“The Doctor Knows You” Project 4.0 and a Nationwide Medical Information Network Officially launched in October 2018, Thailand 4.0 is the Thai government’s 20-year strategy to accelerate the Kingdom’s development. Thailand 4.0 is designed to promote and support innovation, creativity, research and development, higher technologies and green technologies. Taking heed of this ambitious program of nation-building, indeed anticipating it in an ambitious and innovative manner, the Dean of the Faculty of Medicine (Associate Professor Dr. Sirikasem Sirilak, MD, MBA), with the support and cooperation of the Director of the Phitsanulok Provincial Health Office who oversees all government in and in the 2nd Health Region, (highlighted in the map to the right), together with the Department of Electrical and Computer Engineering in the Faculty of Engineering at , proposed, developed and delivered an information system to enable and support an ambitious new public health structure in the Region and to improve the efficacy, efficiency and effectiveness of the delivery of medical and health services. As well, the system was to enable the collection of essential medical and public health information and intelligence to properly inform the public health and medical administrators and decision makers. In many respects, this system must be seen as the center piece of a medical intelligence gathering system that goes right to the heart of the public health system in Thailand: that is, the village, and which enables the delivery of primary health services and health information distribution at the village level. Equally, the system enables the flow of valuable grassroots health data upwards to decision makers at all levels with a volume and quality never previously possible or envisaged. The importance of the emphasis on the village as a unit for the delivery of services and information, and for the gathering of information, cannot be understated given the essentially rural nature of the Region, and the difficulty in providing quality and convenient medical services to villagers in these areas. Delivery of essential primary health services and information is difficult and wanting, but nonetheless imperative to meet the fundamental Determinants of Health for the population, at the grassroots level: population genetics, social and physical environment, health system efficacy, population behavior. There is an essential need for both micro and macro public health data to inform decision makers, and this system satisfies that need exceptionally well, together with bringing services to patients wherever located. The fundamental problems to be addressed in this development were twofold: first, to bring medical services to the village level and help in overcoming the dearth of trained, expert medical personnel accessible to rural villagers, and second, the urgent requirement for a significant information and medical intelligence gathering system. Hospitals in Thailand have not, prior to this, ensured the commonality and connectivity of their information systems. This has made the construction of a comprehensive medical information system difficult resulting in a breakdown in the continuum of care for patients. This problem extends to a significant lack of communication ability between patients and medical providers, amongst medical providers, and between all other participants in the medical care sphere, such as pharmacists, dentists, physical therapists, district nurses and, importantly, village health volunteers. The urgent need for a solution to this problem was clearly indicated in the Thai governments public health delivery plan encompassing the “near the home / near the heart’ campaign that focused on the village level, grassroots level primary patient care requirements. 1 The effective administration of public health services requires a stream of comprehensive, reliable and timely information to be available to inform forward-looking policy making, and prompt responses to medical and epidemiological situations, such as potential outbreaks of dengue hemorrhagic fever which can spread with devastating health effects if not promptly checked, identification of tuberculosis, another deadly public health danger, and disease prevention programs such as mosquito larva eradication, and vaccination campaigns. The resulting “The Doctor Knows You” application emphasizes the knowledge “connection” or network between doctors and patients, medical administrators and all other participants. It is a comprehensive medical information and management support system.

Figure 1: Schematic of "The Doctor Knows You" System The best way to see the importance of this system is to start at the bottom, at the system component of significant relevance and usefulness and which in many ways is the information foundation stone of the situation: The Village Health Volunteer. The Doctor Knows You: Village Health Volunteers Application There are about 15,000 Village Health Volunteers active in each Province, with an expected cohort in each Province nationwide of up to 20,000. Within the 2nd Health Region there are about 90,000 Village Health Volunteers at present. Nationwide, there are just in excess of 1 million Village Health Volunteers whom it is intended and hoped will be joined together with the The Doctor Knows You system. These are the grassroots, village level cohort of local people who are part of the community, known and trusted by the villagers. The Village Health Workers are paid a small monthly government allowance, and each one is responsible for 15 households in the village. In the past, the role of the Village Health Volunteer was limited to data collection on social and medical matters of interest to the medical authorities. However, their new role is now focused on improving the basic health status and access to medical services of the villagers. This component of The Doctor Knows You system supports their significantly expanded data collection role to include village census data; with the GPS location of each household, reporting the incidence and prevalence of disease, occurrence of diseases such as tuberculosis and dengue hemorrhagic fever, and Non Communicable Diseases (NCD), assistance in mosquito larva eradication, as well as basic health care information distribution. The information gathering aspect of their work has enabled a significant database of grassroots level health information to be created, and the reporting of outbreaks of dangerous diseases allows a prompt response to deal with that. The epidemiology and public health value of this information gathering and reporting network, enabled by The Doctor Knows You system is enormous. There 2 are now literally thousands of Village Health Volunteers providing useful, detailed information to inform medical authorities on those fundamental Determinants of Health for the population, at the grassroots level, and this is enabled by the Village Health Volunteer component of The Doctor Knows You system.

As well as their information gathering and dissemination roles, the Village Health Volunteers are also responsible for the basic health needs of the villagers. Home visits to bed-bound patients, ensuring medications are correctly administered, providing basic health and hygiene services as necessary, taking appropriate health and physical measurements, such as blood pressure, BMI, fasting blood sugar level, calling in the family physician as necessary and in a timely fashion, making and doctor appointments as necessary on the patient’s behalf, and providing advice and information to the patients on personal and household hygiene, self-care and harm prevention. To ensure quality in these services, the Village Health Volunteers must themselves be further educated, and educational materials are distributed via the Village Volunteer component of The Doctor Knows You system. The system also has facilities to test the knowledge of the Village Health Volunteers.

The Doctor Knows You: The Patient Support Application Another of the four major components of The Doctor Knows You system has brought a significant level of health safety and health care access to patients. Participating patients have their entire medical history on their smartphone, including, importantly, their treatment history, medication history, Laboratory test results history, allergies and drug warnings, that they carry with them for Anywhere/AnyTime access and which is updated on an AsNeeded / Where-Needed / When-Needed basis. This system component also dovetails with the Village Health Volunteer component and situation, where Health Volunteers always have up-to-date information on their patients and household members in the 15 household cluster for which they are responsible. The systems have brought a level of convenient access to medical assistance that is essential for patients in rural and remote areas and those who may be confined to their homes, or are far from their private doctor or usual hospital, or have great difficulty in traveling to a medical facility. From a patient perspective, once The Doctor Knows You app is installed on their smartphone, all their medical history is downloaded on to their smartphone from all participating medical centers and stored in the smartphone (or Tab computer) and is then available to be viewed by any physician or Volunteer Health Worker participating in the project. Subsequently, at the new point of contact; a hospital, a health center or primary care health facility, or a home visit by a physician or a Volunteer Health Worker, the health history and medication history of that patient is immediately updated from the network of participating data sources (hospitals, health centers, primary care health facilities or physicians) and made available for viewing on the patient’s smartphone. An important aspect of this solution is that, even where there is no reliable Internet connection available, the patient is carrying their medical history with them on their smartphone for immediate viewing. The significant achievement of this component is the real-time availability of patient medical information and medical history, stored on the patient’s smartphone. Being stored on the smartphone means that access to the information is not reliant on Internet availability.

3 The Doctor Knows You: PCC Team Application The provision of medical services in the Health Region is organized in “Primary Care Clusters” (PCCs) which comprise 3 family physicians, 12 nurses, a dentist, 3 dental technicians, a pharmacist and 3 pharmacy technicians, a physical therapist, 3 Thai traditional medicine practitioners, 12 public health professionals, and village health volunteers. Each PCC is overseen by a District hospital and also includes 3 Sub- District hospitals, each of which serves about 3,000 people. Overall, a PCC serves about 10,000 patients in the villages in 3 Sub-Districts. The PCC service delivery structure meets government requirements for the extension of primary care in Thailand. Using the NU MED e-Consultation application (discussed next), the PCC Team component is an important communication channel between the various participants, and particularly for patient communications, to and by the patient. Using the Patient component provides real-time patient medical, medication and laboratory test information, available to all PCC participants. The Doctor Knows You: NU MED e-Consultation Application An additional system that provides significant complementary features to The Doctor Knows You system, and which provides the central function utilised by all participants, known as the e-Consultation System, utilizes advanced technology: Hololens®, Augmented Reality and haptic devices for remote device control, and a communication network, to enable communications and remote consultations with specialist physicians, surgeons, specialist obstetricians and pediatricians, and other Critical Care medical staff located at Buddhachinaraj Hospital, to provide remote consultations with medical and nursing personnel at District and Sub-District hospitals. The system plays an integral role in The Doctor Knows You system, is nonetheless a most useful complement to this system. Supporting Information for the Success of the Project The system is now operational in the 2nd Health Region covering 5 Provinces: Phitsanulok, Petchabun, Tak, Sukhothai and Uttaradit. Within each Province there are 9-11 Districts (Amphur), and in each District there are between 8 to 10 sub-districts (Tambol) and one Tambol covers 10 villages. Hospitals and health clinics and facilities are distributed within this administrative structure, including 10 hospitals (Tertiary and Academic hospitals and District Hospitals, and 147 sub-district hospitals: and, of course, the reason for it all, the grassroots level of health services need and provision, the villages. The extent of the 2nd Health Region covers an area of 54,345 km2 Figure 2: Usage and Access Statistics indicating the early success of the system with a population of 3,324,435. Information Security Medical information is considered to be an area of significant sensitivity, demanding a high level of security against unauthorized access and display, and, before all else, the informed authority to actually keep that information. To ensure the highest level of security possible, all participants were carefully and fully informed, and signed an Informed Consent Form allowing their health information to be accessed for downloading to their smartphone. Participating medical service providers were required to ensure 4 patient data security and allow the “The Doctor Knows You” app to retrieve the data as required. As the apps become more prevalent, and the network is expanded beyond its current geographical boundaries, the matter of information security will become more serious. It is intended to explore biometric security measures including fingerprint recognition (available on smartphones today), facial recognition and even more sophisticated retinal scanning. Currently, these features are on the “must have in the future list”. The Enabling Technology The major problem to be overcome was creating a network that interfaced with a large variety of information systems in the various hospitals connected to the network. This problem was overcome by the development of intelligent software agents working as front-end agents to intercept incoming communication messages and convert them into the local protocol, and also to convert communication messages created by the local information and convert them into the Internet MQTT protocol for transmission to the Data Center in the Cloud. This was a significant technological feat. This project ticks all the boxes of innovation, creativity, research and development, and the application of higher technologies for this important and indeed potentially life-saving medical application to serve the Thai community-at-large. Research Funding and Development Support Research Funding and Development Support Research funding was obtained from the National Broadcasting and Telecommunications Commission (NBTC). The total cost of development, for both software and hardware acquisition, and also including administrative support personnel, was just in excess of USD$700,000. Conclusion This is a fully proven system currently in use in a significant geographical area of Thailand. A feature of the system is its ease-of-use in the hands of often unsophisticated IT users. The system is ready-to-go to be propagated nationwide to become the national medical information sharing network. Its usefulness to any participant, be it a patient, health volunteer, a community health worker – pharmacist, physical therapist, dentist, or a hospital or medical post, is enormous, to the point of being a life-saving use of technology. Its potential importance in the public health sector of the Thai economy is considerable. It can only be regarded as an outstanding ICT achievement with significant benefits to the Thai population. As a software development project, it has more than provided solutions to the problems found in the Health Region, as elaborated above. In this, it is a resounding success. The processing by the app, in downloading patient data from a network of many different and otherwise incompatible data sources, is only made possible by the novel and innovative use of a networking protocol and architecture modified from the MQTT protocol and utilizing M2M communications protocol. This is, without question, a project that is an outstanding achievement in harnessing ICT to demonstrably provide significant improvements in patient care and safety, with a simplicity of operation that allows it to be very effectively used by participants to address the major challenges facing public health authorities. The project team, in submitting this application, feel confident that the judging criteria, especially the patient care and safety criteria, are well and truly met and accurately described.

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