Digital General Practitioner (GP) Model

Healthcare in Bangladesh is in dire state. There is no referral system that can route a patient to a higher level of services. People don't know where to go when they are sick, causing late diagnosis and higher healthcare expenditure. There is no health insurance, causing 74% of the healthcare cost to be out of pocket. There is no health record that can help a doctor learn about patient history and provide more efficient services. Huge number of people are suffering due to obesity, cardiovascular diseases, diabetes and many other Non-Communicable diseases, causing nearly a million deaths every year. Majority of them are breadwinners of the family, causing a massive economic burden on the society. The situation is even worse for people belonging to lower economic circle and/or people belonging to professions usually looked down upon by the society starting from prostitutes, street hawkers, garbage collectors etc.

However, research suggests that preventive healthcare can minimize the health care risk, cost and time of an individual and of the nation. There is a strong digital infrastructure in Bangladesh allowing technology to reach every corner of our county. We also have over 15,000 govt. certified paramedics without a job. CMED is working towards solving healthcare challenges by connecting people with healthcare resources utilizing its Digital Healthcare Platform with smart diagnostic tools.

CMED Health is a health-tech startup transforming the healthcare landscape in Bangladesh using its end-to-end comprehensive multi-layered scalable digital Healthcare platform by connecting over 3.3 Million people with health services, early diagnosis, health education & referrals for intervention to achieve Health Inclusion (UHC) for SDG. 

To ensure that, CMED introduced Digital Health Account - a health account made through its apps called ‘SuSastho’ ( Good Health) where the health vitals are collected and stored through SMART Health kit and is stored in the cloud, able to be retrieved by a General Practitioner during medical consultation or telemedicine and thus provide informed judgement. Each Digital Health Account also has several benefits including price-offs in referral system, diagnostic tests, hospital bookings and no matter how and where the patient belongs in the social hierarchy, an access or priority is given to those DIgital Health account users to facilitate in-time medical care.

The goal of CMED health is to reduce health risk, health care cost & time by utilizing smart medical technologies integrated in smartphone applications. The concept of CMED was born in the AIMS Lab, United International University, Bangladesh in 2015. The research was then patented and published in the internationally acclaimed Elsevier Journal. From there CMED was developed, nurtured and finally established as an impact initiative in 2016 to create health inclusion. Aligned with the vision of Digital Bangladesh, supported by the ICT ministry of Bangladesh, CMED has come up with a number of technologically integrated devices that measure important health vitals and provides feedback through Android and iOS based mobile apps.

Digital GP Model

CMED has developed their GP model with comprehensive Primary & Preventive Healthcare delivery utilizing IoT enabled A.I. driven cloud based digital platform. Family members of every household will have a digital health account where all their health data will be preserved. They will receive digital primary & preventive healthcare services health education & health screening at their doorstep from Health Volunteers (HV). HV will refer the patients to the Community Clinic through an automated referral system. The Health Visitor/ Health Officer will attend the patient, provide appropriate care and refer to the GP doctor at Union GP Center if required through the referral system. The GP doctor will provide treatment to the patient. For higher level healthcare services, the GP doctor will refer that patient to Upazila Health Complex.

Fig 1: GP Model utilizing Digital Health Platform to establish structured referral system

Fig 2: GP Model utilizing Digital Health Platform aligned with government infrastructure

Through this model, we can mitigate existing healthcare challenges, reduce out of pocket healthcare expenditure & improve service availability & delivery. Digital Health Account will ensure health inclusion and social safety net. The Digital Healthcare Platform allows us to ensure quality of service, proper monitoring, accountability & transparency. Analyzing the data collected through the system can significantly help authorities to map resources, improve services & develop new policies. In addition, this system can reduce the challenges for periodic census. This way, we can ensure equitable & cost-effective access to healthcare services. We are also reducing economic vulnerability & increasing productivity. Through this model, we can ensure Universal Health Coverage and achieve SDG to build a sustainable future for our people. 

Fig 3: Digital Primary & Preventive Healthcare Services

Fig 4:: GP Model & Referral System Workflow

The usual health-tech services that we give are -

• Digital Healthcare Solution Design & Development

• 360° Digital Healthcare Platform Design, Development & Implementation

• IoT enabled AI-driven Health Risk Assessment and Intervention System Design & Development

• Community Based Digital Preventive & Primary Healthcare Services

• Smart Health Monitoring Devices & Consumables

• Health Promotive Care Services (Education, Counselling, Awareness etc.)

• Data Collection & Data Analysis Tool Design & Development

• Corporate Healthcare Solution

• Telemedicine Services

• Data Analysis and Research

• Connected Health & Virtual Hospital

• IT Enabled Services

• Technical & Operational Support and Training and any amendments, supplements, modifications and/or re-enactment made therein from time to time

The beneficiary: Total 2 million marginalised people scattered in different rural and urban locations around the country  including 75 unions in 67 Upazila in 45 districts.

The impact: The users have fair unbiased access to complete healthcare solution, can access the GP centers without hesitancy, saves their valuable working time by not spending in long cues in clinics, can have the flexibility of the service given at home by paramedics or health visitors, can have affordable diagnostic facility and gets the accurate service from the physicians due to proper medical history report being available on the cloud.

Founded by PhD holders, CMED has a multidimensional team with experienced scientists, professors, software architects and developers, medical and public health experts, business operation and finance professionals. Aligned with the SDG, CMED is bringing a completely new outlook to healthcare service delivery. Especially considering low and middle-income countries like Bangladesh, where there is a dearth of healthcare services in remote areas, CMED is bringing upon change and creating impact by saving lives.

Motivated by our own experience, we are passionately transforming healthcare service delivery using our deep understanding of the problem, research driven solution & the vision to create an ecosystem that connects people with health services & saves lives. We are currently creating the foundation to generate adequate data to develop health protection schemes and build trust in people for easier adoption. We have different teams deployed to carry out the overall solution namely - Medical Services & Operations, Business development & Corporate sales, Technical Team, Digital Operations Team etc. 

Our model and the operation has already won several recognitions, both globally and locally. These are: 

Accolades and Awards

•     Bangladesh Business Innovation Awards 2019, Category: Healthcare

•     Asia Pacific ICT Awards (APICTA) 2019

•     BASIS National ICT Award 2019

•     Seedstars Global Innovation Prize 2018

•   The Head Foundation Innovative Social Enterprise Award in DBS-NUS Social Venture Challenge 2018

•     Bangladesh Business Innovation Awards 2018, Category: SDG Inclusion

•     BASIS National ICT Awards Bangladesh 2017

•     Seedstars Regional Winner - Dhaka 2017

•     Innovation grant from ICT division of Government of Bangladesh

Exposure and scalability: Considering the huge population that are currently underserved in our community, It is a mammoth task for CMED to make healthcare accessible and digitally enabled for all without the proper funds and infrastructure to scale the operation any further. Also we believe that the solution that we designed should not be limited by geographical borders. The same model, with few alterations, can be deployed in other marginalized societies in other continents. Hence, CMED is looking for further global recognition, opportunity to attract more investors for infrastructure as well as policy support to make the solution available for all and thus ensure equitable health. We are also looking for scopes of best practice sharing to reduce any trial and error on the process of escalation. As MIT SOLVE is a very prestigious platform, we hope and believe that being recognized by the SOLVE global challenges will give us the exposure needed to drive our healthcare initiative forward and help us to scale effectively.

The GP model is the first model in our country that embraces an end-to-end, holistic healthcare approach which ranges from preventive healthcare to tertiary care. The solution is also designed in a way so that it encourages public-private partnership opportunities to ensure effective and efficient operation and thus has the flexibility and agility to be escalated to distant regions in a very short period of time.

Our goal is to reach 100 million people of the total population of Bangladesh and ensure their Digital Health Account creation by 2032. In case of impact goals for next year and next five years, we are driving towards achieving 3 million people under our digital health account scheme by 2023 and 20 million people within this scheme by the end of 2027. However, among these Digital health accounts, majority will be people living below the property line. 

Being a cloud-enabled healthcare solution provider, we find it very easy to track our progress and evaluate each step of our journey. We provide a gate-keeping opportunity to every level through health visitor dashboard, physician dashboard, admin dashboard and other mechanisms. The targets are set based on organizational capabilities and the model is flexible enough to adapt to different localities or needs. Depending on the requirement of the population targeted, multiple approaches are taken and public-private partnership or corporate CSR avenues in healthcare are explored.

Our theory of change implies - Equitable healthcare can be made possible if the marginalised, left out communities are given the opportunity to access end-to-end healthcare service in an affordable, informed and planned way which can only be made possible by technological intervention. We also believe such change procedure includes some assumptions - 

• Creating health awareness among the underserved community to respond to outreach and engage with the project.

• Need to create personal communication with these families to get involved and be supportive.

• The public authority needs to be involved in order to make the distribution of such service truly mass and universally appreciated.

• The physician and health service providers also need to be trained and made aware to fight against the biased, inaccurate healthcare system and voice against the malpractices.

1.           Languages: Java, Python, Kotlin, PHP

2.           Spring, Spring Boot for backend application framework

3.           Odoo

4.           Gradle for dependency management

5.           oAuth2 for authentication

6.           REST APIs for client-server communication

7.           Swagger for API documentation

8.           Redis for caching

9.           Elasticsearch for search and analytics engine

10.        Scheduled ETL jobs

11.        Apache Kafka, RabbitMQ as message broker

12.        PostgreSQL, MySQL, Oracle, MS-SQL Server, Postgres, SQLite

13.        Other: RUP, XP, Kanban, Global Health Informatics, IHE, HL7 FHIR

14.        Healthcare standards: HL7 v2/v3/CDA, HL7 FHIR 

15.   Data Analytic Software: Pentaho, Jasper, Mondrian, OLAP/XMLA, RStudio/Shiny, Spark, Kibana/ES, Metabase

16.        Application Server: Tomcat, Nginx, Jboss

17.        Android application: Kotlin, Android SDK, MVVM Architecture

18.        Web Frontend: Angular, TypeScript, Bootstrap4, SASS, JavaScript, JQuery

19.        UI/UX Prototyping: Figma for Android and Web application development

20.  Cloudflare: Firewall, DDoS protection, rate limiting, bot management Encryption

21.        Open Source Platform: OpenMRS, Bahmni, OpenSRP

22.        HTTPS is used for encrypted data transmission using TLS                            

23.        Data at rest is stored in encrypted storage at Cloud server

24.        Gitlab is used as code repository and for CI/CD pipelines

25.        Redmine is used for issue tracker and software development

We have an internal value system - INSPIRE of which ‘N’ stands for Neutral. We are fair to all, irrespective of class, gender, age, race etc. Our service is designed to serve the people in disadvantageous social or economic positions. We also regularly hold a census or survey in the locality we serve to find out the number of disabled people, widowed or divorced poor women, left out senior citizens, freedom fighters, children fighting with malnutrition etc and ensure those are taken care of, if needed with additional and more frequent services. Our model also includes job creation for paramedics of which a significant percentage is marginalised women. 

Meanwhile, as employers we have many female employees in different departments including the executive committee. We also show strong support to WOMEN in TECH - as the ratio of female engineers involved in our company is almost 40% and we hope to make it more.

Based on the locality we serve, we have two different GP model with rGP standing for Rural General practitioner and uGP standing for Urban General Practitioner. The models are as below: 

Fig 4: Rural GP Business Model

Fig 5: Urban GP Business Model

The long-term sustainability of our business model depends on scale. As our core idea is to make healthcare accessible and affordable through technological advancement, the more we can grow the user base, the more efficient the system will become. Providing a tech-based solution itself has some cost-implications. Hence, we are planning to scale up our operations through partnership with local and global corporations, willing to tag with impact investors and innovations grants, and use existing distribution channels as shared economy vehicles instead of growing a centrally owned distribution modality. By applying these procedures and the minimum amount that we are charging as service fee to the user will be adequate for us to be completely sustainable.

We have been proud partners of several internationally acclaimed development organisations as well as have managed to be aligned with public service authorities which helped us to go for the sustainability journey we are looking for. Some of our trusted partners are - 

• Palli Karma Sahayak Foundation (PKSF)

• UNICEF

• Ministry of Women’s & Child    Affairs, Govt. of Bangladesh

• Non-Communicable Diseases Control Program (NCDC), DGHS

• Community Based Health Care (CBHC), DGHS, Ministry of Health and Family Welfare, Govt. of Bangladesh

• BRAC

• UNDP