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Diabetes care in the age of Informatics: Kuwait-Scotland Health Innovation Network

Diabetes care in the age of Informatics: Kuwait-Scotland Health Innovation Network

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Published by Dari AlHuwail
In this paper, we describe the initial experience of implementing informatics support for the treatment of chronic conditions in Kuwait, including diabetes. We consider the broad requirements of service improvement and provision of clinical data. We describe work undertaken in the foundation and pilot phases of the Kuwait Scotland Health Innovation Network programme.
In this paper, we describe the initial experience of implementing informatics support for the treatment of chronic conditions in Kuwait, including diabetes. We consider the broad requirements of service improvement and provision of clinical data. We describe work undertaken in the foundation and pilot phases of the Kuwait Scotland Health Innovation Network programme.

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Published by: Dari AlHuwail on Apr 30, 2011
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Diabetes care in the age of Informatics:Kuwait-Scotland Health Innovation Network
Dari AlHuwail
Dasman Diabetes InstitutePO Box 1180Dasman 15462, Kuwait+965 99107122
dari.alhuwail@dasmaninstitute.orgRodrigo Barnes
Aridhia Informatics LimitedHobart House, 80 Hanover StreetEdinburgh EH2 1EL, UK+44 141 229 7580
 In this paper, we describe the initial experience of implementinginformatics support for the treatment of chronic conditions inKuwait, including diabetes. We consider the broad requirementsof service improvement and provision of clinical data. Wedescribe work undertaken in the foundation and pilot phases of theKuwait Scotland Health Innovation Network programme.
Categories and Subject Descriptors
 J.3 LIFE AND MEDICAL SCIENCES (Health); K.6.1 Projectand People Management; E.1 DATA STRUCTURES
General Terms
 Management, Economics, Reliability, Human Factors,Standardization
 Health; Informatics; Diabetes; Service-Oriented Architecture.
The Kuwait Scotland Health Innovation Network is adopting anintegrated approach to disease management. This collaborationaims to develop and support systems of high quality patient carein Kuwait . This will include the core components of patientregistration, clinical guideline and standard development, patientand professional education, audit and monitoring for serviceimprovement and patient information. All this is underpinned by astate of the art informatics solution that will allow the appropriatesharing of information across the clinical community usingscalable Service-Oriented Architecture (SOA).
Chronic conditions have been a major burden to many healthcaresystems around the globe. Diabetes ranks the highest of suchconditions and has had a huge impact on the healthcare system.The International Diabetes Federation (IDF) estimated theprevalence of Diabetes Mellitus to be 6.4 per cent worldwide. The
IDF’s Diabetes Atlas ranks the State of Kuwait in the 7th place
with 14.6 per cent (comparative prevalence to that of the world) of its population affected with Diabetes. [1]Diabetes Mellitus is associated with many complications affectingdifferent organs of the human body; it affects the eyes, kidneys,the heart and the coronary circulation, the brain and cerebralcirculation, the peripheral nervous system, and the lower limbs,especially the feet. The IDF Diabetes Atlas body-plan(Figure 1) outlines the different complications associated with diabetes.
Figure 1: Diabetes and its Complications
Due to such complications, the cost of care is quite high direct andindirect costs to the individual and society are considerable. TheAmerican Diabetes Association reported that in 2007 and in theUnited States of America alone, the cost of 
Diabetes care “$174
billion, including $116 billion in excess medical expenditures and$58 billion in reduced national productivity. Medical costsattributed to diabetes include $27 billion for care to directly treatdiabetes, $58 billion to treat the portion of diabetes-relatedchronic complications that are attributed to diabetes, and $31
 billion in excess general medical costs.”
According to the World Health Organization (WHO), and theInternational Diabetes Federation (IDF), the level of diabetes in
the State of Kuwait has reached an “epidemic level” affecting 26
per cent of the population. [3]
Such figures are alarming to the state of Kuwait’s population and
have a dire impact on the economics of the country. The cost of medical care alone will account for a large portion of the bill, butthe productivity of the citizen will be lowered due to the variouscomplications that people are affected with at younger ages withthe lifestyle.
Tackling the rising growth of diabetes and its complications mayrequire responses on a number of parallel tracks. It is not enoughto provide medicines and a physician on demand to all. For a lotof people with Type 2 diabetes, the disease is managed throughlifestyle changes and with regular medication and monitoring thatdoes not need expensive medical consultation.Kuwait is fortunate enough to have a comprehensive healthsystem, where care is delivered (essentially) free at the point of care, provided by the Ministry of Health [4]. There is a standardcivil identity system [5] that doubles as a single patient identifierand more or less systematic record keeping. Existing databases arenot connected and data sharing is limited.For a wealthy country, it can be hard to see why one cannot
simply provide the “best doctors” to those who need them. It is
not just doctors that are needed but rather the most effectivepartnership between the patient, their family and a team of healthcare professionals including, but not relying on, specialistphysicians.Analytic approaches of how to improve health care provision inchronic conditions is problematic given the
nature of diabetes and its complications. Diabetes and cardiovasculardiseases can be seen to emerge from metabolic syndrome, whichis diagnosed using at least 5 factors [6]. As a diabetic patient, onemay have to monitor and manage those 5 factors (and more,depending on complications). Changing one may affect the others,but this may be in a non-linear way.Designing the optimal healthcare response to diabetes and itscomplications, one might ask a number of questions, including:
Who should take a blood pressure - doctor or nurse?
Who should run a blood test - special lab or primarycare lab?
Who should decide whether a blood test should be run -doctor, nurse, patient, algorithm?
How often should a patient be seen - on demand, onschedule?
What situations require specialist and not generalpractice attention: Hospital or Primary Care?
What combination of drugs should diabetic patientstake, and which combinations conflict?
Who is at greatest risk or need of medical support?In responding to the rise of diabetes, we are not designing thesystem, we have to think in terms of change, improvement and themanagement of this change and improvement. Experience inindustry shows that large organizations can achieve change butonly through a conscious use of the tools of prioritization,measurement and participation.The Institute of Medicine set out priorities for a safer, moreeffective healthcare system in 2001 [7], in a model that can beextended to Kuwait. The core needs of the healthcare systemshould be:
Figure 2: IOM Principles for healthcare improvement
: avoiding injuries to patients from the care that isintended to help them.
: providing services based on scientificknowledge to all who could benefit, and refraining fromproviding services to those not likely to benefit.
: providing care that is respectful of and responsive to individual patient preferences, needs,and values, and ensuring that patient values guide allclinical decisions.
: reducing waits and sometimes-harmful delaysfor both those who receive and those who give care.
: avoiding waste, including waste of equipment, supplies, ideas, and energy.
: providing care that does not vary in qualitybecause of personal characteristics such as gender,ethnicity, geographic location, and socioeconomicstatus.Service improvement is an umbrella term for the processes thatpush change through according to your priorities. This bringstogether the participation of healthcare professionals and patientsin improving their own care, but also the effectiveness of a team,or a department or a hospital.The Institute of Healthcare Improvement is one organization thathas taken the practice of service improvement forward asking the
question “how to improve” [8]:
Forming the team2.
Setting aims3.
Establishing measures4.
Selecting changes5.
Testing changes - Plan/Do/Study/Act
This is a generic model, based on the work of Denning [9] andShewhart [10] that can be applied in many corporate situations.Responses to chronic disease epidemics have been studied. Awidely accepted study by Wagner [11] suggests a model forchronic disease that decentralizes the response to disease,empowering the patient and a multidisciplinary team.
Principles (Wagner et al) Informatics Requirements
Effective chronic illnessinterventions generally rely onmultidisciplinary care teams
Effective data sharingSuccessful teams often includenurses and pharmacists withclinical and behavioral skills
Faceted views of patienthistory
Communication toolsSuch teams ensure that criticalelements of care that doctorsmay not have the training ortime to do well are competentlyperformed
Systematic collection of key clinical variables
Professional educationThese elements includepopulation management,protocol based regulation of medication, self managementsupport, and intensive followup
Service redesign andstandardization
Risk stratification andaudit
Call Recall
Patient self-managementtoolsThe participation of medicalspecialists in consultative andeducational roles outsideconventional referrals maycontribute to better outcome
Online support forManaged ClinicalNetworks
Patient educationThe Health Innovation Network in Kuwait is a partnershipbetween the Dasman Institute, University of Dundee and AridhiaInformatics, aiming to improve healthcare provision in Kuwait,starting with diabetes care.In Scotland, the National Health Service has been proactive indeveloping and applying the ideas of service improvement
 including the Scottish Patient Safety Alliance [12], QualityImprovement Scotland [13]. For diabetes, the Diabetes ManagedClinical Network (MCN) at NHS Tayside has developed over anumber of years to coordinate the provision of diabetes careacross the region, reducing variation in care, and boundariesbetween elements of the healthcare sector in the region. Thisnetwork model and systematic use of information technology hasled to a sustained improvement in diabetes outcomes. [14] Withinthe broader national context, the Long Term ConditionsCollaborative extends the network approach and appliesimprovement science to other conditions. [15] This has resulted insharing of experience, the development of toolkits across thesector [16].Outcomes are also promising. Initial research in Tayside createdand validated a record linkage system for identification of allpeople with diabetes in a population.
The system in daily use now supports the care of 20,000people with diabetes in Tayside and 218,000 people withdiabetes in Scotland and supports the National DiabeticRetinopathy Screening System which is regarded as world-leading.
The system has allowed both process and outcomeimprovements in health to be documented. For example, 40%reduction in amputation rates [17] and 40% reduction in sightthreatening retinopathy from 2003 to 2009 [18] have beenreported.
To reduce the risk of Diabetes to the population while loweringthe overall cost to the healthcare system, effective communicationbetween all stakeholders and elements of the healthcare sector isneeded. At present, the Kuwaiti healthcare system faces manychallenges and obstacles to efficacious communication. Access toInternet and e-communication services (e.g. email, corporateintranets, online literature) is not available across the differentelements of the healthcare system; rather sporadic efforts havebeen adopted by a few facilities. Those who do have access tosuch e-communication channels do operate in isolatedenvironments.Through the Health Innovation Network that was created inpartnership with MoH, the University of Dundee, National HealthService (NHS) Tayside, Aridhia Informatics and DasmanDiabetes Institute, e-communication tools will be provided andoffered to the healthcare providers. Such services include accessto email service, a comprehensive view of the patient
s clinicalpathway aggregated from different sources, annotating documentsonline, and access to medical and scientific websites.These tools are nothing but a driver for service improvement andmore effective and timely communication between all thestakeholders in the healthcare system.
Patients may assume that heavy investment in informationtechnologies already provide a unified view of their medicalhistory. Levels of awareness and IT literacy vary, and most people
don’t recognize the organizational and technical barriers to
achieving that result. In a health system that doesn't have a visionor policy for integrated pathways of care, organizational silos canadd further barriers, with no agreed protocol for sharing databetween clinical groups, for example between general andspecialist practitioners.In strict technical terms, there are few real barriers to producingthat unified view. In other fields, huge volumes of data at personallevel, both transactional and descriptive data, are processed as
Permission to make digital or hard copies of all or part of this work forpersonal or classroom use is granted without fee provided that copies arenot made or distributed for profit or commercial advantage and thatcopies bear this notice and the full citation on the first page. To copyotherwise, or republish, to post on servers or to redistribute to lists,requires prior specific permission and/or a fee.For more information, please contact:Dari AlHuwail dari.alhuwail@dasmaninstitute.org

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