Digital Health Services to Bridge the Health Disparity

The term “cardiovascular disease” (CVD) refers to any disease of the heart, vascular disease of the brain, or disease of the blood vessel. This broad term includes a large range of specific diseases including; Coronary Artery Disease (CAD), Myocardial Infarction, Arrhythmia, Heart Failure, Congenital Heart Defects, Cardiomyopathy, Peripheral Artery Disease. While this term, CVD, encompasses a broad span of diseases, a majority of specific diseases under CVD are grave in and of themselves. CAD involves the hardening and narrowing of the coronary arteries, producing blockages in the vessels that carry blood to the heart. Myocardial Infarction (MI), or heart attack, happens when blood flow to the heart is severely reduced or cut off, due to the hardening and narrowing of the coronary arteries from the buildup of fat, cholesterol, and other substances, known together as ‘plaque.’ A blood clot forms around the plaque, blocking blood flow.

This results in permanent damage or death of part of the heart muscle. Another disease, Peripheral Artery Disease (PAD), is a type of vascular disease (diseases that affect the circulatory system) that occurs when fat and cholesterol deposits, or ‘plaque,’ build up in the peripheral arteries (which are the blood vessels outside the heart). This build up narrows the artery walls, restricting the amount of blood flow to the body’s tissues.

In America, heart disease is the leading cause of death, before cancer and chronic lower respiratory disease. Cardiovascular disease (CVD) causes one in three (approximately 800,000) deaths reported each year in the United States. In all three of the examples listed above in the previous paragraph (CAD, MI, PAD), one major factor in its prevalence is the buildup of fat. One widespread American staple known for contributing to this, is fast food.

American food in general is notorious for being unhealthy and for being consumed in exorbitant portions. The annual direct and overall costs resulting from CVD are estimated at $273 billion and $444 billion, respectively.1 It’s interesting to think how much of these costs could be offset if Americans made a nation wide effort to eat healthier. Of course, there have been campaigns throughout the country to make America’s food habits healthier, and there has been an increase in vegetarianism and veganism in the country. However the reality is, even with all these efforts, a large portion of Americans, especially low income individuals, continue to eat unhealthy whether for social or economic reasons. Fast food is less expensive than healthier alternatives.

Cardiovascular disease is the No. 1 cause of death globally: more people die annually from cardiovascular than from any other cause. The World Health Organization has a target goal for countries to reduce the prevalence of CVD in participating countries and have started the Global Hearts Initiative in partnership with the US CDC. However, even with all these efforts, a research article over the trends of cardiovascular disease in India over the course of twenty years show that the prevalence of cardiovascular disease has worsened. In addition, the incidence of cardiovascular disease is rapidly increasing in rural areas as well. Perhaps this large increase is due to the fact that there are many factors and many forms of cardiovascular disease.

For example, in China, coronary disease due to plaque build-up is less prevalent, but stroke prevalence is much higher compared with most Western developed countries. On the other hand, cardiovascular disease death rates in India are substantially higher than compared with those reported in China over a similar time period—and may relate to a truly higher cardiovascular disease risk in India.5

People in poor countries tend to have less access to health services than those in developed countries. Deprivations that lead to ill health are common in developing countries, and the poor population in developing countries are particularly at risk. The relationship between poverty and access to health care is cyclical, where poverty leads to ill health, which in turn maintains poverty. Worldwide, about 150 million people a year face catastrophic health-care costs because of direct payments such as user fees, while 100 million more are driven below the poverty line. Even if they could , access to doctors would be a challenge. Low-income countries have almost ten times fewer physicians than high-income countries. Nigeria and Myanmar have about 4 physicians per 10,000, while Norway and Switzerland have 40 per 10,000. Thus the first step to solve such a problem, especially a problem such as Cardiovascular Disease where people tend to discount its symptoms until the problem worsens, is to ensure that those in developing nations and rural areas have access to proper health care.

Digital Health Services

One way to combat this rising disparity in health care between low income nations and high income nations is through the use of digital health solutions, or telemedicine, which includes the remote diagnosis and treatment of patients by means of telecommunications technology. Almost 70 percent of the world’s mobile phone subscribers are in the developing world, yet people in such areas can travel around 100 kilometers to reach the nearest health professionals. Out of the total world population of approximately 7.5 billion, internet users encompassed 4 billion people as of 2018. Meaning more that 50 percent of the world has access to the internet.

With such a large user base available, digital health services can remove the need to travel long distances for non critical services, and even in some cases for more critical services. Telemedicine can improve the quality of care for patients with both medical and mental health conditions. A study by Harvard Medical School showed that with telemedicine, patients had: 38% fewer hospital admissions, 31% fewer hospital readmissions, 63% more likely to spend fewer days in the hospital, and were overall more engaged in their healthcare. The US government, through nationwide health programs has begun to encourage the growth of telehealth services.

According to the Medicaid website, Medicaid views telemedicine as a cost-effective alternative to the more traditional face-to-face way of providing medical care. The federal Medicaid program encourages states to use the flexibility inherent in federal law to create innovative payment methodologies for services that incorporate telemedicine technology. The idea behind telemedicine and its current market focuses on the idea of bringing the quality health care of big and urban areas in the US to rural hospitals in order to minimize the need to transport critically ill patients and to minimize the growing disparity between low income and high income individuals. However even then, it still remains an relatively untapped source of potential in the field of health care. Out of the 50 states in the country, twenty states cover telehealth services the same as its traditional health care counterparts, and two states have enacted partial parity laws that require a limited coverage of and reimbursement for telehealth services.

If such an idea can work successfully connecting rural areas in America and urban areas, what is preventing the same idea from being implemented for rural areas of developing countries?

The four areas that would need to be addressed while considering treatment options in third world countries are; routine check-ups, critical condition care, post surgery rehabilitation, and in home support.

Routine Check-ups

Telehealth, regardless of geographic location, fosters a patient’s ability to connect with a health system on a more flexible basis and often without an in-person visit. Patients are able to receive services by using secure cloud servers that will allow information exchange including video or data, often with the added benefit of reducing travel to health care facilities. A systematic review by the American College of Cardiology found that the use of telehealth in cardiovascular disease provides consistent benefit for communication and counseling and for remote monitoring of patients with chronic conditions, improving outcomes including mortality rates, quality of life and reduced hospital admissions.

Through routine check ups, different risk factors for Cardiovascular Disease can be monitored and stored in the cloud database such as blood pressure, fasting LDL and HDL (cholesterol), body weight, blood glucose, and diet. While seemingly arbitrary tests, these can help the doctor determine any increased risks or early onsets of Cardiovascular disease. High blood pressure greatly increases the risk of heart disease and stroke; obesity raises the risk for health problems such as heart disease, stroke, atrial fibrillation, congestive heart failure; High blood glucose levels increases the risk of developing insulin resistance, prediabetes and type 2 diabetes, which if left untreated can lead to many serious medical problems including heart disease and stroke. In rural areas, where access to health care is limited, the opportunity cost of travelling long distances to receive check ups and non critical care tends to be higher as it removes from time that could be spent being productive, thus these factors tend to be overlooked. This goes on to prove that connecting patients in rural areas to experts in the field, regardless of distance, can be beneficial in improving health outcomes.

Critical Condition Care

Critical care medicine is the specialty that cares for patients with acute life-threatening illnesses where intensivists look after all aspects of patient care. Nevertheless, shortage of physicians and nurses, the relationship between high costs and economic restrictions, and the fact that critical care knowledge is only available at big hospitals puts the system on the edge. In this scenario, telemedicine might provide solutions to improve availability of critical care knowledge where the patient is located, improve relationship between attendants in different institutions and education material for future specialist training. Current information technologies and networking capabilities should be exploited to improve intensivist coverage, advanced alarm systems and to have large critical care databases of critical care signals.

With time, evidence has accumulated that rapid attention is critical not only for trauma victims but also for cardiovascular emergencies. ICU telemedicine may promote evidence-based practice via prompting and checklists facilitate early recognition and treatment of physiological deterioration and improve care coordination between interprofessional care providers to prevent critical situations from even arising.

While in cases of critical care, digital health services cannot serve as a replacement for traditional physicians, they can aid and play hand in hand with traditional medicine. The current models in operating rooms and emergency rooms follow the framework in which a specialist is present at all times to monitor the patient’s recovery, assessing the patient’s condition and history and monitor vitals. What is preventing the surgeons from fulfilling these responsibilities from a remote location?

Post Surgery Recuperation Monitoring and Support

In general, patient willingness towards telemedicine use in the postoperative setting is high. For example, in the field of vascular surgery, a sizable proportion of patients, around 90 percent reported willingness and confidence in provider ability to conduct remote postoperative care including blood pressure monitoring, medication adherence guidance, and evaluation of postoperative wounds. Since many of these local hospitals provide care to wide geographic regions and have patients with significant traveling distances, patients are more likely to prefer remote follow-ups through the use of telemedicine as it can save time for the patient.

The economic implications extend beyond the person directly affected by the disease. First, it would decrease the amount of able people available to participate in the workforce and remove a source of income from a family. This in turn would prevent any potential children from being able to receive an education, either due to a lack of available funds or a need for the child to work or care for the family. Not only does this have a detrimental impact on the individual family, but it also affects the country as a whole. Through this cycle, the number of workers decrease, which means the output of the countries decrease, which means the GDP of the country is not at its full capacity. It can be seen why efficiency in the healthcare system is of the utmost importance in these countries. Telemedicine achieves this goal of efficiency by removing the factors of distance and time from post. Patients and their families can potentially avoid taking time off from work and other responsibilities by utilizing telemedicine for postoperative care

Resource for Local Surgeons

In addition to providing direct aid to rural areas, building a scientific infrastructure for local physicians and specialists to thrive independently is important as well. Quite simply, without the contribution of indigenous specialists, there will be a barrier of misunderstanding in terms of societal norms and traditions which could have a substantial effect on the most effective and comfortable practice of combating diseases. For example, South and East Asians culturally tend to place more of an emphasis on filial piety that Americans do. Hospice care would be a better solution for geriatric care in Asian countries more than in patient care or nursing homes, which are more popular in America.

This idea stems from the famous Chinese proverb “If you give a man a fish, you feed him for a day. You teach him to fish and you give him an occupation that will feed him for a lifetime.” For example, in the case of Botswana’s anti-AIDS program, the program had received $50 million from the Bill and Melinda Gates Foundation and the Merck Foundation. However, the program has only been able to spend about 70 percent of that money, largely due to a shortage of healthcare workers and a lack of clinics, laboratories, and warehouses. In promoting action from within the country, not only does it allow for more efficient care, as diseases manifest differently based on geographical and cultural variation, but it also allows individuals in the country a chance to break out of the cycle of poverty and puts more autonomy in the hands of the people.

Telemedicine can also be used between low and middle income countries (LMIC) and high income countries as a training mechanism for the local doctors. In small rural hospitals in developing countries, the likelihood of specialists being available in emergencies pertaining to their field is slim – especially in cases pertaining to more specialized fields.

How It Would Work

The patients would be able to record any information necessary such as blood pressure and weight through the equipment provided transmitting information via text, audio, video, or still images and send them to a specialist anywhere on the globe. This information would be placed in an encrypted cloud server that the physician or surgeon could access.

Current advances in technology opens up the possibility of using information and communication technology effectively. This solution bridges the gap in physical distances between patients in remote areas and medical specialists around the world. The recent advances in broadband technology facilitates anytime, anywhere access. It is not required for the doctor to be present physically at the hospital instead cloud computing based framework could be used to deliver virtual medical care. Digital solutions have real benefits for both patients and clinicians; it can help patients to better manage and understand long-term health conditions and it can help clinicians to track their patients’ health statuses and to intervene in a timely manner when potentially negative trends or abnormal measurements are observed beyond physical boundaries.

The digital solution being proposed will have four distinct domains of applications:

• Live video (synchronous): this is a secure, real-time, two-way interaction between a patient and a cardiovascular clinician. Live video can be used for consultation, diagnostic, and treatment services.
• Store-and-forward (asynchronous): this includes the transmission of patient data (such as blood pressure, pulse rate, blood test results, x-rays etc), recorded videos via secure communication systems to the medical specialist, who can then review this information and provide a consultation at a later time. Store-and-forward telemedicine systems can leverage secure cloud storage for its many benefits including on-demand scalability.
• Post-Surgical Remote patient monitoring: this involves post-surgical care of patients via electronic communication technologies, which is transmitted to a provider, or often a nurse call-center, (sometimes via a data processing service) in a different location for use in patient care and support, which may include escalation to a patient’s primary care or specialist physician when warranted. This data can be stored in secure cloud domains and used for analyzing the patient’s future conditions and understanding their health history.
• Mobile Health: involves using smartphones and mobile applications in cardio care.

Traditionally, telemedicine systems have run on enterprise systems, which are large-scale application software packages. These can end up costing healthcare organizations upwards of thousands of dollars for a singular telemedicine cart (An all-=in-one cart can range anywhere from $20,000 to $200,000). For smaller scale institutions, such as those in rural areas, this can be a bit of a problem. They have neither the resources to sustain such efforts not the capacity to house it over a long period. Having a cloud-based service can save thousands of dollars, directly impacting a provider’s bottom line. Cloud services maximizes storage and, by placing it with a third party vendor, removes the need for a physical data center.

The secondary part of applying telemedicine to the real world is applying the cost of equipment and other medical peripherals. This includes digital stethoscopes which enables users to digitally chart information directly from the stethoscope to a internet connected source, including computers and cell phones).