Reports, Findings, and Conclusions

A substantive portion of my final report to the embassy:

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Use of Mobile ECG Units in Diagnosing Cardiovascular Disease

 

As a result of information derived from my travel experiences/interviews, I concluded that a mobile health application suitable for further research exploration and possible implementation in Kazakhstan would be the use of mobile ECG units in diagnosing Cardiovascular Disease.

            World Health Organization data suggests that 53% of deaths due to non-communicable (not contagious) disease in Kazakhstan occur due to Cardiovascular Disease (World Health Organization, 2011).  Cardiovascular Disease is an umbrella term that is used to describe a number of different disease patterns, including Coronary Heart Disease, Hypertension and Stroke.  Annual deaths due to Coronary Heart Disease (48,000) and Stroke (23,000) in Kazakhstan are great enough that Kazakhstan ranks 5 and 13 internationally for deaths due to these causes (World Life Statistics, 2010). 

             Cardiovascular Disease (CVD) presents a unique set of challenges and opportunities for prevention and treatment in Kazakhsan where there exists an emphasis on tertiary care and a high level of specialization. The majority of the risk factors for CVD are lifestyle related, such as unhealthy diet, physical inactivity, and tobacco use for both Coronary Heart Disease and Stroke, making nation-wide prevention strategies difficult to implement.[1]

             Kazakhstan’s health care system characterized by large hospital systems, overspecialization of physicians (Katsaga, Kulzhanov, Karanikolos, & Rechel, 2012), and central oversight by the Ministry of Health makes innovative strategies directed at preventing CVD challenging. Despite the focus on primary care that the 2005-2010 State Run Program of Healthcare Sector Reform and Development and the 2009 Code on People’s Health and the Healthcare System which specifies the “prioritization of prevention,” actual movement within the healthcare sector has been slow (Katsaga, Kulzhanov, Karanikolos, & Rechel, 2012).

             Beyond primary prevention of CVD through lifestyle changes, there are secondary and tertiary treatment options available for CVD; surgical approaches are available, but often the use of drugs such as ACE inhibitors, aspirin, beta-blockers, and lipid lowering medication can lower two year risk of acute illness by as much as 75%.[2] However, here again, an emphasis on tertiary care and a high level of specialization present obstacles to early diagnosis and treatment. A re-distribution of labor from physicians to nurses and other primary care workers has only partially relieved the problem of physician overspecialization. Physician extenders (i.e., nurses, community health workers, technicians) play a much smaller role in medical practice compared to many of their international counterparts and are often restricted on care that they can provide. Despite a progressive policy aimed at establishing a profession similar to Physician Assistant in the United States, current roles within the system are unlikely to be changed in such a way that will directly help in treating CVD. In addition, the payment of these health care providers (along with that of physicians) lags behind regional averages, and the ratio of health workers per 100 000 population is on a decline (Katsaga, Kulzhanov, Karanikolos, & Rechel, 2012). All of these factors result in obstacles to access including long wait times at hospitals.  

              Given these access concerns, diagnosing CVD can be problematic (i.e., correctly identifying the condition the patient is experiencing). It is often the case that patients experiencing symptoms of CVD would have stopped feeling the symptoms by the time they access healthcare in Kazakhstan where resources are stretched in hospitals and wait times are often long. An accurate diagnosis in CVD can often be made using an Electrocardiogram (ECG) to assess heart rhythm, which can then be used to structure a treatment. It often happens that when a patient feels the symptoms that signify an irregular heart rhythm, by the time they reach a hospital their heart beats as normal.

             However, a recent technological innovation has adapted small ECG units to be used in conjunction with Mobile (Lin, Wolf, Benjamin, & Belanger, 1995) (Governent of Kazakhstan) telephones, creating so-called “Mobile EKGs.” This provides an alternative to seeking a facility with an ECG when symptoms emerge, that is, the mobile ECG monitor can be carried around by individuals in whom CVD is suspected.  The devices are easy to use. They are the size of a mobile phone and fit into a pocket or handbag. One can register his or her ECG by simply putting two thumbs on the device and holding them there for 30 seconds. By pressing the send button they can transfer the ECG reading over a cellular network to a doctor who can check the result as long as they are within the coverage area of the network. 

             The units can be provided to patients by their physician to take with them to measure the ECG at exactly the right moment when they feel their symptoms. In many cases, the ECG will be normal and the symptoms probably caused by stress. In some cases, however, the ECG will show an abnormality requiring some form of treatment to protect the person from complications. Thus, the mobile-ECG holds the potential for early diagnosis and treatment of CVD, saving lives and reducing human suffering. In addition, loaning a mobile ECG unit to a patient can reduce the use of hospital resources in addition to enabling more accurate diagnoses. 

Technology and Infrastructure Investment: Mobile ECG

             At the 24th Plenary Session of the Foreign Investors’ Council on Bringing New Technology to the Infrastructure Sector via Private Investment in Astana, May, 2011, Lakshmi Venkatachalam, Asian Development Bank Vice President, makes a great observation. “Investors in rapidly growing enterprises are no longer satisfied with long and gradual processes for upgrading of infrastructure services (Venkatchalam, 2011). Instead, they are “leapfrogging” such long transition periods through the quick implementation of new technologies, so as to faster achieve competitive positions in the world market.” Venkatachalam continues, “All over the world, governments are turning to private infrastructure investors as a key means to upgrade technology, particularly in sectors which are experiencing major research advances in efficiency and cost reduction.”

            Implementing smartphone technology performs exactly this type of “leapfrogging.” The broader array of technologies that mobile ECG is a part of is called mHealth. Various mHealth applications have been used worldwide and their efficacy has been well documented. Mobile ECG in particular has been successfully used in environs as diverse as the Philippines, Sweden, Guatemala, and Norway, and has recently been approved for clinical use in the USA by the Federal Drug Administration (Mobile Health News, 2012). 

             The “Compendium of new and emerging health technologies,” published by the World Health Organization, explains, “the system is a proprietary push delivery and review platform allowing remote review using the internet and cell phone network of ECG’s/medical images. Medical data is recorded at the point of care and then uploaded to the system’s server from which it is then delivered to a physician’s smartphone or PC. The transaction is fully traceable and secure.” Using smart phones eliminates slow, non-traceable systems such as faxes and paper mail, and offers concurrent modules for medical services, patient management, administration and finance. The mobile system can easily reach to any area that offers telecommunications access. The Kazakhstan Embassy’s page on infrastructure indicates that telecommunications developments from 2006-2008 resulted in a great number of cellular subscribers: ”87 per 100 citizens.” Therefore, the units can be used within existing systems.

[3]

Nazarbayev University and National Medical Holding

            Hierarchical decision-making causes innovation in combatting CVD in Kazakhstan difficult. Most care is specified by the Ministry of Health under the Guaranteed Benefits Package. Doctors often look to the Ministry of Health first before trying any new treatment or procedure. Recognizing the importance of innovation, the government of Kazakhstan recently purchased the National Medical Holding, a large hospital system in Astana, in order to merge its functions with the academic and research mission of the newly built Nazarbayev University with internationally aware medical personnel, an emphasis on research, and national influence. The partnership will seek to implement various aspects of the Kazakhstani government’s goals in healthcare, including new diagnostics methods, adherence to international treatment standards, and clinical trials and research, and will serve as a model hospital for the rest of the country.

            The government of Kazakhstan’s investment in the National Medical Holding on behalf of Nazarbayev University proves the partnership actively seeks medical technology investment. A medical communication system that integrated smartphones certainly fulfills the second general strategic objective of the Holding: “to develop research and innovation activities and ensure efficient transfer of technologies to Kazakhstan’s public health system.” It would also further the first objective, especially for rural citizens: “to meet the patients’ demand for high-tech, quality and accessible medical services.” A research-oriented mission distinguishes Nazarbayev University and National Medical Holding as a good site for research.

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Also included in the full report are notes/observations from the various interviews conducted and a proposal for further research. For more the full protocol, send me an email at cjsantos@live.unc.edu.

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