The dusty lanes of the Vidarbha hinterland painted a stark picture and grim reality. Despite the economic and technological advances elsewhere, life is an everyday struggle for existence in this hinterland. Interaction with many panchayat members brought up the age old issues of education, healthcare and livelihood. For such rural communities healthcare availability hasn’t increased much and the affordability has worsened. A health issue could often wipe out the savings of many years and push the entire family towards poverty. This is true not just in Indian hinterland, but in any part of the world which is as deprived. While it is a huge effort to increase the healthcare infrastructure in the long term, small investments in the connecting the unconnected and focusing on the right interventions will go a long way. New innovations in Telemedicine are making it effective at very low cost and low bandwidth and will greatly help the field workers.

Here are a couple of success stories from such an innovative non-profit tech startup – Intelehealth. In remote Odisha, there was a patient with chronic symptoms of kidney stones. The local doctor had asked a huge sum the patient couldn’t afford. The patient comes to the health worker, who using the Intelehealth app initiates a diagnosis with the remote doctor. With the remote doctors advice and help, he gets a surgery arranged under RBSY (Govt. health insurance scheme) at a fraction of cost, thus saving the family from years of debt. A great example of right advice at the right time at the door step.

In another instance, Intelehealth field worker’s 16 year old son suffered on injury to his head that required a major surgery. She sold her jewelry and mortgaged her farm to pay for treatment. Post surgery, her son suffered from frequent seizures and couldn’t join school or work. Debt made it impossible for her to pay for travel and treatment at a city hospital. He was one of the first patients at the teleclinic and the doctor was able to prescribe medications to manage his seizures. He has now joined a job and lives a healthy life.

Intelehealth was part of the first Cisco CSR & N/Core Tech – incubator for non-profit startup cohort. Having toiled for long in this space, I found the approach was refreshingly intuitive. It was proven to work by Dr Soumyadipta Acharya, a doctor turned technologist at John Hopkins and his team. The essence is to take standard medical protocols, codify them into a mind map, which in turn becomes a comprehensive questionnaire which the health worker uses to collect information. The responses get uploaded and summarized to the remote doctor who could provide a diagnosis and a prescription or ask the health worker to collect more information. All this work flow is enabled by a software stack using open-source components where possible. As Dr Acharya says the intent is to provide scientific, evidence based, and dignified care. Partnering him is Neha Goel, doctoral student at John Hopkins, who believes every life is valuable and to lead a happy, healthy life is a basic human right. An entrepreneur, technologist and a social activist all rolled into one she likes to take challenges head on. Together they co-founded Intelehealth as a non-profit along with Amal Afroz Alam and Emily Eggert in June 2016.

When you want to do something good the Universe conspires with you. Fast forward to three years later Intelehealth has built the software stack, and looking to scale its operations in India, Syria, Philippines and has an awesome team that believes in the vision. I am glad and excited to join hands with them to reach the remote corners of the world. While capitalism is widening the divide between haves and have-nots, we shall make every effort to use technology to reduce that divide.

#Telemedicine #RuralHealth #HealthcareForAll #Intelehealth

Hypertension or elevated blood pressure is one of the largest contributors to the global burden of disease and affects more than 1 billion people all over the world [1]. A recent study about the prevalence of hypertension in 140,000+ adults showed that 40% of adults had an elevated BP. Of these, only 46% were aware of their diagnosis of hypertension. What’s also concerning is that of those who were aware of the diagnosis, 87% were taking medications but only 32% people had achieved BP control! [2] There is a lot of room to improve diagnosis and treatment of hypertension.

The World Health Organisation (WHO) celebrates a themed World Hypertension Day every year on 17th May and the International Society of Hypertension has designated the month of may as May Measurement Month. This year’s theme is ‘Know your numbers’ which is an encouragement for people to get their Blood Pressure (BP) checked and know their status.

What is Hypertension?

Blood pressure is the force of blood pumped by the heart, in every heartbeat, pushing against the walls of blood vessels.  Normal adult blood pressure is 120 mm Hg when the heart contracts and pushes the blood out (systolic) and 80 mm Hg when the heart relaxes to receive the blood (diastolic).  Any blood pressure reading above 140/90 mm Hg is Hypertension.

Hypertension is usually mostly asymptomatic and sometimes vague symptoms like dizziness, headache, nose bleeds, etc. are present which can be easily mistaken for other diseases. Chronic high pressures cause damage to the heart and delicate blood vessels in leading to major diseases in target organs (see pic).[3]

Hypertension in low and middle income countries

It’s a myth that hypertension is a disease only seen in affluent countries. In India the prevalence of hypertension is 24-30% in urban areas and 12-14% in rural areas. Plus there are many more who have never checked their Blood Pressure. A survey conducted by the Rural Health Progress Trust in rural Maharashtra showed that 76% of adults had never had their BP checked even once in their life! The reasons could be ignorance of the chronic nature of the condition, non-availability of specialized doctors, myths that hypertension does not affect people living in rural areas, low quality of care and money, time and distance constraints.

The lifetime cost of controlling hypertension is also high, since one has to continuously take medications and also manage other comorbidities. Because of these constraints, strategies need to be developed that overcome these barriers to improve the diagnosis and management of hypertension in low and middle income countries.

WHO has laid down a set of low cost interventions for primary healthcare in low resource or resource poor settings called WHO PEN (Package of Essential Non Communicable Diseases Interventions) protocol. PEN is a key is key to achieving objective 4 of the WHO Global action plan for the prevention and control of noncommunicable diseases 2013-2020. It aims to provide and integrate cost effective technology guidelines, implement and monitor cost effective approach to NCDs and establish standards for health care delivery in terms of providing treatment protocols and standardizing medications prescription and delivery mechanisms. Management and control of hypertension in order to reduce the underlying risk factors for NCDs forms a significant part of the PEN protocols.

Community health workers can use telemedicine for screening, diagnosis and management of hypertension

We need effective and innovative approaches to diagnose and treat hypertension in low resource settings such as rural areas. However, non-availability of experts in rural areas is a big barrier.

Telemedicine can help shift evidence based Hypertension screening, providing diagnosis and treatment through remote experts and lifestyle modifications advice (via app prompts) to Community Health Workers. App based educational material (eg. videos, pamphlets) can be standardized and quality of care maintained across centers.  Regular app based notifications for follow up and medication reminders also help in managing Hypertension effectively and economically.

History includes onset, duration, progress, any associated symptoms and risk factors. Past history, family history and Health Risk assessment(HRA) is also made easy to understand and to record via app prompts for the CHW. Certain simple  physical examinations like Vitals (height, weight, BP, pulse, temperature, SpO2) and General examination (inspection of pallor, jaundice, neck masses, etc.) can be task shifted and the rest skilled specific system examination ( Palpation, Auscultation, Fundoscopy, etc.) can be done through referral system.

Once the CHW gathers data about the case (history and physical examination), she shares it with the doctor. The doctor then calls the patient to build up a rapport and add any missing pieces of the case. The doctor then evaluates and manages the case remotely and provides his prescription, all via the app. CHWs can also perform the important function of health education a behavior change counselling using videos and pamphlets to counsel the patient.

Studies have also shown that integrating HTN screening and monitoring in Telemedicine helps to create a safe and patient centered network among healthcare professionals (patient, CHWs and the Doctor). It improves the screening and management of hypertension and related comorbidities, and consequently achieves an effective prevention of cardiovascular diseases in the community thereby decreasing the burden on health infrastructure. [4]

Intelehealth is piloting hypertension control as part of its comprehensive primary health care delivery pilot in India and will soon launch the same in conflict-affected communities in Syria.

As the global community rises to combat this silent killer, innovative approaches to combat hypertension are the need of the hour. Are you interested in learning more about how the Intelehealth platform can be used to combat hypertension and also deliver community-based comprehensive primary health care? Reach out to us through our contact page!

REFERENCES:

[1] Chow, Clara K., et al. “Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries.” Jama 310.9 (2013): 959-968.

[2] Olsen, Michael H., et al. “A call to action and a lifecourse strategy to address the global burden of raised blood pressure on current and future generations: the Lancet Commission on hypertension.” The Lancet 388.10060 (2016): 2665-2712.

[3] Chethana KV, Anusha T, Mane A, Prasad VM, Sunkad VM. Prevalence of hypertension and its risk factors among adults in urban field practice area NMC, Raichur, Karnataka, India Int J Community Med Public Health. 2017;4(1):45-50

[4] Omboni S, Ferrari R. The Role of Telemedicine in Hypertension Management: Focus on Blood Pressure Telemonitoring. Current Hypertension Reports. 2015;17(4):1522-6417

Intelehealth is a Digital Health Platform to support Health workers to deliver primary health care services at the last mile.