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Global Medicine: Kuwait

BIDMC Team Helps Curb Kuwait's Diabetes Epidemic Through a Cutting-Edge Electronic Health Record System

This story is part two in a series about our Department of Medicine's global projects and collaborations.

Dr. Charles Safran, Chief, Division of Clinical Informatics at BIDMC; Dr. Antoine Kaldany, BIDMC nephrologist and Executive Director of International Initiatives, Harvard Medical Faculty Physicians; Judith Goodwin, Vice President and Managing Director, Strategic Initiatives, Joslin Diabetes CenterBy now many of us are familiar with the alarming statistics regarding diabetes here in the US. According to the Centers for Disease Control and Prevention, an estimated 25.8 million Americans - that's over 8.3 percent of the population - are affected by the disease. But what we may not realize is that we are part of a global epidemic. The World Health Organization estimates that more than 346 million people worldwide have diabetes and that, without intervention, this number is likely to more than double by 2030. Among the world's countries with the highest rates of diabetes is Kuwait, a small oil-rich country at the top of the Gulf.

In an effort to combat this pandemic, The Dasman Diabetes Institute, Kuwait's national diabetes center, has partnered with an interdisciplinary team of clinical informatics experts, educators and physicians here at BIDMC and affiliated institutions. Their goal: to develop a new electronic health record system that will help clinicians, patients, family members and public health officials effectively prevent and treat the disease. For the last two years, a team headed by Charles Safran, MD, Chief of Medicine's Division of Clinical Informatics, and Antoine Kaldany, MD, Executive Director of International Initiatives at Harvard Medical Faculty Physicians, has worked with Dasman to develop Knowledge-Based Health Records (KBHR), an exciting model for the next generation of electronically-supported, patient-centered diabetes treatment and prevention.

"The human and economic toll that diabetes is taking in the world and in Kuwait is huge," says Dasman's Director General, Kazem Behbehani, MD. In order to address the epidemic, he notes, "We have to change how we deliver care." Dasman currently sees 4,000 patients a month and is providing largely tertiary care, he explains. "We're working to establish one network so that no matter where you are, you're part of a central system with good care throughout, including prevention," says Behbehani, "and KBHR is crucial to this effort."

Experts estimate that an alarming 25 percent of Kuwaiti nationals have diabetes and that children are increasingly at risk. Type 2 diabetes, which accounts for 90% of cases, is influenced by environmental factors such as diet and lack of physical activity. In Kuwait and throughout the Gulf region, where rates tend to be similarly high, experts believe there may be some genetic predisposition to diabetes. But they also point to environmental influences such as the extreme heat that often deters people from being physically active. Furthermore, the country has become wealthy quite quickly - over the last 60 years - and this affluence has resulted in both dietary changes and a more sedentary lifestyle.

KBHR is designed to provide quality management metrics, clinical decision support and continuing education. The system includes important tools for physicians such as alerts and reminders and decision-supports, along with links to continuing education resources and sophisticated analytics. Physicians receive important feedback on their patients' outcomes and the care they provide, which can help them improve as clinicians. Behbehani notes, "The new technology will help us to not only be more efficient but also to make better decisions around diabetes and its complications. We will have more cost effectiveness with better outcomes."

Front row (L-R): Dr. Phil Stashenko, Dr. Kazem Behbehani, Dr. Frank Hu, Dr. Manuel Carballo. Standing (L-R): Dr. Antoine Kaldany, Dr. Peter Beales, Dr. David Matthews.In fact, KBHR already appears to be making a difference. In a pilot of KBHR at Dasman the results were quite dramatic. In just 90 days, patients who received care at the Institute, using KBHR, had a highly significant decline in their A1C or glycohemoglobin levels. A1C levels are used to diagnose diabetes and to determine diabetes treatment. A reduction in A1C levels is associated with a decreased risk of diabetes-associated morbidity and mortality.

Drawing on over 40 years of expertise with electronic health records, Division members have helped the Institute develop a state-of-the-art system that shows great promise, in part, because it is tailored to the specific clinical and cultural priorities of its patients and clinicians. "There's really nothing like this and we've done this in a year - that's remarkably quickly," says Safran. "It's unlike anything that could be commercially acquired with monographs for patients in Arabic and the use of novel approaches to physician documentation, such as the use of graphical examination notes."

Ultimately, the KBHR system will also be accessible to patients for a variety of purposes, including accessing their health records or educational materials. KBHR will have the capacity to send patients text messages reminding them about upcoming appointments or encouraging them to participate in research projects. The team also envisions a time when patients will have blood pressure cuffs at home that submit readings electronically to clinicians. The clinician will then be able to track the patient's health remotely and arrange for in-person visits, if necessary. Additionally, KBHR will enable family members and caregivers to be engaged in their loved one's health.

KBHR has great potential to promote high-quality, patient-centered diabetes care at Dasman and throughout Kuwait. However, as Safran explains, it is only a piece of a larger transformation of health care taking place at the Institute, in Kuwait and across the region. This broader effort, which goes well beyond diabetes care, is being lead by Kaldany. A native of Syria, who attended medical school in Beirut and trained in the US, Kaldany has long been committed to improving health outcomes in the Middle East. His interest in using technology to promote health and advance the field of medicine globally goes back over 30 years when, as a nephrologist, Kaldany began consulting with physicians and patients in the Middle East via a telex machine, well before the age of the Internet.

Kaldany envisions a national public health infrastructure in Kuwait that's both patient-centered and supported by the best of modern technology. He is working closely with Behbehani at Dasman, the Kuwait Ministry of Health and the country's 104 local Primary Health Care Centers (PHCs) to create a well-coordinated, efficient system that best meets the needs of patients. "We want to establish continuity of care where there's accountability and quality monitoring. We want to identify the system's weak links and close the loop of communication," says Kaldany. The team has begun to pilot KBHR at several local health clinics in an effort to better coordinate patient care between Dasman and the PHC's where patients receive most of their health care. KBHR and related technology allow the Ministry to collect epidemiologic data vital to Kuwait's public health infrastructure. For instance, using the unique identifier that each Kuwaiti national receives coupled with a geographic information system, the Kuwait's Ministry of Health can better understand and track where patients with particular health care needs live and allocate health and education resource accordingly.

Kaldany and Behbehani share a vision and a strong track record in international ehealth initiatives. As the World Health Organization's Assistant Director-General for External Relations and Governing Bodies from 2003 to 2005, Behbehani was instrumental in the passage of a WHO eHealth Resolution. He's proud to report that over 100 countries have already developed ehealth initiatives based on this resolution. Now, through KBHR, the Dasman-BIDMC team hopes to further this effort by providing a model for other countries in the Middle East - a model from which they might learn and further develop their own ehealth strategies to address diabetes and other public health concerns.
In addition to developing KBHR, the team has partnered with Dasman to build an education and training program with the Shapiro Institute at BIDMC and Harvard Medical School and is currently working on a diabetes education project with the Joslin Diabetes Center, under the oversight of Nuha El-Sayed, MD, a Joslin physician and the Co-Director of International Initiatives at HMFP. The team is also collaborating with the BIDMC Department of Medicine to develop a webcast platform that will enable Dasman physicians in Kuwait to watch Medical Grand Rounds lectures delivered here in Boston.