Using Information Technology for Healthcare in Ghana

1
Using Information Technology for Healthcare in
Ghana

• Melissa Ho
• UC Berkeley School of Information
• Ghana Physicians and Surgeons Foundation
  Conference
• Embassy of Ghana, Washington, DC
• Saturday, April 29, 2007

2
1
3
Overview
About

• Introduction About ICT4D and TIER
• Research TIER Work in Ghana
• Networking A Tutorial on Networking
• Findings Whats in Ghanas Hospitals?
• Software Enabling Asynchronous Telemedicine in
  Ghana

4
Technology and Infrastructurefor Emerging
Regions (TIER)
About
http//tier.cs.berkeley.edu
5
What is ICT4D?
About

• Information and Communications Technology for
  Development
• Seeking sustainable ways to use ICTs to improve
  development
• OpenMRS Open Source Electronic Medical Records
• GrameenPhone Microfinanced cell phones
• Akshaya Networks Rural Information Kiosks
• Aravind Eye Hospitals Telemedicine

6
Aravind Eye Hospital
About

• Network of 5 hospitals in South India
• Mission Eradicate needless blindness

Patient Throughput
2006 1.8 Mn patients, 270K surgeries, 1.5K free
mobile eye-camps
7
Approach 1 Eye Camps
About

• Team of doctors sent out to remote areas
• Conduct comprehensive eye exams
• 2005 1335 eye camps, avg. 327 patients/camp
• Only reached 7 of target population!
• Other Issues
• Raising Awareness
• Delayed treatments, no care seeking behaviour,
  limited opportunities for follow up
• Also, not solving the doctor utlization problem

8
Approach 2 Vision Centers
About

• Rented room in village home (Rent 50/mo)
• Staffed by 2 ppl (Total salary 100/mo)
• Equipment Slit lamp, refractive testing setup,
  lens grinder, PC with webcam for Telemedicine

9
Aravind Telemedicine Network
About
10
Patient Data
About
Growth Rates Ambasam 1.4 Andipatti 3 Bodi
13.5 Chinna 15.4 Peria 14.9
11
Summary of Total Patient Data
About

• 18,210 remote video consultations
  (Jan 06 Feb 07)
• 3000 significant vision improvement
• 1868 patients/mo (June 06 Feb 07)

Real Patients
12
Overview
Research

• Introduction About ICT4D and TIER
• Research TIER Work in Ghana
• University Deployment
• Healthcare and Computing
• Networking A Tutorial on Networking
• Findings Whats in Ghanas Hospitals?
• Software Enabling Asynchronous Telemedicine in
  Ghana

13
Research
20m
9.2 km
80m
20m
12.9 km
18.2 km
University of Ghana Intranet Deployment (Accra)
14
Projected Network
Research

• University of Ghana at Legon
• Korle Bu Teaching Hospital
• Cape Coast University
• Takoradi Technical Institute
• Winneba Teaching College
• Kwame Nkrumah University of Science and Technology

15
(No Transcript)
16
The Problem of Brain Drain
Research
17
5
Can Technology Help Doctors - Combat
professional isolation? - Fix gaps in referral
infrastructure? - Leverage their social networks?
18
5

• CHALLENGES
• Physical Infrastructure
• Sustainability
• Outreach

19
Healthcare and Computing
Research

• Winter 2005/2006 Initial Needs Assessment
• Trust Hospital, Korle Bu Teaching Hospital
• Bolgatonga and Wa Regional Hospitals
• Korle Bu Polyclinic
• Winter 2006/2007 Design Validation
• Korle Bu and Komfo Anoyke Sword Teaching
  Hospitals
• Most of the Regional Hospitals
• Selected District Hospitals
• Summer 2007 Pilot Deployments

20
5
21
Site Surveys and Design Interviews
Research

• Visit hospitals to assess existing infrastructure
• Availability of computers
• Local Area Network
• Internet access
• Interest in communications technology
• Status of landlines and mobile phones
• Key Questions for doctors
• What access do they have to computers and the
  Internet? Do they use e-mail?
• How do they do consultations now? Do they
  leverage their social networks?
• What kind of information is useful for
  consultations, and how should it be formatted?
• How do we establish trust between doctors?
• What information do they feel comfortable sharing?

22
Road Trip
Research

• Accra
• Tema (Greater Accra)
• Ho (Volta)
• Gamenu (Volta)
• Ada Foa (Volta)
• Kumasi (Ashanti)
• Tamale (Northern)
• Bolgatonga (Upper West)
• Navrongo (Upper West)
• Wa (Upper East)
• Sunyani (Brong-Ahafo)
• Berekum (Brong-Ahafo)
• Winneba (Central)
• Cape Coast (Central)
• Takoradi (Western)

23
Tele-consultation Pilot
Research

• Korle Bu Teaching Hospital
• Kasseh Hospital (Ada)
• Winneba District Hospital
• Cape Coast Regional Hospital
• Cape Coast District Hospital
• Takoradi Regional Hospital
• Takoradi District Hospital

24
Overview
Networks

• Introduction About ICT4D and TIER
• Research TIER Work in Ghana
• Networking A Tutorial on Networking
• Network Infrastructure Options
• Infrastructure in Ghana
• Choosing an Infrastructure
• Findings Whats in Ghanas Hospitals?
• Software Enabling Asynchronous Telemedicine in
  Ghana

25
Very Small Aperture Terminal
Networks
VSATs
Up 64kbps Down 0.5-2Mbps
Hub Station
MSSRF Telecenter Villianur, Pondicherry, India
26
Fixed Line InfrastructuresFiber, ADSL, and
Dial-Up
Networks

• Dial-up
• 56kpbs, requires existing land line
• ADSL
• Up to 1.5 Mbps download, 256 kbps upload
• Requires existing land line
• Fiber-optic
• 1000/km in India
• 100,000/km in urban United States

Ghana Telecom Broadband4U DSL School Pricing
27
GhanaPlanned Fiber
Networks
TO OUAGADOUGOU (BURKINA FASO)
BAWKU SUBSTATION
TUMU
NAVRONGO
BOLGATANGA
U
P
P
E
R

E
A
S
T
DAPAONG (TOGO)
SUBSTATION
HAN
R
E
G
I
O
N
UPPER WEST
REGION
WA
NORTHERN REGION
LEGEND
SAWLA
YENDI
TRANSMISSION LINES FITTED WITH OPGW
BOLE
TRANSMISSION LINES PLANNED
KINTAMPO
BUI
BRONG-AHAFO
REGION
WENCHI
TECHIMAN
BEREKUM
SUBSTATION
SUNYANI SUBSTATION
TRANSMISSION LINES FOR FUTURE OPGW BEING
CONSIDERED
DORMAA
MIM
ASHANTI REGION
KUMASI
KPANDU
NKAWKAW SUBSTATION
KPEVE
KONONGO
HO (69KV)
OBUASI
SUBSTATION
EASTERN REGION
SUBSTATION
LOME (TOGO)
NEW OBUASI
ASIEKPE SUBSTATION
SUBSTATION
TAFO
SUBSTATION
SUBSTATION
AKOSOMBO GS
Map of the Volta River Authority OPGW Layout in
Ghana
KPONG GS
KOFORIDUA
SMELTER
SUBSTATION
DUNKWA
W
E
S
T
E
R
N

R
E
G
I
O
N
SUBSTATION
NEW TEMA
SUBSTATION
VOLTA
SUBSTATION
C
E
N
T
R
A
L

R
E
G
I
O
N
BOGOSO
GREATER ACCRA
SUBSTATION
ACHIMOTA
REGION
SUBSTATION
PRESTEA 161KV
SUBSTATION
WINNEBA
PRESTEA 225KV
SUBSTATION
ABOBO
TARKWA
SUBSTATION
SUBSTATION (COTE DIVOIRE)
SUBSTATION
CAPE COAST
ABOADZE G.S
TAKORADI
SUBSTATION
28
Wireless InfrastructureWiLD, WiMax, WLL, CDMA450
Networks

• WiFi 802.11a/b/g
• operates at 2.4MHz (b/g) or 5.8 (a)
• Up to 250m
• Long Distance WiFi (WiLD)
• Use directional antennas
• Up to100 km
• WiMax
• Most equipment operates at 3.5-3.7 Ghz
• Point-to-Multipoint
• Base station costs 20,000
• CPE costs 450

29
Wireless vs Wired Costs
Networks

• Towers are a bulk of the cost for wireless
  deployments
• 200/m up to 30 meters
• 300/m over 30 meters
• 150m tower can cost over 100,000
• In Ghana, material availability is a problem, and
  towers degrade after a few years
• Spectrum Licensing
• Steerable Antennas
• Fiber is high capital cost
• Copper can be stolen it is hard to protect

30
Postscripts
Networks

• Notes on Coverage
• Subscriptions have outpaced network capacity
• Urban coverage is better than rural
• Cross-network calls are expensive and
  oversubscribed

• Notes on Services
• SMS
• Flashing
• Prepaid vs Postpaid
• Voicemail
• BubbleTalk

31
Delay Tolerant Networking
Networks

• Store and Forward A network architecture
  designed to be reliable when network connectivity
  is designed to be intermittent or highly delayed
• Sneakernet use data mules to physically
  transport data between rural and urban locations
• Network Outages weather conditions or power
  outages may prevent simultaneous end-to-end
  connectivity
• Opportunistic Network access the network when
  user is in the coverage area
• Examples
• United Villages (aka DakNet/First Mile
  Solutions),
• Wizzy Digital Courier
• Saami Reindeer Herders
• Other Uses Space, Sensors

32
Mobile Wireless GSM
Networks

• Frequencies
• Most countries operate at 900 and 1800 MHz
• US and Canada operate at 850 and 1900 MHz
• Identification
• SIM Cards Subscriber Identity Module
• Range
• 22 miles

33
Mobile Wireless CDMA
Networks

• Frequencies
• CDMA2000 1900 MHz
• CDMA450 450 MHz
• Identification
• ESN Electronic Serial Number is tied to the
  handset
• Range
• Varies with frequency

34
Mobile Wireless Data ServicesGPRS, EVDO, 3G
Networks

• CDMA ?EVDO (Evolution-Data Optimized)
• 1xRTT (153 Kbps)
• 1xEVDO (2.44Mbps/153Kbps)
• GSM ?GPRS/EDGE
• GPRS (3240 kbit/s)
• EDGE (236.8 kbit/s)

35
(No Transcript)
36
Ghana GSM Coverage
Networks
Areeba
Tigo
OneTouch
?
current OneTouch Data not available
37
When is Intermittent Okay?
Networks

• Pros
• Cost better use of resources, more tolerant of
  problems
• Reliability delay hides transient problems
• Ease of deployment can be more ad hoc, less
  coordination than a synchronous system
• Coverage Intermittent coverage gtgt full time
  coverage
• Cons
• Not really interactive, or only interactive in
  some areas
• Need to design apps around this model
• Dont know what delay is OK (depends on the app)
• Less appropriate for emergency situations

38
http//www.telegeography.com/
39
In Africa
Networks

• Concentrated in urban areas
• SAT3/WASC/SAFE submarine fiber to Portugal
• Exclusive rights initially granted to select
  investors
• Access is generally overpriced
• Largely served by VSAT
• AfrISPA has established Internet Exchanges in 13
  countries

Image taken from Fiber-optic Cable Wires
Africa. Red Herring. Nov. 11, 2005
Image taken from Network Startup Resource Center
(http//nsrc.org/AFRICA/afr_ix.html) Feb 27, 2007
40
Choosing an Infrastructure I
Networks
41
Choosing an Infrastructure II
Networks
42
Overview
Findings

• Introduction About ICT4D and TIER
• Research TIER Work in Ghana
• Networking A Tutorial on Networking
• Findings Whats in Ghanas Hospitals?
• Hospital Infrastructure
• Health Informatics Applications
• Software Enabling Asynchronous Telemedicine in
  Ghana

43
Accessing the Network
Findings

• Broadband available in Accra
• Dial-up and VSAT elsewhere
• Dial-up is slow.. And requires a phone line
• VSAT is expensive (generally donated)
• Newer Hospitals have local area network, although
  not necessarily computers and Internet access
• Sunyani Hospital has an internet café on site,
  but no computers and Internet access in the rest
  of the hospital
• Hospitals are willing to invest in networking
  infrastructure
• but there are obstacles (e.g. disappearing VSAT
  provider)

44
(No Transcript)
45
(No Transcript)
46
(No Transcript)
47
(No Transcript)
48
North South Disparity
Findings

• Communications infrastructure is much worse in
  the north
• Often couldnt receive mobile calls
• Phone lines frequently not working, or not
  working for data/modem
• Fewer Internet cafes of varying reliability
• Some VSAT sites
• Travel to deployment sites is difficult and long
• Communications infrastructure in the North is
  rapidly developing
• Broadband is available in Accra and Kumasi, and
  targeted for expansion into the north
• Fiber connects Kumasi, Accra, and Ho

49
5
50
Key Motivators
Findings

• Paper medical record keeping is failing
• Axon Incorporated and Korle Bu Dental School
• Pro Resolve and Komfo Anoyke
• CSIROpenMRS and Zebilla Hospital
• MoH and others
• National Health Insurance Scheme requires a means
  of maintaining up-to-date billing records
  nationwide
• VRA has made it a priority to do telemedicine
• Indian Government providing VSAT and
  DICOM-enabled equipment to Kumasi and outlying
  hospitals

51
(No Transcript)
52
Appropriate Telemedicine
Findings

• Video-conferencing between doctors and patients
  in rural clinics has specific local requirements
• Aravind Ghana
• Bandwidth Dedicated Long-Distance Varies
  depending on available
• Wireless ISPs, and monetary resources
• Medical Full-time specialists, and Shortage of
  doctors, especially
• Personnel highly trained health
  workers specialists, adequate general
• (private training program) training for health
  workers
• Hospital Private eye care hospitals, Government
  hospitals required
• Infrastructure planned facilities, growth to
  cover population, spread thin
• matching available resources, with unequal
  distribution of
• fully equipped rural clinics personnel
• Maintenance High availability of
  technically Trained administrators localized
• Infrastructure trained systems administrators arou
  nd Accra, unwilling to migrate
• Different environments will require different
  solutions and new partners
• Local partners must be able to sustain the
  technology logistically and financially
• c o d e s i g n c o d e p l o y

53
5
Can Technology Help Doctors - Combat
professional isolation? - Fix gaps in referral
infrastructure? - Leverage their social networks?
How can we develop telemedicine solutions that
local partners can sustain logistically and
financially? What software architecture is
appropriate for the locally available
infrastructure and personnel?
54
Overview
Software

• Introduction About ICT4D and TIER
• Research TIER Work in Ghana
• Networking A Tutorial on Networking
• Findings Whats in Ghanas Hospitals?
• Software Enabling Asynchronous Telemedicine in
  Ghana
• Goals and Key Features
• Plans for the Summer
• Where you come in!

55
Professional Networking
Software
Updates on Your Colleagues Learn about cases from
your colleagues, identified either explicitly
when creating your profile or implicitly through
patterns of interaction.
Personal Accountability Doctors are given
immediate feedback on cases which depend on their
contribution.
Flexible Case Assignment Doctors can give cases
to individuals or groups, allowing them to create
new contacts from existing professional networks
or to draw on existing contacts.
Integration with Referral Infrastructure Support
of both private and public cases will allow this
system to be used both for patient referral and
for open consultation.
56
Software

• Updates on Your Colleagues
• Learn about cases from your colleagues,
  identified either explicitly when creating your
  profile or implicitly through patterns of
  interaction.
• Personal Accountability
• Doctors are given immediate feedback on cases
  which depend on their contribution.

57
Integration with Referral Infrastructure
58
Flexible Case Assignment
Software
Doctors can give cases to individuals or groups,
allowing them to create new contacts from
existing professional networks or to draw on
existing contacts.
59
Adapting to Local Infrastructure
Software
60
Tele-consultation Pilot
Software

• Korle Bu Teaching Hospital
• Kasseh Hospital (Ada)
• Winneba District Hospital
• Cape Coast Regional Hospital
• Cape Coast District Hospital
• Takoradi Regional Hospital
• Takoradi District Hospital

61
We need participants!
Software

• Create a Profile (today!)
• Invite Your Colleagues
• Create Cases (in Ghana)
• View Your Cases
• Respond to Cases
• Discuss Cases for Continuing Education
• Give us Feedback!

62
Thank you to Dr. Debra and the GPS Foundation for
inviting me to speak today, and to all of the
members who have already volunteered for
interviews. Thank you to Eric Osiakwan, Dr.
Ghartey, Dr. Kwamin, and Dr. Vortia for being our
guides and advocates in Ghana. Thanks also to
Kwaku Boadu and all the engineers at Arrow
Networks for all their work setting up the
wireless networks. Thanks to the Blum Center,
NSF, and Intel Research for funding this project,
and to my advisors Prof. AnnaLee Saxenian, Prof.
John Chuang, and Prof. Eric Brewer. Special
thanks to my collaborators Rowena Luk and Paul
Aoki for their tireless efforts designing and
implementing this system.
Questions?