Sahil Sandhu, Lillian Blanchard, Chunxi Ding, Alexandria Hurley, Chelsea Liu, Jackie Xu, Natalie Yu
A lack of coordination in healthcare is a major barrier globally to high-quality care and population health. A health system consists of a diverse set of actors with their own roles and incentives. Health outcomes suffer when different sectors (academia, industry, and government) across distinct levels of care (prevention, treatment, and recovery) do not work together. Although such fragmentation is problematic in the Chinese healthcare system, the prevalence of technology in China has opened the opportunity to connect these stakeholders who can develop new tools to improve communication to provide patient-centered care. Seven members of our Bass Connections team traveled to China during this past fall break to learn more about healthcare infrastructure and the use of technology.
Our Bass Connections team, Global Alliance on Disability and Healthcare Innovation (GANDHI), studies comparative health systems and explores outcomes related to disability after acute hospitalization. This academic year, we are focusing on stroke outcomes in China with the goal of improving transitions across components of the care continuum. These include health promotion and public health prevention interventions in the community, stroke symptom awareness, acute hospital care, rehabilitation therapy, follow-up care in outpatient settings, and home care. To better understand these different levels in the Chinese healthcare system and the different stakeholders addressing healthcare fragmentation, we visited an academic institution, a public hospital, and private health service organization.
Peking University: Electronic Health Records and Disease Prevention Research
To understand preventative care work conducted in China, we visited Dr. Pei Gao, Dr. Xun Tang, and their research team at Peking University School of Public Health, Department of Epidemiology and Biostatistics. Dr. Gao and Dr. Tang work to improve disease risk prediction models for non-communicable diseases like stroke. They redesign statistical formulas developed in Western settings to fit the Chinese population. Among other sources, they draw data a data system integrated with a regional electronic health record (EHR) from Ningbo, a city just south of Shanghai. Ningbo was one of the first locations selected by the Chinese National Commission of Health and Family Planning to test these new EHR systems. Since the mid 2000s, health centers in Ningbo have been collecting patient data, supplemented with interviews, to create an incredible base for longitudinal cohort studies and mining field for researchers.
While Dr. Gao and Dr. Tang expressed excitement over having access to this data, the barriers they encountered revealed inherent difficulties in collaboration between academia and the healthcare system. For example, government approval to use this data for research has been a slow and laborious process. After finally obtaining permission, the Peking research team had to expend huge efforts to “harmonize” and “tidy” these government-maintained administrative datasets. Due to concerns over patient data security and variation in the type of data collected, administrative data often looks different from research data.
Sometimes, health researchers resolve this discrepancy in data types through double data entry: personnel enter one record for administrative purposes and another intended for a research study. Other times, academics stick to retrospective analyses with the administrative data they have access to, making the best of missing entries and inconsistent measurement methods. In these cases, they have no control over how the data was collected. When asked if Chinese researchers have a role in designing EHR systems, Dr. Gao responded with a “not really” and a chuckle.
As Dr. Gao’s explained all these difficulties with data collection and analysis, we began to realize how messy public health research can be. In our research methods classes at Duke, our professors teach us about the importance of high quality data and designing rigorous studies. Rarely, do we actually talk about realities of the research process and how imprecise it can be. For example, even when researchers can build their own studies, a lack of a consistently trained staff affects data quality. Similarly, selection bias from unenrolled patients taints the applicability of database findings. In China, patients have no financial incentive to answer follow-up questions, and most are wary of calls from unrecognized numbers due to the high presence of fraudulent phone calls. Some research teams are beginning to harness the power of WeChat, a widely popular and all-encompassing mobile messaging app (similar to Facebook’s Messenger in the United States) to collect follow-up information.
Our visit at Peking University revealed the need for greater collaboration with other sectors of healthcare and for new technology to drive high-quality data collection. The quality of stroke prevention research in China would greatly improve if researchers could work prospectively with clinicians and government to determine how health data is collected.
Tiantan Hospital: Acute Care and Quality-Improvement Research
After learning about preventative care at Peking University, we went to Tiantan Hospital to learn about hospital care for stroke patients. As the first stroke unit established in China, Beijing Tiantan Hospital’s Comprehensive Stroke Center is officially an academic institution that conducts research on stroke and comprises a 24-hour neuroimaging center for stroke patients in the hospital. Much of its research is directly applied to acute treatment in the hospital and follow-ups in outpatient settings.
When we arrived at Tiantan Hospital, we were greeted by Dr. Liping Liu, a neurologist who is the director of the Neurological Intensive Care Unit. With one of her doctoral students, we walked through a typical stroke patient’s experience at the hospital. When patients first arrive at the hospital after a stroke, they are triaged at the emergency department. There, a diverse team of health professionals collaborate to move patients along the appropriate treatment pathway. Nurses take the patients’ vitals and perform blood tests; medical students record patients’ electrocardiography and assess the Glasgow Coma Score; and neurologists stationed in the ER put patients on different clinical pathways based on the suspected time of stroke onset and the imaging results.
Patients on the “green pathway” can bypass further neuroimaging to receive a tissue plasminogen activator (tPA) drug, the gold standard treatment for ischemic stroke. The timeframe for diagnosis is especially important for tPA treatment since it can only be administered 4.5 hours after stroke onset. Any patients diagnosed after 4.5 hours must undergo additional testing and explore other treatment options. After receiving tPA or other treatments, stroke patients are placed in the Emergency Intensive Care Unit (EICU) for a mandatory period of observation. Then patients are either discharged, transferred to a community hospital, or moved to the inpatient unit at Tiantan.
Tiantan Hospital has already cut down its total door-to-treatment time, putting it ahead of many American hospitals. The stroke center itself is a leader in treatment efficiency and outcomes with its continual innovation and research. One of its major achievements has been the development of the China National Stroke Registry (CNSR), which has informed many of its practices in acute and outpatient settings. The CNSR is a multicenter, prospective, and comprehensive registry of stroke patients in China, first launched in 2007 and currently completing the third iteration of data collection. This registry contains a broad range of data collected during stroke patients’ hospitalization and after discharge. There are over 400 centers in the registry’s network and it serves to create a comprehensive picture of how stroke care can be improved in China. Using data in this registry, physician-researchers at Tiantan have identified many quality indicators and best practices that they have since applied to treatment of stroke patients. In fact, they have published over 100 papers in international journals on these findings.
The comprehensive stroke unit offers an example of how large amounts of data collected from clinical settings can be used to inform healthcare management. However, for all the discussion on data collection in China, Tiantan remains singular in implementing such a system. The challenge that healthcare providers in China now face is translating their ideas into a unified approach towards building health databases across the country.
Pinetree: Home Health and Community-Based Care
To understand patient care after a hospitalization, we had the opportunity to visit Pinetree Rehabilitation Nursing and meet with company executives. Pinetree, a Beijing-based company run by Ninie Wang, provides care for older patients who have had a stroke or any acute hospitalization. Pinetree applies an innovative home care model utilizing both physical door-to-door visit and telemedicine remotely using phone and video technology. Already in Beijing, Shanghai, and Hangzhou, Pinetree plans to extend its services to other regions.
Pinetree hires professional personnel with backgrounds in nursing, physical therapy and medicine to answer questions and provide care. Cultivating the top talent from many disciplines has allowed Pinetree to become an industry leader. The company actively recruits young professionals to bring innovative ideas into geriatric care. After multidisciplinary training, these caregivers then form teams to provide personalized treatment and establish relationships with their patients. Pinetree also partners with hospitals to recruit recently discharged patients for post-hospital care. In fact, some hospitals even provide Pinetree office space for consultations.
Once the patient returns home, Pinetree uses remote communication devices to communicate and manage care. The HealthPlus (小鱼儿) device, a tablet platform with text-to-speech and video chat functions, allows patients to communicate with Pinetree staff. HealthPlus also functions as a data transmission platform: patients can input their daily blood pressure data, which is then monitored by Pinetree. If a Pinetree staff member notices a significant fluctuation in patient blood pressure, he/she will send them a WeChat message to check in.
The need for post-hospital care is not widely acknowledged in China. As a result, health insurance only covers primary and hospital care. While high income patients can afford home-health services and low income patients may be able to receive government subsidies, middle-class citizens are currently unable to afford this rehabilitative care. Pinetree is actively working
We ended our trip by visiting Duke Kunshan University, where we attended the Duke Kunshan Conference on Digital Health Science and Innovation: Partnerships between Academia and Industry. We interviewed experts to learn their perspective on partnerships for facilitating improved health with digital health technology. The discussions and presentations at the conference encouraged us to think critically about our three experiences in Beijing. While Peking University, Tiantan Hospital, Pinetree Rehabilitation each played a critical role in the care continuum for patients, they each represented a different sector of healthcare: academia, government, and industry respectively. All three leveraged new technologies to improve stroke patient outcomes, but greater collaboration across these sectors is still needed.
Ultimately, health system strengthening requires collaboration across academia, government and industry. Fostering a culture of interdisciplinary collaboration can never start too early. Of the seven Bass team members who went to China, no two had the same majors. Our majors stretched from electrical and computer engineering to public policy to psychology. Every team member engaged in this experience with a unique lens and raised different questions. Moving forward, we hope to integrate these perspectives to develop innovative solutions in addressing the global burden of stroke and other non-communicable diseases.