician Gynaecologists, Paediatricians, Surgeon and Physicians

4 Referral Hospital and 34 Remote points Hdh. Kulhudhufushi Regional Hospital Indira GandI Memorail Hospital Gdh. Thinadhoo Regional Hospital S. Hithadhoo Regional Hospital

Current Situation

Sporadic Cases No designated personnel Trained staff unavailable to provide service Insufficient attention to Telemedicine due to inadequate number of Clinicians at referral centers Expensive equipment under lock and Key No existing referral system Use of M-Health; applications like whats ap for case discussion by Clinicians
AIM: Strengthening of existing services

Map I

Innovations and Applications of EHealth / Telemedicine

Tele-Education Department of Child Health, IGMH and AIIMS, New Delhi Dengue Season 2011; CMEs in all 4 Centres Staff at Thinadhoo Regional Hospital had participated in the Workshop on Management of Dengue Cases conducted in association with WHO and QSNICH via tele-education 2011

Telemedicine Potentional for development Dermatology Pathology Radiology Orthopaedics General Medicine /Paediatrics

Strengths
High Priority Project for Ministry of Health and

Family Health workers at remote points are motivated to learn and maximize use of Telemedicine Clinicians at the Referral Centers are committed to attend to cases Human Resource Development

Weaknesses

Central Lack of an Alert System Unaware of the enhanced equipment availability Remote points Inadequate number of Clinician to attend to inpatient and outpatient facilities, hence telemedicine is not made a priority No designated personnel / infrastructure 1:38 Ratio of telemedicine carts; central: peripheries Peripheral High turn over of trained staff Nurses trained under Telemedicine project refuse to go back to the island Inadequate infrastructure and power supply at HC to support equipment Unavailability of Medications and Basic investigations Common Telemedicine Network has not been integrated with the Hospital Networks No networking between focal points Lack of awareness among doctors about Telemedicine License for teleconferencing has to be purchased; hindrance for tele-education Lack of awareness among clinical staff and management at the hospitals Lack of telemedicine trained specialists Referral centers do not have telemedicine links with Regional Centres abroad

Opportunity
SAARC Telemedicine Project
Collarboration with Regional Centres; AIIMS Reduce expenditure on Health insurance referrals to

male and abroad. Gain the confidence of the public in the health sector

Threats
Remote island losing hope due to failure to attend to

cases promptly Lack of maintenance of equipment may lead to loss of equipment performance Referral centres do no have the necessary consultants

Way Forward

Encourage doctors to utilize telemedicine To integrate M-health in to the telemedicine system officially To train the personnel responsible for the telemedicine and assign roles To assign personnel to manage the telemedicine equipments and to give responsibility of maintaining them To assign login responsibilities to the individual doctors, rather than the institute To include teleconsultation in the duty roster To assign CME points in return to the tele-consultation hours spent To give bonus salary for the cases spent on tele-consultation To give preference to tele-radiology To provide basic equipments to the remote kiosks, like USG machines, ECG machines and X-ray machines and maintain the supply to the basic laboratory investigations Assign budget for telemedicine WHO and other NGOs support to implement these services and to train personnel In assigning the login responsibilities, the MOH should assign license to telemedicine Include tele-consultation in National Insurances (ASANDA) patient evacuation system, to minimize the cost of improper referral and improper referral diagnosis thus reducing cost of referral system.

Conclusion
Telemedicine is a great promise to Maldivians to

achieve better healthcare without having to travel by highs seas to the nearest referral centre, and then inevitably to the capital. Telemedicine is the alternative route to achieving the best possible treatment rather than referring abroad for issues which can be resolved within the country, hence better utilization of resources.

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