MEDINFO 2015: eHealth-enabled Health
I.N. Sarkar et al. (Eds.)© 2015 IMIA and IOS Press.
This article is published online with Open Access by IOS Press and distributed under the termsof the Creative Commons Attribution Non-Commercial License.
doi:10.3233/978-1-61499-564-7-79

79

Mobile Healthcare System for Health Checkups and Telemedicine
in Post-Disaster Situations
Min Hua,b,c, Megumi Sugimotob, Andrew Rebeiro Hargraveb, Yasunobu Noharaa, Michiko Moriyamad,
Ashir Ahmedb,e, Shuji Shimizuc, Naoki Nakashimaa,b,cb

aMedical Information Center, Kyushu University Hospital, Japan
Institute of Decision Science for a Sustainable Society, Kyushu University, Japanc
Telemedicine Development Center of Asia, Kyushu University Hospital, Japand
Clinical Nursing Research Laboratory, Hiroshima University, Japane
Department of Advanced Information Technology, Kyushu University, Japan

Abstract
Portable Healthcare Clinic (PHC) is a mobile healthcare
system comprising of medical sensors and health assessment
criteria. It has been applied in Bangladesh for the last two
years as a pilot program to identify non-communicablediseases. In this study, we adapted PHC to fit post-disasterconditions. The PHC health assessment criteria areredesigned to deal with emergency cases and healthcare
worker insufficiency. A new algorithm makes an initialassessment of age, symptoms, and whether the person isseeing a doctor. These changes will make the turn-aroundtime shorter and will enable reaching the most affectedpatients better. We tested the operability and turn-around timeof the adapted system at the debris flow disaster shelters in
Hiroshima, Japan. Changing the PHC health assessment
criteria and other solutions such as a list of medicine
preparation makes the PHC system switch into an emergency
mode more smoothly following a natural disaster.
Keywords:
Paper, Medinfo 2015; Post Disaster; eHealth; mHealth;
Teleconsultation; Public Health Informatics.

Introduction
The World Health Organization declared that 58 crisis
countries, including Bangladesh, face acute Human Resources
for Health (HRH) crisis [1]. Many countries experiencecatastrophic natural disasters. In Bangladesh, 26% of the
population is affected by cyclones, and 70% live in floodprone regions [2]. Natural disasters result in casualties anddamage medical facilities and the health workforce [3]. The
2011 Tohoku Earthquake demonstrated the need for disastermanagement in aspects including healthcare. Although mostcasualties in the Tohoku Earthquake were because ofdrowning, the bad living environment in post-disaster sheltersworsened the health condition of victims [4]. Strategies forpost-disaster management are urgently required, and mobile
healthcare systems may reach disaster victims quickly.
Kyushu University Hospital and Grameen Communications
conducted a health management study using information
communication technology. The Portable Healthcare Clinic(PHC) with medical sensors provided immediate consultation
with the remote doctor over Skype for non-communicablediseases (NCDs). Following consultation, the remote doctor
gives the patient an e-prescription. Data collection was
conducted in 10 locations of Bangladesh between July 2012
and February 2014 [5].

However, little is known about the feasibility of introducing
PHC into post-disaster areas where the healthcare conditions
are different from those in non-disaster areas.
We examine the feasibility and risks of post-disaster
healthcare management with a general health evaluation
targeting disaster-related symptoms caused by trauma,
infectious and chronic diseases, and mental disorders. Afterdisasters, the findings of this study would be useful fordeveloping an emergency mode of PHC to support postdisaster areas in Bangladesh, Japan, and other countries.

Methods
Logistics Classification Research
We collected data and performed a literature review on
disasters in Bangladesh to understand the risks in post-disasterareas. We collected data from EM-DAT and Asian Disaster
Reduction Center and used the keywords "natural disasters,""disease," "healthcare," "impact," "epidemiology," and"shelter" to collect literature through PubMed and Web of
Science to classify disaster-related healthcare risks.
Revising Triage Rule for Post-Disaster Situation
The PHC has the following devices: weight scales, tapemeasures, blood pressure meters, glucose meters, body
thermometers, pulse oximeters, urine test strips, andhemoglobin meters. Through examinations with these devices,a health assessment can be made. The health assessment logic,
called Bangladesh logic (B-Logic), was introduced into all thedisease management activities of PHC in Bangladesh [5].
In B-logic criteria, the results are divided into four stages(green, yellow, orange, and red), and they form a healthassessment of Bangladeshis under non-disaster conditions. Blogic criteria do not address the post-disaster conditions
because there is often a shortage of healthcare workers, andthe unavailability of medicine is more serious in post-disasterthan in non-disaster conditions. Therefore, we designed a
triage protocol using B-logic and conducted a series of
medical questionnaires on possible symptoms in post-disasterareas. The symptoms are assigned with risk assessment.
Operation Test
To examine the feasibility of the designed triage protocol, an
operation test was conducted in chosen areas of Hiroshima
City that were affected by a large debris flow in August 2014.
This debris flow resulted in many casualties with 74 deaths
and 44 injured [6]. Some victims were still living in disaster80

M. Hu et al. / Mobile Healthcare System for Health Checkups and Telemedicine in Post-Disaster Situations

shelters in October 2014. We performed an operation test in
the post-disaster shelters of Hiroshima on October 25th tobetter understand their health conditions and to classify theoperation, suitability, and efficiency of PHC performance inpost-disaster areas.

Results
Logistics Classification Research Result
The investigation shows that in Bangladesh, floods andcyclones cause destructive damage during and after thedisasters. They are the two disasters in the top 10 disasters that
affected most people from 1985 to 2014 [7].
As the most frequent disaster in Bangladesh, flood disasters
cause deaths from drowning (67.6%), physical trauma(11.7%), heart attack (5.7%), fire (3.6%), electrocution(2.8%), and other (8.6%) [8]. In addition to the direct impactof the disaster, health conditions of post-disaster populations
are also affected by poor sanitary conditions of shelters,
increasing tobacco abuse, and more stress.
Fever, diarrhea, respiratory problems, and abdominal pain are
the most common symptoms in post-disaster Bangladesh.
Approximately 20–40% of these subjects had diarrhea thatmainly resulted from cholera and rotavirus infections [9-11].
For acute respiratory infections, a moderate increase in risk
during the six months after the flood and the subsequent 18
months were found [12]. Chronic stress after natural disasters
may also significantly affect cardiovascular risk factors [13].
People with NCDs are more vulnerable in emergencies anddisasters, when emergencies exacerbate NCDs, leading toacute complications [14]. Natural disasters cause a higher
prevalence rate of NCDs and negatively impact people withpre-existing conditions [15, 16].
Triage protocol using a new logic
The PHC algorithm was redesigned to target disastersituations. In the Disaster Logic (D-Logic) algorithm, thecriteria for teleconsultation were adjusted for fewer people tosee a doctor. This adjustment was acceptable in the short term,
just after a disaster, to avoid congestion. A new assessment
was added into D-logic for better coverage in disaster-related
physical and mental health conditions.
D-logic was introduced to provide initial assessments of age
and symptoms. Assessments based on sensor data andsymptom questionnaire were created for a generalexamination of healthcare risks in our logistics classificationof disasters. With the obtained results of D-logic, the remotedoctor will make decision and instructions by Skype and eprescription.
The D-logic triage was designed in the following steps:
1. Make an initial assessment with three questions
shown in Figure 1 for the disaster patients.
2. According to the results of the initial assessment,
disaster patients will be divided into five groups withdifferent examinations (Figure 1).
3. Following check items and criteria are designed as Dlogic_1 and 2, which are two examinations. D-logic_1 isbased on the sensor measurements (Table 1). The red

items in Table 1 are adjusted based on B-logic to fit withhealthcare worker insufficiency in a post-disaster area.
Referring to the index of symptoms questionnaire (Table2), D-logic_2 (Table 3) will also perform a questionnaire
examination with the criteria to decide if the subject
needs a teleconsultation with a remote doctor. Symptoms
in Table 2 will be checked based on the result of an initialassessment (Figure 1). From the data presented in Table
2, scores for each observation in Table 3 can be added toshow if there is a minor or major abnormality. As a result,subjects with more than two scores will be required tohave a teleconsultation with remote doctors.

Figure 1 – Initial assessment and Flowchart of D-logic
Operation Test
To verify the operation, suitability, and turn-around time of
the adapted PHC system to a post-disaster area, we tested the
D-logic at the debris flow disaster shelters in Hiroshima,
Japan.
We prepared the questionnaires and medical sensors to
conduct the examination of two criteria, D-logic_1 and Dlogic_2, to the victims who were still living in disastershelters. Three disaster shelters and one area affected bydebris flow in the city were chosen for the operation test.
We used three disaster victims as test subjects and used the
medical sensors and questionnaires based on D-logic_1 andD-logic_2. Some problems and improvements to theprocedure were clarified through the operation test as
mentioned below.
All the subjects in our limited operation test answered thatthey did not feel any health problems during the initialassessment. However, through the questionnaires andexaminations we found that two subjects showed someabnormalities on the examination results. Though neither ofthem was aware of abnormalities in their health conditions
before we made the examination, one of them had a bloodpressure of 158/94 mmHg, whereas the other one had a blood
sugar of 150 md/dl two hours after eating. The ages of these
two subjects were over 65, and this point indicates a higher
risk of NCDs.

M. Hu et al. / Mobile Healthcare System for Health Checkups and Telemedicine in Post-Disaster Situations

Table 1 – D-logic_1 (Red parts are the adjusted items based on B-logic, ordinal criteria)
Test

NormalCautionRemote medicine

Body Weight
Change (x kg)
Blood Pressure(x mmHg systolic
BP and y mmHg
diastolic BP)
Fasting Blood Sugar(x mg/dl)
Postprandial Blood
Sugar (x mg/dl)
Urine test
Urine Proteinx < ±1.0±(3.0 ≤ x < 5.0)

x < 140(x < 130)y < 90(y < 85)
x < 100±(1.0 ≤ x < 3.0)
or unknown
140 ≤ x < 160(130 ≤ x < 140)90 ≤ y < 100(85 ≤ y < 90)
100 ≤ x < 126

Remote medicine &Encouragement to visit
clinic±5.0 ≤ x

160 ≤ x < 200(140 ≤ x < 180)
100 ≤ y < 120(90 ≤ y < 110)126 ≤ x ≤ 200

200 ≤ x(180 ≤ x)
120 ≤ y(110 ≤ y)200 ≤ xx < 140140 ≤ x < 200

200 ≤ x ≤ 300

300 ≤ x

- /±
(-)
- /±
(-)
±

+
(±)
≥+
(±)

≥2+
(≥+)
(≥+)

60 ≤ x <
100
None
None

50 ≤ x < 60 or
100 ≤ x < 120

x < 3737 ≤ x < 37.5

x ≥ 96x ≥ 1293 ≤ x < 96
10 ≤ x < 12Urine Sugar
Urobilinogen
Pulse Ratio
Arrhythmia
Number of Fresh
Skin lesion
Temperature(Celsiu
s degree)SpO2(x %)Hemoglobin(x g/dl)+≤(≥+)
X < 50 or 120 ≤ x
Yes
None

2 or more

37.5 ≤ x < 38.5
(37.5 ≤ x)
90 ≤ x <93
8 ≤ x <1038.5 ≤ x
x < 90x<8Table 2 – Examination Item Index for D-logic_2 Check sheet

S1
S2
S3
S4
S5
S6
S7
S8
S9
S10
S11
S12
S13
S14
S15
S16
S17
S18
S19
S20
S21
S22
S23
S24

Symptom
Loss of consciousness
Depression
Flash backFever without any symptoms
Fever with respiratory symptoms
Fever with gastrointestinal symptoms
Fever with trauma
Fever with other symptoms
FatigueDizziness
Respiratory symptoms
Headache
Palpitation
Chest pain
Paralysis
Nausea or vomiting
Diarrhea
Stomachache
Abdominal pain
Constipation
TraumaOther symptoms
Risk of pulmonary thrombosis
Dehydration

Checksheet Number
1
2
3
101
101
101
101
33
1
1
12
1
6
19
1
7
7
7
7
11
1
33
32
5

31
3

109
6

7

102
go to S24
go to S11
go to S11
go to S21,S24

101
2
4
13
4
17
20
4
8
8
8
8
26
27

24

5
101
14
8
19
103
21
9
9
9
9

6
103
15
9
101
105
22
10
10
10
10

7
105
16
31
105
106
23
11
11
11
11

101
106
17
101
106
107
31
25
25
25
25

102
108
101
103
108

103

103
31
101
101
101

105
101

28

29

30

31

101

25

32

101

102

103

105

go to S24
107
go to S24
106

107

109
go to S24
go to S24

go to S24

105

81

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M. Hu et al. / Mobile Healthcare System for Health Checkups and Telemedicine in Post-Disaster Situations

Table 3 – D-logic_2 (Symptoms based check sheet)
D-logic2
Number1

Minor Abnormality(score 1)
Yes

2
3
4
5
6
7
8
9

Confusion or loss of
consciousness
Sleep disturbanceFlash backDizziness
Thirsty
General fatigue
Loss of appetite
NauseaVomiting

Normal(score 0)
No
No
No
No
No
No
No
No
No

Yes

10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

Stomach ache
Abdominal pain
Cough
Nasal congestion
Sore throat
SputumHemoptysis
Respiratory distress
Headache
Palpitation
Chest pain
Paralysis
Dysarthria
Visual disturbanceUrination

No
No
No
No
No
No
No
No
No
No
No
No
No
No
Normal25
26
27

Diarrhea
Defecation
Surface injury

No
Normal
No

28
29
30

Swelling
Joint pain
Pain of injury

No
No
No

31
32

Head trauma
Staying or sleeping in
narrow place
Any other symptoms
Fever (Celsius degree)
Loss of body weight (kg)

No
No

33
101
102
103
105
106
107
108
109

Observation

Systolic blood pressure(mmHg)
Pulse rate
Arrhythmia
Low oxygen in arterial
blood (%)
Anemia (x g/dl by
Hemoglobin meter )Japanese Coma ScaleNox < 37x < ±1.0

Major Abnormality(score 2)

Yes
Yes
Yes
Yes
Yes
Yes
Yes, only one time without
bloody emesis
Yes, mild
Yes, mild
Yes, mild
Yes
Yes, mild
Yes

Yes, two times or more, or bloody emesis
Yes, severe
Yes, severe
Yes, severe
Yes, severe
Yes

Yes
Yes, mild
Yes
Yes, mild

Yes, severeLess than normal
Yes, not watery
Less than normal
Yes, mild, and bleeding (-),
and pus formation (-) now
Yes, mild
Yes, mild
Yes, tolerable without pain
relieverYes, severe
Yes
Yes
Yes
Anuria or oliguria (≤2/day) or much more thanusual
Yes, watery
Severe (no defecation for more than 5days)
Yes, severe, or bleeding or pus formation
Yes, severe
Yes, severe
Yes, intolerable without pain reliever
Yes

Yes
Yes
37.5 ≤ x < 38.5x ≥ ±3.0

37.0 ≤ x < 37.5
±1.0 ≤ x < 3.0 or change is
unknown
140 ≤ x <160 or 80 ≤ x <100x < 80 or x ≥160

50 ≤ x < 60 or 100≤ x < 120

x < 50 or x ≥ 120

93 ≤ x <96

Yes
x < 93x ≥12

10 ≤ x < 12x < 10x=0x = 1 or 2 or 3

100 ≤ x <140
60 ≤ x <100
Nox ≥ 96

During the operation test interview, some items were difficult
to answer. These items are clearer to the people around thesubjects. In the future, the items of the questionnaire can bedivided into subjective and objective symptoms. Only theitems on subjective symptoms will be questioned, and theexaminer or the subjects’ family can judge the items on
objective symptoms. Other items such as arrhythmia or
number of skin lesions were chosen as D-logic_1 and Dlogic_2 components, increasing the examination turnaroundtime.
We conducted a full examination of D-logic and measured theturnaround time. In total, approximately 15 min on average
was taken from the interview and 6 min on average was takenfrom the examination by medical examiners. In this operation
test, the disaster ended a few months ago, which may be thereason why many victims were not fully cooperative at first.

x ≥ 10Extra time was needed to communicate with the victims forthem to join the test. Months after the disaster ends, healthseeking behavior is poor. However, health-seeking behavior isprevalent earlier in post-disaster areas when possible trauma
and shelter conditions are considered [17].
Among the three subjects, two had trauma due to tumbling on
the second day after the debris flow. The debris flow sanddeposit increased the chance of slipping. Secondary injuries ina post-disaster area should be considered when responding to
the healthcare risks after disasters that cause wet and slippery
conditions.

Discussion
Limitation of the System
Disaster damages may lead to a power outage and network
malfunction, and this will affect the PHC consumables.

M. Hu et al. / Mobile Healthcare System for Health Checkups and Telemedicine in Post-Disaster Situations

Battery backup may be too limited to cover all patients in a
post-disaster area. To relieve the situation, an initialassessment can be used to screen the victims with the mosthealth risks and relieve the pressure on consumables,
resources, and healthcare worker insufficiency. However, an
operation test on a large number of subjects is necessary in
the future to improve the efficiency of triage by D-logic.
In Bangladesh, pharmacies and drugstores are common evenin rural areas. Para-professionals, pharmacy, and drugstore
sales people were the major healthcare providers to disasteraffected people after Cyclone Sidr [18]. Necessary medicine
can be prepared in advance from the drugstores in Bangladesh
and help the patients in the worst condition. However,treatment for PHC in Japan is limited to emergency usage.
Different preparations should be planned depending on thepolicies of different countries and situations.
Further Improvement
Disasters have impacts on critical infrastructure leading topower outrage and network failure. PHC devices arevulnerable to post-disaster power outage and wet conditions.
Backup for device consumables and waterproof measurement
are necessary for future use of the post-disaster condition.
During the operation test in Hiroshima, questionnaires dataand examination were manually recorded. In the future, PHC
will automatically switch from B-logic to D-logic by
information technology, and this will result in less turnaroundtime and more efficiency in post-disaster settings.

Conclusion
PHC is a disease prevention program in Bangladesh and has
undertaken health checkups for more than two years. It isbeing developed to reach the low-income people. Its mobility
and agility make it easier to be carried into the rural and postdisaster areas. With widespread use in ordinary conditions,the emergency mode can become more suitable and rapidly
introduced in post-disaster areas. Existing packages in disasterareas can be switched into emergency mode immediately after
the disaster ends to respond rapidly to the post-disaster healthrisks.

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Address for correspondence
humin@med.kyushu-u.ac.jp 3-1-1 Maidashi, Higashi-ku,
Fukuoka 812-8582, JAPAN