Portable Health Clinic: An Advanced Tele-Healthcare System for Unreached Communities

Abstract

The Portable Health Clinic (PHC) system endeavors to take healthcare facilities along with remote doctors' consultancy to the doorsteps of the unreached people using an advanced telemedicine system. Thus, the necessity of having physical healthcare peripheries specially in the developing countries can be mitigated. The PHC system promotes preventive healthcare by encouraging regular health checkups so that diseases can be prevented as well as their severity can be mitigated, leading to a reduction on healthcare expenses. Thus, the number of patients along with excessive workload on existing healthcare human resources can be minimized. The current project in rural Bangladesh alone has served more than 41,000 people so far by the PHC system and a simple analysis of this data shows some significant findings on regional health status. A simple expansion of this program, covering a wider service area, can produce a big data to reflect the whole country's health profile.

Full text

Portable Health Clinic: An Advanced Tele-Healthcare System for Unreached
Communities
Rafiqul Islama, Yasunobu Noharaa, Md Jiaur Rahmanb, Nazneen Sultanab, Ashir Ahmedc, Naoki
Nakashimaa
a Medical Information Center, Kyushu University Hospital, Fukuoka, Japan
b Grameen Communications, Dhaka, Bangladesh
c Department of Advanced Information Technology, Kyushu University, Fukuoka, Japan
Abstract
The Portable Health Clinic (PHC) system endeavors to take
healthcare facilities along with remote doctors’ consultancy to
the doorsteps of the unreached people using an advanced
telemedicine system. Thus, the necessity of having physical
healthcare peripheries specially in the developing countries
can be mitigated. The PHC system promotes preventive
healthcare by encouraging regular health checkups so that
diseases can be prevented as well as their severity can be
mitigated, leading to a reduction on healthcare expenses. Thus,
the number of patients along with excessive workload on
existing healthcare human resources can be minimized. The
current project in rural Bangladesh alone has served more than
41,000 people so far by the PHC system and a simple analysis
of this data shows some significant findings on regional health
status. A simple expansion of this program, covering a wider
service area, can produce a big data to reflect the whole
country`s health profile.
Keywords:
Preventive Healthcare, Telemedicine, Triage
Introduction
Healthcare facility is a basic right for all human beings.
Unfortunately, the shortage of qualified doctors and health
workers, insufficient medical facilities and lack of healthcare
awareness remain as some major obstacles for ensuring a
standard level of healthcare service in the developing countries
[1, 2]. Under this circumstance, telemedicine with preventive
healthcare could be considered as a key to overcome this
situation. Keeping this in mind, the Portable Health Clinic
(PHC) system has been developed as an advanced telemedicine
system for the rural communities in Bangladesh [3, 4]. This
system, also called “Doctor in Box”, enables bringing
healthcare services to the doorsteps of the rural communities at
a affordable price (Figure 1).
Nowadays, the prevalence of non-communicable diseases like
Diabetes Mellitus and Hypertension has increased to a cautious
extent. Being a developing country, Bangladesh is not an
exception. From our studies, we have learned that not only the
urban people, but the people in suburban and rural areas are
equally affected by these diseases. These diseases and the
consecutive complications can be effectively prevented by
taking cautions beforehand. Prevention is more important in
countries like Bangladesh because of the limited ability of
people to spend on health bills and the absence of provision
from government. Preventing such diseases to occur or
diagnosing it at early stage can help people to save substantially
on medical bills. For this, regular screening of health status is
important which can be facilitated by the PHC. Thus, the PHC
system has been developed in a preventive healthcare approach
with a special focus on non-communicable diseases [5, 6]. One
of the main obstacles for ensuring basic healthcare service in
developing countries is the poor doctor-patient ratio. According
to World Health Organization (WHO), where it requires at least
12 doctors for standard healthcare service to every 10,000
populations, Bangladesh have just 4 doctors. However, it is not
that easy to increase the number of doctors in a short period of
time. When it is not easy to improve this doctor-patient ratio by
increasing the number of doctors alone, decreasing the number
of patients is very important. The PHC system also aims to
contribute in improving this doctor-patient ratio by introducing
preventive healthcare to reduce patients by advance
intervention to the problem.
Figure 1. Portable Health Clinic (“Doctor in Box”)
The PHC system made it possible to provide primary healthcare
services to the doorstep of the rural communities through a
telemedicine system. However, to ensure better consultancy by
the remote doctor, accurate and a wide range of diagnosis
reports of the patient are required to be available to the remote
doctor. Unfortunately, most of the developing countries do not
have enough quality diagnosis laboratories in the rural areas
with qualified pathologists for producing reliable reports.
Therefore, this work introduces a new module to the PHC
system called the “Tele-Pathology” system that enables rural
laboratory technologists to gain assistance from a remote
professional pathologist using an online tele-healthcare system
and receive the verified report from the pathologist [7]. This
involves a very simple technology using available devices like
a camera and microscope, and it can be easily replicated.
While providing this primary healthcare service in rural
Bangladesh, a huge need of eye care services was identified.
MEDINFO 2019: Health and Wellbeing e-Networks for All
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This article is published online with Open Access by IOS Press and distributed under the terms
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doi:10.3233/SHTI190296
616

Considering this demand in rural Bangladesh, this work also
added another new module with the PHC system called the
“Tele-EyeCare” system for ensuring eye care services [7].
The main objective of this work is to improve the PHC system
and expand the service scope so that it can respond to the wide
range of demands of rural patients with quality consultancy
aided by accurate diagnosis. Addition of Tele-Pathology and
Tele-EyeCare modules will contribute significantly in this
direction.
Methods
PHC System Structure & Operations
The PHC system consists of 4 components: 1) PHC box with
various medical sensors, internet enabled tablet pc and printer,
2) health worker 3) online dataserver for sharing and
preservation of health data and 4) remote doctor call center
(Figure 2). The health worker brings this PHC box to the patient
to measure the vital information and upload this data, along
with the medical history of the patient to the online server using
the system application (app). The remote doctor gains access to
this data and makes a video call to the patient for further
verification. Finally, the doctor produces an online prescription
and preserves it in the server under the patient`s personal file.
Then, the health worker prints the prescription from the server
and passes to the patient with detail explanation instantly
(Figure 3). The whole process to serve one patient takes about
15 minutes excluding doctor`s consultancy time.
Figure 2. PHC System Structure
The PHC system introduces a triage process based on the
concept of “B Logic” for the people of Bangladesh. It classifies
the subjects under investigation in four categories, namely, (i)
green or healthy (ii) yellow or caution (iii) orange or affected
and (iv) red or emergent, based on the gradual higher risk status
of health [8-11]. The subjects under orange and red are
primarily diagnosed as in the risky zone who need doctor`s
consultancy. However, the major part of the subjects who are
diagnosed in the alarming zone (yellow) can be served by the
trained health workers without medication and they can be
prevented from shifting to the risky zone (orange and red) being
under the guided lifestyle. This reduces the pressure on the
doctors, enabling them to focus on the risky patients who
deserve better attention.
Tele-Pathology System
The Tele-Pathology module of the PHC system enables the
rural diagnostic centers operated by laboratory technologists
(diploma) for producing quality pathological report with the
support of the qualified remote pathologist (Figure 3). At
present, this system is capable of a blood hematological (CBC)
test, routine examination of urine, routine examination of stool
and a skin scarping test. In this system, the rural laboratory
technologist (1) collects the sample, prepares the physical
report, produces the test slide, (2) takes a number of
microscopic images of the slide with varying positions and then
(3) uploads the images along with the physical report to the
online server. The remote pathologist then (4) diagnoses the
sample based on the microscopic slide images with the
reference of physical report, finalizes the pathology report and
preserves to the online server.
Figure 3. Tele-Pathology System
In case a pathological report is required by the call center doctor
(physician), the doctor can gain access to the report from the
online server for preparing a prescription. If needed, the
laboratory technologist can also download this report to deliver
to the patient.
Tele-EyeCare System
The Tele-EyeCare module of the PHC system ensures primary
eye care services for the rural communities. This module has
added a Digital Fundus Camera to the PHC box for retinal
imaging (both Mydriatic & Non-Mydriatic) of the patients. This
enables the health workers to have a better view of the retina
and the peripheral for identifying the problem with certainty.
Thus, the trained local health workers check and classify the
patients as per severity of the problem. Low risk patients with
simple complications are served by the health workers.
However, in case of doubtful cases, the patients` vital
information, initial primary checkup reports and ophthalmic
images are shared with a remote ophthalmologist using the
online server (Figure 4).
Figure 4. Tele-EyeCare Service System
The ophthalmologist then checks the initial primary checkup
reports produced and shared by the local health worker,
investigates the ophthalmic images, directly talks to the patients
over video conference system, reconfirms their status and
finally, provide online prescriptions. If needed, the
ophthalmologist can ask for further investigation of the patient
by the health worker and can also provide glasses prescription
with the support of the health workers. Thus, this system
enables to provide basic eye care to the ordinary patients by the
health workers and special care for the critical patients by
R. Islam et al. / Portable Health Clinic: An Advanced Tele-Healthcare System for Unreached Communities 617

professional ophthalmologist who really deserve special
attention.
Village Service Delivery Model
In village service delivery model, preferably one female health
worker works in a village as she can gain better access to the
female patients due to privacy reasons. Usually, she uses a local
village medicine shop (pharmacy) as her service point for daily
service and general village patients come there for PHC service
(Figure 5). However, she also visits door to door in case of
elderly or disabled patients, pregnant women, emergency
patients or special on-call service.
Figure . Village Service Delivery Model
Urban Service Delivery Model
Although, it was developed for the low income rural
communities, it is found equality useful for the urban, rich, and
aged community for home delivery service. The main clients
are aged people who are suffering from non-communicable
diseases like hypertension and diabetic that need regular
checkups. Although, they are financially rich but as it is
difficult for them to visit hospital regularly due to physical
stress, trouble to arrive at doctor`s appointment at expected
time, traffic congestion, etc. So the PHC home delivery service
is offered to the pre-registered urban patients and the health
workers visit the patients as per schedule.
Personal Health Record
The PHC system preserves all medical data of the patients in
the online server so that the doctor can refer previous data in
need. All checkup data, pathological reports, medical histories
and prescriptions are preserved sequentially. Also, all the
patients are provided with their respective user id and password
for their access to their personal, health record which is
maintained with high security and privacy (Figure 6). They can
change their profile information but only monitor the health
records with graphical representations.
Figure 6. Personal Health Record & PHC Prescription
The prescriptions produced in the PHC system are unique in
shape and format considering the targeted patients of the rural
communities (Figure 7). It contains both the measured health
data in the left side and doctor medication with advice on the
right side. As most of the patients do not understand the
significance of digits, it shows all health data with
corresponding color sign. The same four colors of the triage
system (green, yellow, orange and red) are used against each
data point so that they can easily understand the severity of any
particular item.
Results
The PHC healthcare services have been offered in 18 districts
of Bangladesh at more than 70 service points all over the
country (Figure 7). Until April 22, 2018, the number of patients
served by the PHC system in Bangladesh alone was 41,949.
Besides, the PHC activities are also continued in Cambodia,
India, Thailand and Pakistan under the supervision and
management of local partners.
Figure 7. PHC Service Statistic in Bangladesh
The diagnosed major diseases found in PHC healthcare services
are hypertension (1,944), diabetes (1,365), anemia (647), and
ophthalmic problem (138).
The Tele-Pathology service started in 4 rural diagnostic centers
under 4 districts (Barisal, Bogura, Manikganj and Thakurgaon)
of Bangladesh. So far, this system has served patients with a
total of 1,610 Hematological (CBC) reports and 918 Routine
Examination of Urine using remote pathologists.
The Tele-EyeCare mobile service has recently started in 1 rural
center called “Vision Center” in the Nator district of
Bangladesh on a test basis. So far, it has already served 2,410
checkups for 2,046 patients using remote ophthalmologists.
Soon this service will be extended to other parts of the country.
Discussion
Out of a total 41,949 PHC healthcare patients, 61% (24,786)
was green and yellow patients who were served by the health
workers alone. The rest of the patients 39% (16,198) were
served by doctors who needed medication. So, the PHC system
can reduce the work load of a professional doctor by 61% that
can be managed by local health workers. Thus, the best use of
the valued resource of a doctor can be ensured and only the
people who really need expert`s consultancy can avail it.
Due to its easy operation, a huge number of health data can be
collected by the PHC system and this big data can be used for
countrywide disease pattern analysis. For example, this
research has found some significant differences of health
parameters in different areas. In one area, we have found a
5
R. Islam et al. / Portable Health Clinic: An Advanced Tele-Healthcare System for Unreached Communities618

significantly small number of anemic cases among the adult
women compared to the rest of the country. In another area, we
have identified very high urine protein compared to the rest.
Thus, the detail analysis of this data may show some significant
findings including environmental issues.
Similar to the shortage of physicians, there is a huge shortage
of ophthalmologists and it is just 0.063 ophthalmologist for
every 10,000 populations in Bangladesh. The Tele-EyeCare
module of the PHC system can highly contribute to ensure the
best use of this valued resources for dealing with complicated
cases and manage ordinary cases by health workers. For the
further advancement of the Tele-EyeCare system, a new
development has been started using Artificial Intelligence (AI).
It will use ophthalmic image recognition technology with the
aid of neural network and deep learning for automatic diseases
identification. This will facilitate both the village health
workers and ophthalmologists for better and prompt services.
Conclusions
At present, the PHC tele-healthcare system offers a unique
opportunity for ensuring better healthcare service covering
primary healthcare, eye care and pathological services to the
unreached rural communities. However, this modular system
will gradually be expanded in other healthcare service areas to
cover common healthcare issues based on the local demand.
Now, we are working on an Obs & Gyne module and Dental
Care module to be added soon to the PHC system.
The concept of the PHC system came from the local demand of
Bangladesh. However, since most of the developing countries
are facing the same problem and having similar situations, an
easily replicable PHC system can be in good use there. So far,
this system has been replicated in India, Pakistan, Cambodia
and Liberia with some localizations. However, there is still
plenty of opportunities for further improvement of the system
and expansion of the service to the other parts of the world.
Since the aging communities are increasing in the developed
countries, they are also facing a similar crisis of doctor shortage
in their rural areas. Therefore, there will arise a huge demand
of PHC services in the developed countries as well [12]. To
address this demand, the PHC system can be further improved
with the aid of technologies. One of these attempts is to include
Bluetooth enabled medical sensors so that the measured vital
data from the sensors will be automatically transferred to the
online server to avoid typing error from manual data entry [13].
Also, there is a requirement to develop the PHC box as an
integrated unit so that it will be low cost, handy and light weight
for easy operation by a rural health worker.
Acknowledgements
This research has been supported by Grameen Communications
of Bangladesh and Kyushu University of Japan. The authors
sincerely acknowledge the contribution from both the sides.
References
[1] S.M. Ahmed, M.A. Hossain, A.M. Rajachowdhury, A.U.
Bhuiya, The health workforce crisis in Bangladesh:
shortage, inappropriate skill-mix and inequitable
distribution, Human Resources for Health, 9(1), 3, 2011.
[2] D.T. Jamison, J.G. Breman, A.R. Measham, G. Alleyne,
M. Claeson, D.B. Evans, P. Jha, A. Mills, P. Musgrove,
Disease Control Priorities in Developing Countries,
Second Edition, World Bank and Oxford University Press,
Washington, DC, 2006.
[3] A. Ahmed, A. R. Hargrave, Y. Nohara, R. Islam, P. Ghosh,
N. Nakashima and H. Yasuura, “Portable Health Clinic: A
Telemedicine System for UnReached Communities” in
Smart Sensors and Systems, Springer International
Publishing, 447-467, 2015.
[4] P. Ghose, R. Islam, N. Nakashima, Y. Nohara, A. Ahmed,
S. Shimizu, Effectiveness of Preventive Healthcare
through Telemedicine in Bangladesh, Proceedings of 18th
ISfTeH International Conference, 2013.
[5] F. Yokota, A. Ahmed, K. Kikuchi, M. Nishikitani, R.
Islam, N. Nakashima, Diabetes, obesity, and hypertension
in Bheramara Kushtia District, Bangladesh - Results from
Portable Health Clinic Data, 2013-2016, Proceeding of
Social Business Academia Conference, 2016.
[6] Y. Nohara, E. Kai, P. Ghosh, R. Islam, A. Ahmed,
(another 4 authors), S. Shimizu, K. Kobayashi, Y. Baba, H.
Kashima, K. Tsuda, M. Sugiyama, M. Blondel, N. Ueda,
M. Kitsuregawa, N. Nakashima, Health Checkup and
Telemedical Intervention Program for Preventive Medicine
in Developing Countries: Verification Study, Journal of
Medical Internet Research, Vol.17, No.1, 2015.
[7] R. Islam, A. Ahmed, N. Nakashima, S. Shimizu,
GramHealth: An Integrated Tele-Healthcare System for
Unreached Communities, Proc. of 11st Asian Telemedicine
Symposium, 2017.
[8] Metabolic syndrome criteria of International Diabetic
Federation http://whqlibdoc.who.int/publications/2011/
9789241501491_eng.pdf (accessed on April 1, 2019)
[9] Criteria of Obesity using BMI by the National Institutes of
Health, USAhttp://www.nlm.nih.gov/medlineplus
/ency/article/007196.htm (accessed on April 1, 2019)
[10] Guideline of American Heart Association
http://www.heart.org/HEARTORG/Conditions/HighBlood
Pressure/AboutHighBloodPressure/Understanding-Blood-
Pressure-Readings_UCM_301764_Article.jsp (accessed on
April 1, 2019)
[11] Global Guideline for Type 2 Diabetes of the International
Diabetes Federation https://www.idf.org/e-
library/guidelines/79-global-guideline-for-type-2-diabetes
(accessed on April 1, 2019)
[12] T. Hasegawa, R. Suzuki, T. Sakamaki, et.al. Summary of
a multicentre prospective clinical study of home
telemedicine. Japanese Journal of Telemedicine and
Telecare, 13(2), 84-87, 2017-08.
[13] M. Hasan, F. Yokota, R. Islam, A. Fukuda, A. Ahmed,
Errors in Remote Healthcare System: Where, How and by
Whom? Proc. 2017 IEEE TENCON, 170-175, 2017.
Address for Correspondence
Rafiqul Islam (Maruf), Ph.D.
Medical Information Center, Kyushu University Hospital
3-1-1, Maidashi, Higashi-Ku, Fukuoka, 812-8582 Japan
Tel: +81 92-642-5881; Fax: +81 92-642-5889
Email: rimaruf@med.kyushu-u.ac.jp
R. Islam et al. / Portable Health Clinic: An Advanced Tele-Healthcare System for Unreached Communities 619