Doxper digitizes, mines and delivers insights; from regular handwritten prescriptions, case histories, surveys, etc. with just pen & paper!
Problem: Adverse doctor-patient ratio, and population pressure in developing countries leads to less face time with care givers, this leads to quick observations, handwritten notes, prescriptions and case histories. Of all the data types in clinical informatics (imaging, pathology, etc.), doctors’ annotations, be it on prescriptions or case histories are still handwritten, and this is the most serious impediment to Digital Health that everyone is aspiring to overcome.
Solution: Doxper Blu, is doctor side of the app that allows doctors to record keep all their patients prescriptions, case histories, special forms and reports using digital pens & papers. The patient side of the app, Doxper, provides patients the access to their prescriptions in digital format enabling the eco-system. Patients can create their entire medical history and able to share the same with relevant care providers. We digitize and perform analytics on the captured data in a seamless manner. Doxper Blu is available both for iOS and Android. The captured data can be easily integrated with existing HIS/EMR/EHRs.
Company: InformDS is a healthcare informatics company with founders having background in healthcare analytics and technology. Our product offerings solves the healthcare informatics problems at the ground level and builds up. Doxper is already tested and proven for "clinical documentation service" with India’s leading specialists for clinical data capture, storage and retrieval using latest Information Technology tools (Digital Pen and Digital Papers, Cloud storage and Apps on iOS & Android) to complete the ecosystem. Doxper is very seamless, cost effective and intuitive, and doesn’t interfere with the existing clinical workflow for clinical documentation. We use existing paper templates or prepare different paper template formats for different chronic disease specialities for doctors’ prescriptions and other forms that can perform diseases surveillance, audits and other data analytics tasks.
What are the key outcomes and impact of your solution?
Challenges with Electronic medical records (EMRs):Although EMRs promise many advantages like easy access, improved continuity of patient care, efficiency, legibility and security, however there are risks involved with adoption of EMR. Physicians fear the ability to engage effectively with patients will decline as it would be difficult to give patients the ‘face to face’ time they need while simultaneously being required to focus on the computer screen typing patient responses, than actually communicating with the patient, actively listening and assessing non-verbal communication. This altered clinical workflow slows physicians and forces them to change the way they think and work. EMR is still by and large slower than pen and paper because direct data entry is still primarily done by keyboard. EMR interferes with clinical decision making and intrudes on physician patient communication. There is even disagreement as to whether the operating expenses of paperless EMR systems are less than traditional paper systems.
Current Trends: Hospitals have historically maintained paper records but there are few core issues in going forward from manual records to completely electronic records, 1) the doctors are not computer savvy and do not want to type the observation and treatment notes, 2) the patient load in developing countries is very high compared to western world and doctors get few minutes with the patients in which to have social interaction as well as clinical examination, and 3) in case of an unscheduled downtime of the IT system, the entire hospital returns to the manual system.
Our Approach: We work on semi-automated approach for transcribing the medical data using machine learning techniques and manual resolution by trained medical trasncriptionists. The doctor in hospital writes the observation and treatment notes with a digital pen on a digital paper and is transmitted digitally to the cloud. The annotations on the digitized data are segmented and run through a handwritten transcription engine. The raw transcriptions are verified at the backend by inhouse team of medical transcriptionists. The handwritten data on the form is divided into smaller chunks, so that not all information goes to a single verifier and the privacy of the patient remains. The data can be consumed via intuitive Android/ iOS Apps or on the browser. Acceptance has been very high, even by care providers who were admittedly computer phobic. The advantage of this approach is that the patient information is duplicated on paper and electronic form and there is absolutely no disruption to the existing clinical workflow.
Key outcomes and impact: Better patient care starts with better documentation, we empower care givers with our intuitive solution to provide better patient care in short term and provide insights from anonymized data in the long term.
What actions do you propose to realize your stated goals?
Background: Almost all hospitals in developing countries lack information systems to maintain patient data in electronic form. The medical reports consist of handwritten notes that are added in the patient’s file by the physician responsible for the treatment and for follow-up visits. The handwritten notes and other lab reports are consolidated into a single physical file and stored in the medical records department of the hospital. It takes time and effort to retrieve the patient’s file and deliver to the requesting physician for treatment and follow-up. A retrospective study based on de-identified patient data is extremely difficult to conduct as the patients’ records are manual.
InformDS' core business is in Biomedical Informatics as data correctly captured, anonymized, annotated, analyzed and interpreted can shed light on many disease processes and medical areas. Healthcare providers want real-time access to patient, clinical and other relevant data to support improved decision-making and facilitate quality care. Pharma companies want to better understand the causes of diseases, find more targeted drug candidates, and design more successful clinical trials. Researchers want new tools to improve the data workflow e.g., predictive modeling, statistics and algorithms that improve the design and outcome of experiments and epidemiologic studies.
Our product offerings solves the healthcare informatics problems at the ground level and builds up. We envision InformDS products being the product of choice for clinicians for their simplicity, ease of use, and that add value even to existing clinical processes at clinics/ hospitals. We strongly feel that our solutions will fill the need between being current manual processes to going fully digital with EMR/EHRs in short term. The mission of the company is to simplify capture, access, storage, presentation and analysis of medical informatics data. The long term vision is to generate new data driven clinical intelligence/ knowledge with amalgamation of relevant data types (clinical annotations, pathology, imaging, patient monitoring, and personalized medicine data). This will have great ramifications on how medicine is practiced with data driven methodologies.
The transformed knowledge in the data will create an eco-system that will be game changer for clinicians, patients, pharma and medical device manufacturers in population health,  Novel data analysis algorithms that enable integrated knowledge discovery from EMRs,  Analysis and visualizing for summarizing large patient data in EMRs,  Novel algorithms and applications dealing with noisy, incomplete, but large EMR data,  Analysis of longitudinal and time-series data to discover new correlations,  Co-registration of patient data acquired over several time-points in their life, and  Semantics and bio-text mining.
Chronic diseases management details: Chronic conditions differ from acute conditions on a variety of important dimensions. Acute conditions generally have a sudden onset. They last for only a short period of time and usually are stopped with the appropriate care or end spontaneously, without requiring ongoing treatment. They usually end with cure but sometimes with death. In general, an illness or condition is considered chronic if it has persistent or recurring health consequences lasting for a substantial period of time (variously identified as at least three months, six months, or longer), is not self-limiting, waxes and wanes in terms of severity and typically cannot be cured. The essential aspect of a chronic condition is its lengthy duration. A chronic condition is enduring and not simply a series of disconnected complaints. Healthcare based on the acute care model focuses on treating immediate presenting symptoms, and often discounts the sustained impairments that threaten the health status and diminish the functioning of people with chronic conditions. Similarly, acute care’s emphasis on cure seems misplaced when directed to chronic conditions, most of which can never be resolved. The episodic nature of acute care is also at odds with the long-term monitoring and continuous support and care needed by people with chronic conditions to prevent exacerbations and maintain their functional abilities.
In addition to differences in duration, the sudden onset of most acute conditions contrasts with the progressive nature of many chronic conditions. People “come down” with an acute illness, whereas they “develop” a chronic condition. Also in contrast to acute conditions, chronic conditions tend to have multiple causes and can occur long after the causative exposure or behavior. The acute care model leaves little room for the social, psychosocial and behavioral dimensions of chronic illness. It does not provide for the commitment to continuing care. It is also not broad enough to account for and aid understanding of the types of human distress experienced by people with chronic conditions. These include challenges to the “person’s self-image and sense of meaning and purpose in life” and the suffering that occurs due to disruptions in the patient’s “extended system,” including their family, friends, work associates and community. Furthermore, the acute care model undervalues the importance of a variety of other key facets of chronic illness care, including the influence of lifestyle factors such as nutrition and exercise in preventing or managing a chronic condition, the likelihood of depression or other mental health issues accompanying a chronic condition, the vital role of families in supporting and caring for a chronically ill family member and the influence of the environment in understanding the causes of and developing appropriate responses to chronic conditions.
While the current healthcare system does not ignore chronic conditions themselves, it continues to respond to them as if they were acute and episodic, treating symptoms as they occur. The care for persons with chronic conditions is often a “poorly connected string” of clinician patient encounters. Consequently, the system ignores the fundamentally different approach that is needed to care for people with chronic conditions, that is, managing the conditions long-term and responding to the myriad ways they impact peoples’ lives. The problem is not that people with chronic conditions do not receive care in our health care system; rather, the problem is that their care is provided in a system principally designed to treat a wholly different type of condition and thus ill-equipped to adequately respond to chronic conditions, for ex: diabetes, cancer, heart disease, osteoporosis, clinical depression, irritable bowel syndrome, etc. Managing chronic conditions demands skills and knowledge that extend beyond traditional biomedical training for preventing, diagnosing and treating acute conditions. Care coordination abilities, behavior modification techniques and patient education are among the broader set of skills health professionals will need to provide optimal chronic care.
A personal health record (PHR) that is under the direct control of the patient can ameliorate many problems that the acute care focused system cannot address. The current burden of chronic diseases reflects the cumulative effects of unhealthy lifestyles and the resulting risk factors over the life span of people. Some of these influences are present even before a child is born. Connecting patients across the world who share conventional, complementary, alternative and holistic health information about their health conditions so that they are better informed, engaged, and empowered and where they can share personal experiences like struggling to find a diagnosis for their own illness from the patients’ perspective.
In the current system, care for people is often fragmented and poorly coordinated. While this may jeopardize health care quality and efficiency for any patient, it is particularly troublesome for those with more than one chronic condition. To meet their complex needs, patients with chronic conditions often receive care from multiple clinicians, who may work independently from each other. Each of the clinicians may provide one or more of the services that comprise the full spectrum of care the patient needs, such as medical, mental health, rehabilitation, prevention and supportive services. Yet the clinicians rarely communicate with each other about the patient’s care. By functioning in separate “silos”, the clinicians (and the clinics and health care organizations where they practice) often do not have complete information about the patient’s condition or treatment history, a major source of medical errors. This “silo-based” approach to care is a hallmark of our fragmented system, hampering the “coordinated, seamless care across settings and clinicians and over time” that is needed to effectively meet the needs of people with chronic conditions. It also results in inefficiencies since discrete health care providers will often duplicate laboratory and radiological investigations and other diagnostic services, especially if medical records and other patient care information are not shared. Compounding the complexity and inefficiency, each of these segments of care may have its own distinct management information system, payment structure, financial incentives and quality oversight. Patients find this complicated, uncoordinated ‘system’ extremely confusing and a “nightmare to navigate”.
The fragmented system hampers the follow-through and coordination of care across the entire spectrum of care processes. Information about a patient’s health and treatments is rarely centralized, well-organized or easily retrievable, “making it nearly impossible to manage many forms of chronic illness that require frequent monitoring and ongoing patient support”. Coordination of care for a chronically ill patient is particularly important when many different individuals are involved in managing the patient’s conditions. The discrete, yet interconnected tasks performed by these individuals, often in disparate areas of the health care system as well as in the patient’s home, must be linked and coordinated in order to ensure that desired outcomes are achieved efficiently. But the coordination of care for chronically ill patients, including the integration of medical with non-medical services, is often overlooked. Rarely in a fragmented, poorly coordinated health care system is a single health care professional or entity.
The coordination of care for chronically ill patients, including the integration of medical with non-medical services, is often overlooked. Rarely in a fragmented, poorly coordinated health care system is a single health care professional or entity responsible for a patient’s overall care. Instead, clinicians and other health care professionals may feel responsible only for the care and services they themselves provide, and neglect or overlook integrating and coordinating all of the care their individual patients receive. Even when a clinician strives to stay abreast of his patient’s overall care, the system’s fragmentation may thwart such efforts. Imprecise clinician responsibility increases the chance that some services may conflict with others (e.g., medications prescribed by different clinicians may interact and harm a patient) and that still other needed services may not be provided at all.
Our Approach and Strategy: InformDS is in the process of business tie-ups and partnerships with traditional HMIS vendors to enable the care providers to record the handwritten data into electronic format. We are using Medtech channel providers to distribute our solutions to individual doctors, smaller clinics, bigger hospitals and chains. We have had meetings with NABH (National Accreditation Board for Hospitals & Healthcare Providers) and have got in principle approval for our solution in different care settings.
Who will take these actions?
Patients with chronic conditions suffer from fragmented services, when they are treated not as persons but instead are segmented into discrete organs or body systems. If health care professionals treat a malfunctioning system of the body rather than the person as a whole (i.e., treat disease in the patient rather than treat the patient with disease), treatment can become a series of medical interventions that target only the disease and ignore the ill person. Such a disease-centered—as opposed to a person-centered—approach risks providing care that the person may not want. By treating a patient’s diabetes, for example, rather than treating the patient who has diabetes, a clinician may focus narrowly on using intensive monitoring, aggressive follow-up and systematic assessments to control blood sugar levels and other aspects of the disease, thereby reducing the risks of future complications. Even if the patient shares the goal of reducing the chance of blindness or other complications of diabetes, a singular focus on such narrow medical goals may ignore the patient’s interest in keeping the management of the disease from overwhelming other aspects of his or her life.
Generally, people with chronic conditions have better health outcomes and are more satisfied with their care if they participate actively in the management of their health and health care. Yet many patients do not have the needed skills and competencies for this role. Some patients desire a more passive approach to their health and health care or may be uncomfortable managing their own care and thus may not seek to acquire such skills and competencies. For patients who want to become more actively engaged, however, health care providers and health plans often fail to prescribe, provide, or reimburse the necessary educational materials and empowerment tools to build self-efficacy and self-management skills or to support their efforts to manage their own care. Even when patient education services are provided, they are often sporadic, unplanned and superficial, given the lack of coordination among providers. In addition, the current system often fails to acknowledge and address the impact of a person’s chronic illness on other family members, both as caregivers and as family members.
For chronically ill patients, the condition and its consequences “interact to create illness patterns require continuous and complex management”. Effectively managing chronic conditions requires intimate understanding of these illness patterns. Patients, not their clinicians, are best positioned to accurately detect and characterize such patterns. Only they can provide the personal information regarding the impact of the condition on their health and well-being that is necessary for effective management. Effective chronic illness care must therefore allow and encourage patients to be more engaged in their own care.
Improving chronic illness care requires more than minor adjustments and accommodations to a health care system based on the acute care model. Optimal care for people with chronic conditions requires a different type of health care system. A new system is needed that overlays the current system that can only respond in a fragmented and disjointed way to the needs of patients with chronic conditions. Foremost, a new conceptual model of care is needed that would then serve as the foundation for the chronic care component of the system by encompassing the health as well as the social, psychosocial and behavioral dimensions of illnesses.
One of the big challenges in treating people with multiple chronic health conditions is knowing what is the best management strategy. The health system has had a focus on treating single conditions. As a result there is a lack of evidence and a lack of guidance on how to manage patients with multiple chronic health conditions. The evidence on which most guidelines are developed is from relatively short-term randomised controlled clinical trials of single conditions, where the older population or patients with multiple conditions are excluded. Even where research does assess the impact of one treatment on rate of complications in the other, there is very little research where outcomes for both diseases are measured in the one trial. This leads to cases where single disease based clinical guidelines may provide contradictory recommendations for practitioners treating patients with multiple chronic health conditions, some of which, if implemented, would result in harm. A review of 17 Australian clinical guidelines found only two made specific recommendations for patients with multiple chronic health conditions, and only one addressed treatment of older people with multiple chronic health conditions.
We propose “clinical trials by data” in the real world, to aggregate and anonymize the harvested data, to mine the insights for successful management of patients suffering from multiple chronic diseases. The targeted geography will be India. We plan to take up 4 cities in different parts, Northern India (Delhi), Eastern India (Bhubaneswar), Western India (Mumbai), and Southern India (Bangalore). Three chronic and lifestyle diseases will be chosen, for ex: cancer, diabetes and cardio vascular diseases. India is a very rich source of genomic diversity and many novel findings remain yet to be determined that can add to the clinical knowledge of the world.
The current health care system is ill-equipped to treat patients with a chronic condition and breaks down quickly when confronted with patients with multiple chronic conditions. The reactive, crisis oriented acute care model focuses on treating a patient’s immediate needs or symptoms and views each patient interaction with the health care system as an isolated encounter. It typically ignores the interdependent nature of multiple conditions; thus failing, for example, to connect a diabetic person’s depression with the resultant loss of appetite, which can lead to malnutrition, which can exacerbate their diabetes, and so on. Treating and managing multiple conditions highlights the fact that effective chronic care entails moving beyond a series of encounters to monitoring patients over the long term and providing “longitudinal care”. Such care must be consistent over time and coordinated, so that the various services reinforce each other toward achieving common goals. The care provided over the long term varies primarily in intensity, responding to changes in the patient’s health status.
On the patient side and in order to be useful to the patient, the PHR must present data and accompanying tools in ways that enable the individual to understand and to act on the information contained in the record. This is challenging because of patients’ widely varying levels of general literacy and of health literacy. A person who eats foods that are high in saturated fats and hydrogenated oils will inevitably produce more bad cholesterol and will show the symptoms of this so-called disease of high cholesterol.
What do you expect are the costs associated with piloting and implementing the solution, and what is your business model?
In the first year, we envisage US$ 250,000 for hardware and associated services and software licensing costs. For the first year we plan to enroll 500 doctors in our services. Each subsequent year will cost US$ 200,000 to scale the project and include more numbers of doctors, patients and enhancing the Apps, boosting the data analytics capability, cloud storage and computing costs. Each doctor typically has 800-1000 patients that regularly consult him. We plan to enroll 400,000 patients in the first year and 500,000 patients in subsequent year.
InformDS Technologies will contribute with man-power, clinical knowledge and insights generation from data. A separate database will be curated for insights from the anonymized captured data using clinical NLP, SNOMED-CT and other relevant codes and machine learning techniques.
Our solutions will be developed for-profit; we provide value to each of our stakeholders, to doctors-with easy to use and document clinical observations, to administrators- by optimizing the facilities usage depending on the disease profiles being seen and to patients- by providing an easy to use service for storing and consuming personal health records.
The usage of pens & papers is intuitive, universal and entrenched in clinical workflows all across in developing and under-developed countries. A successful pilot in India can be easily translated to different parts of the world facing similar challenges. India has high mobile penetration and it is a good opportunity to let mobiles play their part in chronic diseases management, by facilitating better doctor patient interaction and care.
We envisage a strong clinical program that will involve the following parts, each of these modules will be developed in parallel and with feedback from clinicians and patients:
Consistent, objective information for people with multiple chronic health conditions
Training (via prompts or alerts in the apps) of all health care providers to work within multi-disciplinary teams
Training of all health care providers to incorporate patient preferences
Education of patients about potential treatment conflicts
Education of patients about talking to healthcare providers
Patient advocate or social worker to be involved in the care planning and coordination
Care planning to include multiple chronic health conditions learned from the strategies being currently used
Inclusions of patient preferences in treatment and care strategies, based on clinical and economic factors
Clinical handover processes to be included in all situations of care transfer
Software to flag patients with multiple chronic health conditions and treatment conflicts
Peer support and self-management programs for multiple chronic health conditions
Evaluation of models of care for patients with multiple chronic health conditions including clinics, care plans, shared care providers
Mayo Clinic looked at 2014 survey data from 6,560 US physicians measuring features of work life, including burnout and electronic use. The researchers found a strong link between burnout and time spent doing digital work, 44% were dissatisfied, 63% believed that EHRs made their jobs less efficient, and 50% doctors said that they spent an unreasonable amount of time on clerical tasks.
There are many solutions listed here that offer EMR, data gathering, or questionnaires based on inputs from tablets/ phones. They are difficult to scale up due to change in user behavior required, language, infrastructural issues or the changes and updates required frequently in the field and usage. Senior and knowledgeable personnel do not like being data-entry operators but are happy to share their knowledge that can be generated within their existing clinical workflows. Our solution is complementary to any electronic data capture based solution and we will be happy to collaborate for shared success.
The doctor to patient ratio in India is grim. The following points summarize the Healthcare scenario in India:
There is only one doctor per 1,700 citizens in India; the World Health Organization stipulates a minimum ratio of 1:1,000.
There are 387 medical colleges in the country—181 in government and 206 in private sector. India produces 30,000 doctors, 18,000 specialists, 30,000 AYUSH graduates, 54,000 nurses, 15,000 ANMs and 36,000 pharmacists annually.
Health ministry claims that there are about 6-6.5 lakh doctors available. But India would need about four lakh more by 2020 to maintain the required ratio of one doctor per 1,000 people.
There are 1,48,366 sub-centers, 24,049 PHCs and 4,833 CHCs functioning in India.
Schork NJ, Personalized medicine: Time for one-person trials, Nature, 2015 Apr 30;520(7549):609-11.
How can we help people prevent, detect and manage chronic diseases, especially in resources-limited settings?