Problem of skill shortage
The complexity and criticality of many clinical services demand that an expert makes all important decisions and executes interventions. This is clearly evident in hierarchical decision making in healthcare - and rightly so, for the maximum safety of seriously ill people. But this dependence on experts to make each decision and execute every action is sure to create a bottleneck unless they are supported by a team that executes some of the routine functions on their behalf. An example is commonly seen in teaching hospitals where residents and interns take over some of the clinical responsibilities under the supervision of specialist; or nursing students carry out some of the tasks under supervision of a senior nurse. But there are hundreds of tasks in hospitals, primary care and public health arena that require execution with a certain expertise but seriously fall short of expert hands for obvious reasons.
Rising quality standards coupled with serious shortage of skilled manpower creates a high pressured environment in healthcare where overwork, multi-tasking and stretching of capabilities of existing staff to its maximum (and sometimes beyond) is a common sight. The increasing demand for healthcare services with ageing populations, rising prevalence of chronic conditions and more demanding consumers is expected to further strain the healthcare sector. This grim scenario is a serious setback for underserved populations in remote locations. How can we expect the existing workforce to resolve the needs of rural populations, where the healthcare in cities itself is crashing due to skill shortage!! I do not see any improvement in healthcare delivery to rural populations in coming years unless we look for newer avenues and innovate to optimize our capabilities.
Skill distribution
The trend dictates that more skilled the professional role becomes, rarer their number is going to be. So how can we create a system where without losing the quality or burning out we can enhance the benefit of expertise to more people? The most logical way appears to be controlled skill distribution or "de-skilling".
The real meaning of the word can be understood when we do a thorough work flow mapping and action analysis of a professional in clinical role. For example if we analyse the role of a specialist we come to know that most of the time is taken up by routine tasks like history taking, routine bedside examination and reviewing test results. The real skill of a specialist is realized when the complex clinical problem is resolved and a decision is made after passing through the routine. If most of the routine tasks were handled by relatively less skilled doctor, physician assistant or a nurse and specialist was presented with all the relevant data, his time would be most optimally utilized for problem solving.
However, it is not always easy for a professional to depend on secondary information. Importantly, the solution to successful de-skilling lies in the ability of the juniors to meet the expected standards for basic tasks every time consistently and uniformly. If we can manage this skill distribution successfully then the reach of a doctor can be widened much more, we can care for more people and address skill shortage.
Role of Information Technology in skill distribution
A good IT system for community based healthcare should be able to facilitate standardization of outputs from less specialized workforce and/or feed into the workflow of professional with higher skills for them to be able to make faster, better informed decision that cover wider reach.
In the context of rural healthcare delivery - the community based health worker should be able to complete basic tasks efficiently, uniformly and consistently and be guided to collect appropriate information, seek guidance and execute instructions from a physician. The response to a demand based consultation (when a patient comes with a problem) or Protocol based data collection (when the healthworker makes a house visit) both need to be supported.
The solution design to extend community reach of a physician through the agency of healthworkers should enable some the following elements:
• Redesign work flow to enable graded information processing
• Enable delegation and process automation for routine tasks
• Support training and skill enhancement of healthworkers through knowledge management
• Provide decision support
• Performance mapping and incentive calculation that is linked to performance in the field
Technology to support quality while delivering healthcare at a distance
The physician and the healthworkers are rarely co-located in the same space. In our case the doctors are usually in the cities whereas the healthworkers are located in the villages. In order to match the service needs some of the points that we had to consider were:
• Use of rugged hardware that works in hot, dusty environment and survives rough handling
• It should support multimodal connectivity, meaning if broadband is not available then it should work on GPRS or PSTN line or even be ready for Wi-max connectivity in future
• Since the users are not visible to the decision makers, it is important that user identification is objectively supported (biometrically or banking type solutions)
• System should facilitate cross checking of data integrity e.g. it is not fudged or erroneous (GPS, time, date, user ID stamping on each string of transmitted information)
• System should not only support "on demand" services like consultation, testing or medication dispensing but also support "protocol based services" like hygiene education, immunization records, antenatal screening, water quality tests and chronic care etc.
• The technology should facilitate Point Of Care testing - atleast for basic parameters
The solution should enable recorded billing, issuing receipt, supply chain and transaction management for transparency in cash management and sale of products and services at a remote location
• It should also facilitate quality control by identifying and pointing out errors, emergency situations etc. also facilitate automatic escalation of information based on flagged events
• It should facilitate professional time optimization by mix of asynchronous and real time communications
• As far as possible the system should manage data locally and transmit coded information for decryption at central level in order to address security and optimization of data transfer
Addressing Health @ Bottom Of Pyramid
Despite making breathtaking developments in the field of medicine, we are far from making its benefits reach the last mile. Health disparities remain painfully under-addressed almost across the globe.
Though there have been various attempts made globally to solve the problem of Access, Affordability, Awareness, Accountability and Adequacy of Healthcare Services, our efforts are still fragmented despite years of experimentation. Perhaps the lack of resources and collaborative teamwork with existing stakeholders in a complex system undermines committed people from achieving what is often intended.
Unlike other essential services, healthcare is multidimensional that needs re-engineering of entire ecosystem. Though it sounds like a mammoth task but we need to address major elements impacting healthcare "all at once", in order to create a successful healthcare delivery model that is sustainable, scalable and replicable accross geographical boundaries.
Our extensive field research has pointed us in the direction that our Rural Health Care Re-engineering efforts must include atleast 4 interdependant models that should be seamlessly integrated to achieve desired results. Each pillar of the model recognizes the value of collaboration, i.e. by pooling of expertise, fostering partnerships and sharing of resources, skills & experience wherever possible.
1. Service Delivery Model -
This pillar focusses on facilitating locally empowered and motivated agents of change that can deliver need based services in the village itself. These services should be designed on the basis of primary epidemiological data, address consumer preferances and offer a range of services which may be "Demand based" or "Protocol based". The services be broad enough to include preventive as well as therpeutic interventions, leveraging best of modern allopathic system and traditional alternative systems of medicine.
The components of service delivery are not only delivered in the field but also rely upon strength of established hospitals and Institutions. These could be partner hospitals at local district level as well as larger tertiary care facilities that have dedicated administrative, telemedicine and ambulance command center support.
Essential component of service delivery model is meticulous data collection and analysis that generates useful insights for planning of timely and appropriate interventions and to monitor progress. The program would develop in a constantly learning & evolving fashion.
The bed of this model essentially rests upon mutually supporting partner networks. No single player would have enough capability and resources to meet all the challenges at once. Like minded social entrepreneurs can share their strengths and contribute in collaborative fashion into a common platform. NGOs that work towards nutrition, sanitation, education, local empowerment, entrepreneurship and agriculture are indirectly contributing to improving health. Direct partnership can be as simple as doctors contributing their time online at their own convinience, or be large scale biotechnology, pharmaceutical and biomedical engineering companies contributing innovative solutions. Moreover, public health specialists, engineers, programmers, educationists, social activists, agri-business companies, Governments, funding agencies - there is scope for everyone to contribute "coherently" as team players.
2. Technology Model
The technology can enable a vast range of activities which were not possible in the past. The doctors can see the patients, interact with them and acquire relvant clinical information and even advise using Information & Communication Technology. The entire Medical Record can be maintained online in digital format and be interfaced with Hospital Information Systems, Financial Institutions and all other stakeholders.
3. Supply Chain Model
The doctor's prescription can reach the village in digital format but it is of no use unless it gets executed by either medication supply, sample testing, referral or emergency transportation. These products have to reach the consumer in timely manner, with accuracy and accountability. This pillar attempts to solve the problem of logistics - for making preventive and curative solutions, Medicines, Cheap Point Of Care Diagnostics, Health related products reach the last mile.
4. Financial Risk Pooling Model
All said and done, someone has to bear the cost of the service model. Either the Consumer bears it directly or someone else on his/her behalf. It may be Charity, Government, Risk pooling funds or Other mechanisms that bears the cost to make it sustainable. Innovations in financial model can ride on and support the innovations in abve 3 models.
Our vision is to let innovations in these diverse fields be synthesised and matured to achieve single common objective - "To make it possible for all human beings enjoy the fundamental human right to access healthcare when they need it and in cultually appropriate manner".
We have made a small beginning, you are welcome to join hands.
Though there have been various attempts made globally to solve the problem of Access, Affordability, Awareness, Accountability and Adequacy of Healthcare Services, our efforts are still fragmented despite years of experimentation. Perhaps the lack of resources and collaborative teamwork with existing stakeholders in a complex system undermines committed people from achieving what is often intended.
Unlike other essential services, healthcare is multidimensional that needs re-engineering of entire ecosystem. Though it sounds like a mammoth task but we need to address major elements impacting healthcare "all at once", in order to create a successful healthcare delivery model that is sustainable, scalable and replicable accross geographical boundaries.
Our extensive field research has pointed us in the direction that our Rural Health Care Re-engineering efforts must include atleast 4 interdependant models that should be seamlessly integrated to achieve desired results. Each pillar of the model recognizes the value of collaboration, i.e. by pooling of expertise, fostering partnerships and sharing of resources, skills & experience wherever possible.
1. Service Delivery Model -
This pillar focusses on facilitating locally empowered and motivated agents of change that can deliver need based services in the village itself. These services should be designed on the basis of primary epidemiological data, address consumer preferances and offer a range of services which may be "Demand based" or "Protocol based". The services be broad enough to include preventive as well as therpeutic interventions, leveraging best of modern allopathic system and traditional alternative systems of medicine.
The components of service delivery are not only delivered in the field but also rely upon strength of established hospitals and Institutions. These could be partner hospitals at local district level as well as larger tertiary care facilities that have dedicated administrative, telemedicine and ambulance command center support.
Essential component of service delivery model is meticulous data collection and analysis that generates useful insights for planning of timely and appropriate interventions and to monitor progress. The program would develop in a constantly learning & evolving fashion.
The bed of this model essentially rests upon mutually supporting partner networks. No single player would have enough capability and resources to meet all the challenges at once. Like minded social entrepreneurs can share their strengths and contribute in collaborative fashion into a common platform. NGOs that work towards nutrition, sanitation, education, local empowerment, entrepreneurship and agriculture are indirectly contributing to improving health. Direct partnership can be as simple as doctors contributing their time online at their own convinience, or be large scale biotechnology, pharmaceutical and biomedical engineering companies contributing innovative solutions. Moreover, public health specialists, engineers, programmers, educationists, social activists, agri-business companies, Governments, funding agencies - there is scope for everyone to contribute "coherently" as team players.
2. Technology Model
The technology can enable a vast range of activities which were not possible in the past. The doctors can see the patients, interact with them and acquire relvant clinical information and even advise using Information & Communication Technology. The entire Medical Record can be maintained online in digital format and be interfaced with Hospital Information Systems, Financial Institutions and all other stakeholders.
3. Supply Chain Model
The doctor's prescription can reach the village in digital format but it is of no use unless it gets executed by either medication supply, sample testing, referral or emergency transportation. These products have to reach the consumer in timely manner, with accuracy and accountability. This pillar attempts to solve the problem of logistics - for making preventive and curative solutions, Medicines, Cheap Point Of Care Diagnostics, Health related products reach the last mile.
4. Financial Risk Pooling Model
All said and done, someone has to bear the cost of the service model. Either the Consumer bears it directly or someone else on his/her behalf. It may be Charity, Government, Risk pooling funds or Other mechanisms that bears the cost to make it sustainable. Innovations in financial model can ride on and support the innovations in abve 3 models.
Our vision is to let innovations in these diverse fields be synthesised and matured to achieve single common objective - "To make it possible for all human beings enjoy the fundamental human right to access healthcare when they need it and in cultually appropriate manner".
We have made a small beginning, you are welcome to join hands.
Sunday, November 8, 2009
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1 comment:
Excellent article. Dr. Matsunaga and I have talked about how we would like LHD to be a tool to help enable simpler tasks to be de-skilled and thus localised where they are needed, and keeping costs down too.
Clayton Christensen's "Innovator's Prescription" frames this as using disruptive innovation to move health care down a continuum of intuitive medicine, to empirical medicine, to precision (rules-based) medicine. Each move down the continuum allows cheaper and less skilled help to deliver accetable care levels for the situation.
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