Author: Noah Jaafa

Understanding the Term Telemedicine

TELEMEDICINE OVERVIEW

Electronic health (e-Health) is the use of information and communication technologies (ICT) for health (WHO, 2018), and includes; telehealth, telemedicine, mobile health (mHealth), eLearning, and electronic health records or electronic medical records (Pan American Health Organization, 2018). Telehealth, defined in 1978 by (Bennett et al., 1978) as “the application of telecommunications-based technology in the delivery of healthcare and related services”. Telehealth is a broad term and is considered to incorporate “health related activities beyond patient care including patient and provider education and management of health services” (Bashshur and Shannon, 2010). Telemedicine, which is a subset of telehealth refers to “the delivery of healthcare services, where distance is a critical factor, by all health care professionals using ICT for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities” (WHO, 2010). Therefore, telemedicine allows healthcare professionals to evaluate, diagnose and treat patients at a distance using telecommunications technology (Chiron Health, 2017). Indeed, (Bashshur et al., 2011) stated that telehealth relates to telemedicine the same way that health relates to medicine. It has also been stated that “telemedicine offers people the opportunity to address common medical issues in an efficient, timely and professional manner, using their smart phones, computers and other devices” (Dinesen et al., 2016). It is felt that using telemedicine may assist in overcoming the acute shortage of human resources for health in the low income countries in sub-Saharan Africa (SSA) and accelerate progress towards universal health coverage  through  services such as disease surveillance, tele-consultation, tele-education and research (Miseda et al., 2017; WHO, 2006).

TELEMEDICINE MODES OF DELIVERY
In general, telemedicine can be provided either synchronously (real time transmission; e.g., video conferencing), asynchronously (store and forward; e.g., e-mail), or using hybrid solutions.

Synchronous telemedicine: Synchronous telemedicine occurs in “real-time” and is a two-way communication between participants (usually the patient and their healthcare provider and specialist at a distance) (Kaufman et al., 2009). This mode of telemedicine most commonly uses videoconferencing in its various forms and can be supplemented by external peripheral devices such as digital stethoscopes, otoscopes, dermascopes, and ultrasound devices etc that can be used for remote patient examination.  It can also include the use of live bio-signal monitoring, interactive robotic equipment. The advantage of synchronous telemedicine is that it is live and interactive and provides benefits such as time saving for both the patient and the healthcare provider, improved access to healthcare, improved quality of life, and also allowing a patient to connect with a medical expert from the comfort of their community and at a convenient time (Whitten et al., 2010). However, synchronous telemedicine comes with disadvantages as it is entirely technology-based, expensive, and requires adequate bandwidth (Pappas, 2015). It also requires the co-ordination of the consultations and the patient and provider having to go to a videoconference venue (WHO, 2010).

Asynchronous telemedicine: This form of telemedicine involves gathering and storing clinically relevant patient information or data, and electronically transmitting it at a later time for interpretation by a medical expert at another location and at a later time. This is most commonly done by email, or through a Web site or more recently using mobile phone instant messaging applications. Asynchronous telemedicine is becoming simpler as mobile phones can gather photographs, video, and sound recordings and transmit them by email, the Web and cellular networks (Deshpande et al., 2009). In developing countries, particularly rural areas with a gap in healthcare provision, asynchronous telemedicine would be relevant (Combi et al., 2016; Toh et al., 2016). This is mainly due to the various benefits for both patients and healthcare providers; reduction in waiting time, reduction in unnecessary referrals and improved standard and quality of care (Deshpande et al., 2009). Other benefits are cost effectiveness (it does not require high end or special technology hardware, and also uses email or web applications) as the form of communication for later review by the specialist (Malhotra et al., 2013). The shortcomings of asynchronous telemedicine are the lack in instant feedback, personal interaction, live collaboration and real time activities, which lead to lack of motivation, and calls for self-discipline (Pappas, 2015). Other shortcomings are that it is dependent on the quality and quantity of data provided, and because it is not synchronous it is not appropriate for emergency care (WHO, 2010).

Hybrid telemedicine: Originally, telemedicine was only categorised into asynchronous and synchronous solutions, but technologies are converging to allow technology applications that can do both ‘real-time’ and ‘store-and-forward’ services (Whitten et al., 2010). Hybrid telemedicine is a combination of both synchronous and asynchronous telemedicine (Bhatia, 2015). Examples are the use of store and forward telemedicine to send images and a brief history (asynchronous) followed by a telephone call (synchronous) to discuss the images and history (Mars and Scott, 2017).

BENEFITS AND CHALLENGES OF TELEMEDICINE

Telemedicine is used globally, and in some areas (teleradiology / teledermatology) has gained traction in developed countries. Large scale implementation still lags in many telehealth areas in developed countries, and in particular in developing countries. It is felt that using telehealth may assist in overcoming the acute shortage of human resources for health in the low income countries and accelerate progress towards universal health coverage  through  services such as; disease surveillance, tele-consultation, tele-education and research (Miseda et al., 2017). Although telemedicine has many benefits to offer, challenges still remain. These are summarized below.

The literature shows that telemedicine can save patients time and money to access healthcare services (Hassibian and Hassibian, 2016). These authors have explained several benefits of telemedicine such as bridging the rural-urban gap; reducing healthcare costs; facilitating continuing medical education (CME); improving quality of healthcare; reducing clinician’s workload; reducing medical errors; changing the relationship between physicians and patients; improving access to information; and finally the convenience of tele-homecare (Hassibian and Hassibian, 2016). Other potential benefits include timelier access to providers; decreased hospital readmissions; reduced use of institutional care; reduction or prevention of complications; improved access to patient training and educational resources; and improved continuity of care and case management (Hodgson, 2018). The American Telemedicine Association (ATA) has also identified four areas of telemedicine that can be of benefit, these are: providing access to healthcare services to distant patients; reducing the cost of healthcare in chronic disease management; improving quality of healthcare and patient satisfaction; and increasing demand to seek healthcare (ATA, 2018).

Prior studies have concluded that there is a positive correlation between cost effectiveness and efficiency using telemedicine (Dixon et al., 2016; Marios-Nikolaos and Charalambos, 2017; Thomas et al., 2014). This is especially so for chronic disease monitoring of vital signs (Perego et al., 2017; Rubio et al., 2017). Telemedicine services create a positive perception among patients and care takers as they continue to look at the service for convenience, comfort, and decreased out-of-pocket expenses. For instance, in a study on patient experience with video visits it was reported that all patients surveyed were satisfied with video physician consultations, and the majority said they were open to provider follow-up through virtual visits (Powell et al., 2017). Armaignac et al. compared the effect of the addition  of telemedicine to  progressive care units (PCU) and found telemedicine  significantly decreased mortality,  hospital, and PCU length of stay despite the fact patients in telemedicine PCU group were older and had higher disease severity, and risk of mortality than those in the PCU control group (Armaignac et al., 2018). It is argued that telemedicine has much broader social benefits for remote and rural communities, such as indirectly impacting an individual’s economic, environmental, and cultural security (Graham, 2017).

In addition, telemedicine reduces the need for travel, which is of significance to developed as well as developing countries, but for differing reasons; financial benefit in developed countries (Combi et al., 2016; Wootton et al., 2011) and fundamental issues in the developing world (O’Gorman and Hogenbirk, 2016; Okwaraji and Edmond, 2012; Russo et al., 2016). For example people often have to walk, sometimes for days, to get to a decent clinic or hospital. Also, although limited, and not the focus of telemedicine in the developing world at this time, telemedicine can enable rural patients to access in-house monitoring, e.g., for chronic disease management such as heart disease and diabetes (Bashshur et al., 2014; Goodridge and Marciniuk, 2016). Certainly in the USA, telemedicine has earned legislative support because of the alternative option of care for rural patients (Daniel and Sulmasy, 2015). Several States and the Veteran’s Administration now allow telemedicine across state lines without concurrent licensure (Latoya and Gary, 2016) and the American Medical Association guidelines note that a videoconference consultation can be used to establish a physician – patient relationship even without any prior encounter (Farouk, 2016).

Challenges to Telemedicine: Telemedicine and telehealth projects in developing countries face enormous challenges. People are poor and as a result the tax base is low, the burden of disease is high and there are extreme shortages of health professionals (WHO, 2006). Infrastructure e.g. ICT technology and connectivity is generally poor and power supply erratic. There are organizational issues such as lack of human health resources, shortages in medical supplies and drugs, poor referral system, and inadequate transportation; and financial support seldom extends beyond the initial pilot phase of a project. Added to this is lack of government will, limited technical support, absence of legal and ethical guidelines, and local cultural issues (Mars, 2013). Other challenges that might affect telemedicine and telehealth projects in developed countries may include the need for reimbursement to physicians, the high cost of initial investment, acceptance by patients, and incompatible / non-interoperable systems (Emids, 2016). Further, the lack of an international framework for telemedicine is a hindrance for healthcare professionals to work beyond their own border, and transfer of patient files over the Internet is a threat to patient privacy (Eccles, 2012). Some telemedicine solutions also represent an extra workload and a burden to the health workers; that is, the same doctors and nurses who are already over stressed by the volume of patients (Mars, 2013).

Unlike the more traditional mode of healthcare that allows a face-to-face interaction, evolving technologies also alter the patient-doctor relationship which may affect holistic healthcare (Toh et al., 2016).

In developing countries, the healthcare system (referral process and consultation) is frustrating to both patients and healthcare workers (HW), and previous studies have identified factors relating to health personnel, transportation and communication infrastructure, and finance to explain the challenges facing the referral system (Amoah and Phillips, 2017). A recent telehealth economic cost analysis provided evidence of the economic efficiency and benefits associated with telemedicine interventions for rural populations (Yilmaz et al., 2018). This is in line with the findings of (Freed et al., 2018) who questioned the worth of investing in telemedicine, but found in its favour, recommending that organizations consider deployment of telemedicine initiatives and advocated greater awareness of implementation of best practices. Adoption and uptake of technology programs such as telemedicine is complex. However, a framework for non-adoption, abandonment, scale-up, spread and sustainability (NASSS) was developed to address issues of adoption, non-adoption and abandonment of new technologies together with challenges right from demonstration to full integration (Greenhalgh et al., 2017).

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Article by Dr. Vincent Micheal Kibera, PhD.
Health Informatician,
Makerere University School of Public Health.
https://sph.mak.ac.ug/

e-Learning and COVID-19

The term e-learning which is believed to have originated in the 1980s with the inception of online learning is generally defined as the delivery of instruction on a digital device such as computer or mobile device that is intended to support learning either online or offline ¹.

The use of e-learning for instruction is arguably as effective as or more effective than face to face learning. In blended learning as a way of supplementing the traditional teaching methods, eLearning can increase learner engagement, is learner-focused, is easily updated as new knowledge emerges, and increases access through the removal of geographic barriers².

Further still, there is an increase in number of free and open-source e-learning platforms such as MOODLE and Open edX that can be used to deliver learning electronically. Such platforms are not only highly customizable and scalable supporting large numbers of learners, but also provide functionalities like live classes (Zoom plugin integrations), quizzes, and chats, among others making learning very interactive and enjoyable.

In this ever-changing world, it has become nearly impossible to deliver or receive formal education without the use of advanced technologies, hence the increased application of Information and Communication Technologies (ICTs) in the delivery of education. Covering a wide range of technologies for gathering, storing, retrieving, processing, analyzing, and transmitting or presenting information, ICTs are indeed vital in the delivery of education2. Subsequently, there is a steady rise in investment by various entities including governments, education institutions, and individuals in these ICTs in order to keep up with the current trends.

In Low- and middle-income countries, one rapidly growing aspect of e-learning is mobile learning which focuses on the use of mobile devices to aid learning. This steady rise in the use of mobile technologies has been realized due to the increasingly falling prices of mobile devices leading to increased ownership.

In the face of the COVID-19 pandemic, the role of e-learning has further been emphasized. Many entities, including governments, agencies, and institutions of learning have resorted to e-learning to enable continuity of learning for their staff and students from the safety of their homes where they are not exposed to the virus. There has also been an increase in free online courses from various platforms such as Coursera, Udemy and audacity. In April 2020, UNICEF and Microsoft Corp announced the expansion of a global learning platform to help children and youth affected by COVID-19 continue their education at home.

The Learning Passport which started as a partnership between UNICEF, Microsoft and the University of Cambridge and its departments Cambridge University Press and Cambridge Assessment, designed to provide education for displaced and refugee children through a digital remote learning platform, was expanded to facilitate country-level curriculum for children and youth whose schools have been forced to close due to COVID-19³. In Argentina, the Ministry of Education launched Educ.ar an educational portal aimed at providing curated digital resources for teachers, administrators, students, and families. The program “Seguimos Educando”, developed by the Ministry of Education and the Secretariat of Media and Public Communication, began broadcasting educational content from April 1, 2020, airing 14 hours a day of television content and 7 hours a day of radio content specially produced for students as a result of school closures⁴.

In June 2020, the Ugandan Ministry of Health launched the MOH Uganda Capacity Building mobile application supported by the Community Health Academy- Last Mile Health in collaboration with Makerere University College of Health Sciences, Uganda Chartered HealthNet. This is a health worker learning/training app aimed at closing the gap in capacity building caused by the COVID-19 social distancing guidelines that prohibit the traditional capacity building efforts5. e-learning is therefore poised to play a critical role in the advancement of health education in the future or post COVID as the saying goes. The sudden global shift in learning away from traditional face to face due to the pandemic leaves a question of whether electronic learning will persist post COVID and how this is likely to impact learning world-wide.

REFERENCES

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2.        Gyambrah M. E-Learning Technologies and Its Application in Higher Education: A Descriptive Comparison of Germany, United Kingdom and United States. Policy. 2007. http://edoc.ub.uni-muenchen.de/archive/00007358/.

3.        UNICEF and Microsoft launch global learning platform to help address COVID-19 education crisis. https://www.unicef.org/press-releases/unicef-and-microsoft-launch-global-learning-platform-help-address-covid-19-education. Accessed July 2, 2020.

4.        How countries are using edtech (including online learning, radio, television, texting) to support access to remote learning during the COVID-19 pandemic. https://www.worldbank.org/en/topic/edutech/brief/how-countries-are-using-edtech-to-support-remote-learning-during-the-covid-19-pandemic. Accessed July 2, 2020.

5.        MOH Uganda Capacity Building App – Apps on Google Play. https://play.google.com/store/apps/details?id=ug.go.health.mobile.covid19. Accessed July 2, 2020.

Article by: Balirwa Priscillah,
Health Informatician,
Living Goods Uganda.
https://livinggoods.org/