Telemedicine for improving access to health care in resource-constrained areas : from individual diagnosis to strengthening health systems

In many developing countries there is an acute shortage of trained medical specialists. This does not only hamper individual patients’ access to medical diagnostics but furthermore limits the development of health systems because a major role of the specialists is the provision of continuous medical education of health care personnel. The rapid development of information and communication technologies has enabled radically new forms of virtual collaboration at a distance. So-called telemedicine enables us today to transmit knowledge to the patient rather than to only transport patients to the centres where the knowledge is available; this has promising implications in particular for remote and under-served areas. Initiated by a request from a Swiss surgeon from Solomon Islands, a project for supporting the hospital in Honiara, capital of Solomon Islands, with pathology diagnoses was started between Honiara and the Department of Pathology in Basel in 2001. After a successful start this pilot project found broad interest, and the Internet platform that had been developed was soon utilised by projects from other countries and medical disciplines. Thus, questions arose about the diagnostic accuracy of such remote diagnoses as well as about their acceptance and impact on the local health care system. The work presented here was initiated on this background. It analyses the applicability of telemedicine in the context of resource-constrained areas and in particular the possibilities to extend its impact from improving individual diagnosis towards strengthening health care systems. A central part of this project was the development of iPath, an Internet- and email-based telemedicine platform, which facilitates medical consultations, knowledge exchange and continuous education on a global scale. A particular emphasis was put on the applicability and accessibility for users from developing countries with limited infrastructure and network connectivity. The complete software was released under an open-source licence in order to allow unrestricted reuse for other institutions. The diagnostic accuracy of this form of telemedicine was studied in two projects from the field of pathology. A retrospective review of over 200 glass slides from each project revealed complete diagnostic concordance between the telemedical diagnosis and review diagnosis in 69% and 85% respectively. Clinically relevant discrepancies were found in 8% and 3.3% of all examinations. Selection of images by the non-expert and communication were found to have the greatest impact on diagnostic accuracy. Both factors can be addressed by training and organisation of workflow. In comparison to submitting material for pathological examination by courier, the turn-around time could be reduced from weeks to days or hours. Besides the more rapid availability of diagnosis, telemedicine enabled a direct dialogue between the surgeon and the pathologist and thus facilitated an implicit permanent medical education. The educational aspects of telemedicine were studied within the scope of a tele-dermatology project in South Africa. Distance collaboration with a dermatologist empowered a general practitioner based in a rural area to diagnose and treat a majority of patients with dermatological problems. Besides the direct benefit of saving the patients the cost of transportation to visit the dermatologist, the general practitioner could strengthen his own diagnostic skills under direct guidance and quality control of a specialist. As a consequence he will be able to treat more patients locally, close to their homes and families. The whole project was implemented within the local health system in order to facilitate a future inclusion of other primary care facilities. Regional telemedicine networks play a major role to ensure relevance and acceptability of consultative and educational telemedicine. Within the scope of the Ukrainian Swiss Perinatal Health Program a telemedicine component was included, and it was found that the use of regional language as well as inclusion of the regional specialists are important for the acceptance of telemedicine and should not be neglected in a era of globalisation. The presented results demonstrate that save and reliable telemedicine can be implemented with limited resources. Telemedicine is suitable in particular to strengthen existing international collaborations and to support professionally isolated medical specialists. Regional collaboration and inclusion of regional specialists are desirable if telemedicine shall help to strengthen health care systems. The application of telemedicine should not only focus on providing care to individual patients, but should explicitly incorporate skills development and capacity building of primary care staff. Organisation of work flow and communication have been found to be the most challenging task for the implementation of telemedicine networks. Resources must be invested not only in technology but more importantly in training and organisation. Utilisation of existing technological infrastructure is advisable wherever possible and greatly reduces the complexity of providing support and maintenance. The presented telemedicine platform provides an efficient tool for the organisation of interdisciplinary, regional and international telemedicine networks. We hope that the unrestricted availability of the software developed during this project will enable other institutions to utilise it for their own purpose and that they will thus be able to allocate resources on the organisation of workflow rather than technology

Report on Establishing Telemedicine Services in Iran

The speed of technological changes, the advent of new innovations, and the increasing competition have made the use of new technologies as the focus of the business firms and government. Information technology has had a great impact on health as one of the areas in human social life by forming the information societies. Currently, all the health care processes are highly depending on technology. Whereas its management, transmission, the distance elimination, the diagnosis speed, and the disease treatment are necessary issues. These two major subjects have led to the formation of a new branch in medical sciences called telemedicine technology. Considering numerous advantages of telemedicine technology, the necessity of applying this technology in developing countries, including our country- Iran- is inevitable (1). Providing telemedicine healthcare services essentially involves extensive implications in both ICT and medical services. The range of these concepts is so broad that it may be probable to consider telemedicine as a cultural issue applying the features of communication concepts in health care offer, beyond considering it as a service. It is necessary to a simple telephone communication to establish a psychotherapeutic service, to use smart agents in a trans-continental relationship, using vital signs and various medical images to identify and even treat a patient (2). Remote patient monitoring or telemedicine provides appropriate solutions in urgent medical assistance, long distance monitoring, the management and logistics, the quality assurance and supervision, as well as preparation and training of health care professionals. Telemedicine plays an important role even in the fight against communicable diseases, as well as in helping injured people in disasters and accidents (2,5). Telemedicine has been most beneficial to various healthcare services in some countries, particularly in developing countries such as Iran which faces unbalanced distribution of resources and specialists in various fields of medical sciences, and to make it available in all over the country. Telemedicine services provide the opportunity to improve both the quality and the availability of health care services regardless of the geographical limitations. These services also present numerous socio-economic benefits considering the significant return of resources to investors, service providers and equipment providers can be highly effective in optimizing the use of existing financial and human facilities and resources (7,6). Telemedicine requires careful planning and precise management to perform and develop the goals. Therefore, to achieve the above-mentioned objectives and using telemedicine in a large scale, it is required to evaluate the problems and the performance of this system periodically by planning and making useful changes to overcome them and thereby improve the status quo. Although remote patient monitoring or telemedicine services have great potentials and provide significant long-term benefits to the healthcare system, especially in a country such as Iran that it’s not possible to uniformly distribute power and health services in all areas, the optimal use of this system requires the provision of resources and essential infrastructures in addition to resolve the problems and eliminating the shortcomings. It is also worth noting that for the useful and continuous application of this system, the geographical facilities and limitations of each satellite center should be considered as the reference when deciding to provide the necessary infrastructure. To increase the efficiency and purpose of this system, it is better to first investigate the requirements and shortages of each region in the fields of medical specialties as well as the prevalent diseases and health problems of the region, considering which disease and consultation with which of the specialized and technical services are considered. Besides, due to the recent advent of telemedicine consultation system in our country's health care system and its failure to implement routinely as a result of the inadequate acceptance by physicians, and the consulting hospitals' personnel, it is better to select the satellite centers ensured that there were sufficient psychological acceptance and the willingness to cooperate in the project and to prevent the imposition of this system on recipient counseling centers, which has a deterrent role in helping physicians and nurses work together to advance this plan. In the end, it is necessary to spend sufficient funds and using experiences obtained from the present plan, increasing the number and quality of this type of counseling to be more accurate than the evaluation of the medical consulting system, especially in terms of cost-effectiveness

Horizons and Perspectives eHealth

EHealth platform represents the combined use of IT technologies and electronic communications in the health field, using data (electronically transmitted, stored and accessed) with a clinical, educational and administrative purpose, both locally and distantly. eHealth has the significant capability to increase the movement in the direction of services centered towards citizens, improving the quality of the medical act, integrating the application of Medical Informatics (Medical IT), Telemedicine, Health Telematics, Telehealth, Biomedical engineering and Bioinformatics. Supporting the creation, development and recognition of a specific eHealth zone, the European Union policies develop through its programs FP6 and FP7, European-scale projects in the medical information technologies (the electronic health cards, online medical care, medical web portals, trans-European nets for medical information, biotechnology, generic instruments and medical technologies for health, ICT mobile systems for remote monitoring). The medical applications like electronic health cards ePrescription, eServices, medical eLearning, eSupervision, eAdministration are integral part of what is the new medical branch-eHealth, being in a continuous expansion due to the support from the global political, financial and medical organizations; the degree of implementation of the eHealth platform varying according to the development level of the communication infrastructure, allocated funds, intensive political priorities and governmental organizations opened to the new IT challenges.eHealth, telemedicine, telehealth, bioinformatics, telematics

Telemedicine

Telemedicine is a rapidly evolving field as new technologies are implemented for example for the development of wireless sensors, quality data transmission. Using the Internet applications such as counseling, clinical consultation support and home care monitoring and management are more and more realized, which improves access to high level medical care in underserved areas. The 23 chapters of this book present manifold examples of telemedicine treating both theoretical and practical foundations and application scenarios

Toward a Discourse Community for Telemedicine: A Domain Analytic View of Published Scholarship

In the past 20 years, the use of telemedicine has increased, with telemedicine programs increasingly being conducted through the Internet and ISDN technologies. The purpose of this dissertation is to examine the discourse community of telemedicine. This study examined the published literature on telemedicine as it pertains to quality of care, defined as correct diagnosis and treatment (Bynum and Irwin 2011). Content analysis and bibliometrics were conducted on the scholarly discourse, and the most prominent authors and journals were documented to paint and depict the epistemological map of the discourse community of telemedicine. A taxonomy based on grounded research of scholarly literature was developed and validated against other existing taxonomies. Telemedicine has been found to increase the quality and access of health care and decrease health care costs (Heinzelmann, Williams, Lugn and Kvedar 2005 and Wootton and Craig 1999). Patients in rural areas where there is no specialist or patients who find it difficult to get to a doctor’s office benefit from telemedicine. Little research thus far has examined scholarly journals in order to aggregate and analyze the prevalent issues in the discourse community of telemedicine. The purpose of this dissertation is to empiricallydocument the prominent topics and issues in telemedicine by examining the related published scholarly discourse of telemedicine during a snapshot in time. This study contributes to the field of telemedicine by offering a comprehensive taxonomy of the leading authors and journals in telemedicine, and informs clinicians, librarians and other stakeholders, including those who may want to implement telemedicine in their institution, about issues telemedicine

Teleconsultation perspective for cardiovascular patients in Saudi Arabia

This thesis was submitted for the degree of Doctor of Philosophy and awarded by Brunel University.This research of teleconsultation services aims to improve the quality of diagnosis and treatment for rural cardiovascular patients through utilizing distant medical expertise. Equitable access to expert healthcare as well as improved medical management for these patients can assist in modifying cardiovascular disease (CVD) risk and reduce morbidity and mortality in Saudi Arabia. The objectives were to design and develop a new care pathway for cardiovascular disease patients by utilizing teleconsultation technology, investigate factors and issues that might act as barriers to its adoption, and then evaluate the impact of this model on the stakeholders. A small scale pilot project was used to determine the issues of technology, processes and human resources required to deliver an effective service with the context of the research setting. Four primary healthcare centres, two regional hospitals, fifteen patients and sixty other participant stakeholders were included in this study. An approach using (PCP) patient care pathways was used to introduce the teleconsultation technology and integrate it within the healthcare delivery system. Compared to the traditional PCP, the modified PCP utilising teleconsultation technology improved the quality of healthcare through: Improved access to medical care and quality of diagnosis by obtaining the expertise of a distant specialist. More efficient medical evaluation and management. Enhanced role of primary healthcare centres and participating hospitals by providing all levels of health services for patients. Evidence-based referral (reduced waiting time, reduced burden on outpatient clinics). The telconsultation adoption barriers included: Inadequacy of finance Limited infrastructure Legal and regularity difficulties. Organization issues. Literacy on technology. This study recommends the following for telemedicine implementation in the country: Promote perception and readiness for ICT services with the healthcare community. Enhance structural readiness including appropriate infrastructure and adequate funding, human resources and equipment. Proactive policies to encourage growth of the telecommunication sector and to address concerns regarding privacy and security

Telehealth in primary health care settings within Australia and internationally

Access to appropriate health care services is often limited for people living in rural or remote areas, or for those with restricted mobility. One approach to minimising the inequality in access for those located at a distance from health care services is through telehealth service delivery. This review examined the evidence on telehealth models in Australia and elsewhere, with a specific focus on synchronous, real-time video consultations, where patients and health care providers were present simultaneously