Few reports of telepathology in Africa exist in the medical literature. With the strong need for improvement in health care infrastructure and personnel training in many African nations, telepathology provides a rapid and versatile tool to improve clinical care and foster educational and research opportunities. We describe the challenges faced in establishing robotic telepathology (RT) services at a government referral center in Botswana and reflect on conditions under which such initiatives may be most likely to succeed in sub-Saharan Africa and other parts of the developing world

Binder, Scott W

Fischer, Max K

Introcaso, Camille E

Kayembe, Mukendi K

Kovarik, Carrie L

Scheer, Arnold J

English

PubMed

ScholarlyCommons@Penn

University of PennsylvaniaScholarlyCommonsBotswana-UPenn Scholarly Publications Botswana-UPenn Partnership5-2011Establishing Telepathology in Africa: Lessons FromBotswanaMax K. FischerMukendi K. KayembeArnold J. ScheerCamille E. IntrocasoUniversity of Pennsylvania, Camille.Introcaso@uphs.upenn.eduScott W. BinderSee next page for additional authorsFollow this and additional works at: http://repository.upenn.edu/botswana_scholPart of the Dermatology Commons, and the Medical Education CommonsThis paper is posted at ScholarlyCommons. http://repository.upenn.edu/botswana_schol/16For more information, please contact libraryrepository@pobox.upenn.edu.Recommended CitationFischer, Max K.; Kayembe, Mukendi K.; Scheer, Arnold J.; Introcaso, Camille E.; Binder, Scott W.; and Kovarik, Carrie L.,"Establishing Telepathology in Africa: Lessons From Botswana" (2011). Botswana-UPenn Scholarly Publications. 16.http://repository.upenn.edu/botswana_schol/16Establishing Telepathology in Africa: Lessons From BotswanaAbstractFew reports of telepathology in Africa exist in the medical literature. With the strong need for improvement inhealth care infrastructure and personnel training in many African nations, telepathology provides a rapid andversatile tool to improve clinical care and foster educational and research opportunities. We describe thechallenges faced in establishing robotic telepathology (RT) services at a government referral center inBotswana and reflect on conditions under which such initiatives may be most likely to succeed in sub-SaharanAfrica and other parts of the developing world.KeywordsAfrica, telepathology, dermatology, improve clinical health, educationDisciplinesDermatology | Medical Education | Medicine and Health SciencesAuthor(s)Max K. Fischer, Mukendi K. Kayembe, Arnold J. Scheer, Camille E. Introcaso, Scott W. Binder, and Carrie L.KovarikThis journal article is available at ScholarlyCommons: http://repository.upenn.edu/botswana_schol/16Establishing telepathology in Africa: Lessons from BotswanaMax K. Fischer, MD, MPHa, Mukendi K. Kayembe, MDb, Arnold J. Scheer, DLM, PA, MPHc,Camille E. Introcaso, MDd, Scott W. Binder, MDc, and Carrie L. Kovarik, MDdaDepartment of Pathology, University of Maryland, BaltimorebNational Health Laboratory, Gaborone, BotswanacDepartment of Pathology, University of California, Los AngelesdDepartment of Dermatology, University of Pennsylvania, PhiladelphiaTo the EditorFew reports of telepathology in Africa exist in the medical literature. With the strong needfor improvement in health care infrastructure and personnel training in many Africannations, telepathology provides a rapid and versatile tool to improve clinical care and fostereducational and research opportunities. We describe the challenges faced in establishingrobotic telepathology (RT) services at a government referral center in Botswana and reflecton conditions under which such initiatives may be most likely to succeed in sub-SaharanAfrica and other parts of the developing world.The Africa Teledermatology Project (http://africa.telederm.org) has been providingdermatology support to local providers throughout Africa using store-and-forwardteledermatology/teledermatopathology since 2007. While the outcomes have been verypositive, and similar telemedicine platforms are well accepted,1,2 this method is limited bythe number and quality of images available to the consultant (Fig 1) and by reliance on thereferring provider, who may lack dermatopathology training,3 to produce representativephotomicrographs.In response to these problems, we installed a Zeiss Mirax Live RT system (Carl ZeissMicroImaging GmbH, Jena, Germany) at the National Health Laboratory in Gaborone,Botswana in 2009. With up to 4 slides placed on the motorized microscope, the consultantcontrols stage position, focus, and magnification remotely (Fig 2).Certain factors facilitate the achievement of a functioning telepathology service:1. Availability of reliable histologic processing sets a ready stage for implementingtelepathology. Telepathology systems must also be robust enough to handlesignificant heterogeneity in slide quality, focal planes, and specimen types/sizes.2. Adequate Internet connectivity and a stable power source are crucial. We installeda dedicated wireless broadband connection. An uninterrupted power supply (UPS)device was necessary to protect the equipment, which was configured to operate atlocal voltage.Reprint requests: Carrie L. Kovarik, MD, Assistant Professor of Dermatology, Dermatopathology, and Infectious Diseases, Universityof Pennsylvania; 2 Maloney Building; 3600 Spruce St, Philadelphia, PA 19104, carrie.kovarik@uphs.upenn.edu.Poster presentations at the 46th Annual Meeting of the American Society of Dermatopathology, Chicago, Illinois, October 2009 and atthe Pathology Visions Conference, San Diego, California, September 2009.Conflicts of interest: None declared.3. Demand for specialized pathology services is driven by concomitant availability ofspecialized clinical services (eg, dermatopathology in areas with practicingdermatologists). Given the professional isolation in this region, telepathology canenable solo pathologists to meet such demands, as well as to participate incontinuing education and collaborative research.4. Governmental support is critical in logistical matters such as waiving of customsfees. Applying for a rebate certificate with the assistance of local partnershipscircumvented this.5. Personnel with sufficient technical expertise to install and maintain the equipmentare necessary when there are no in-country vendor representatives. For RT, identifyindividuals familiar with computer hardware, software, and light microscopy.Remote technical support is possible via screen-sharing, Internet telephony, and e-mail. Overstock wearable components such as microscope bulbs, which may needfrequent replacement.In conclusion, telepathology is feasible in resource-limited settings, and its routine use canimprove clinical care and education. The generalizability of our experience is limited bydiffering socioeconomic and health conditions in Botswana compared with other Africannations; thus similar initiatives must be adapted to local settings. On-site technicalprerequisites include tissue processing capacity, high-speed Internet, power stability, andpersonnel to install and maintain the equipment. Select a system that accommodates thetypes and sizes of specimens requiring consultation, differences in slide quality, andinternational bandwidth limitations. Local health professionals and government mustsupport the initiative to fuel demand for such services and ensure ongoing utilization.Further research will need to evaluate changes in service utilization over time, effects ondevelopment of local expertise, and cost-to-benefit analysis of telepathology in thesesettings.AcknowledgmentsFunding sources: The UCLA-Geffen School of Medicine and the Regents of the State of California provided therobotic telepathology equipment. The University of Pennsylvania Center for AIDS Research has provided fundingfor the high-speed Internet connection for telepathology. Funding for the Africa Teledermatology Project has beenprovided by the Austrian Academy of Sciences Commission for Development Studies and the American Academyof Dermatology.References1. Brauchli K, Oberli H, Hurwitz N, Kunze KD, Haroske G, Jundt G, et al. Diagnostic telepathology:Long-term experience of a single institution. Virchows Arch. 2004; 444:403–9. [PubMed:15021986]2. Geissbuhler A, Bagayoko CO, Ly O. The RAFT network: 5 years of distance continuing medicaleducation and tele-consultations over the Internet in French-speaking Africa. Int J Med Info. 2007;76:351–3.3. Weinstein RS. Static image telepathology in perspective. Hum Pathol. 1996; 27:99–101. [PubMed:8617470]Fischer et al. Page 2                                             J Am Acad Dermatol. Author manuscript.Fig 1.Store-and-forward method. A, Color distortion may be a problem. B, Blurry still imagesresult from multiple focal planes. (A and B, Hematoxylin-eosin stain, originalmagnifications: A, ×5 [ final diagnosis: cutaneous T-cell lymphoma]; B, ×40 [ finaldiagnosis: scabies].)Fischer et al. Page 3                                   J Am Acad Dermatol. Author manuscript.Fig 2.Robotic telepathology system. A, The RT system consists of a motorized microscopeconnected to a server. B, Screenshot of the RT remote user interface with stage position,focus, and objective controls.Fischer et al. Page 4                                  J Am Acad Dermatol. Author manuscript.

Establishing Telepathology in Africa: Lessons From Botswana

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Establishing Telepathology in Africa: Lessons From Botswana

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