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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).

Reference

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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

1.        Trump A, Carr C. Assessing the Feasibility of Utilizing eLearning Content in Midwifery Schools in Ghana. 2014.

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/

Biometrics in Healthcare

The term biometrics is always associated to fingerprint but there is actually more to it, biometrics is a term related to our human body itself, whereby biometrics are defined as the physical or behavioral human characteristics that can be used to digitally identify an individual for numerous purposes that include but not limited to: (a) Granting access (b) Identity confirmation and (c) record matching. Examples of biometric techniques include; Deoxyribonucleic acid (DNA), fingerprints, facial, voice, iris, palm, and vein patterns among others.

In this article, we shall focus more on fingerprint biometrics and its application in healthcare and underscore why healthcare practitioners, managers, and enthusiasts should be thinking of adopting biometrics for use in their settings. According to recogtech a security solutions company, fingerprint biometrics are arguably the most used and best-known biometrics. However, facial and iris recognition are steadily gaining tract as years go by. The fundamental reasons as to why fingerprint biometrics stands out in terms of popularity are related to the fact that: (a) Their ease use (b) relatively affordable in terms of software and hardware, i.e. Fingerprint scanners are all over the market unlike DNA profiling machines and (c) Fingerprints don’t consume a lot of computing resources when it comes to storage and processing hence efficient. It should, however, be noted that as the number of fingerprints stored in the database increases, the more resources you will need, the good news is, the increment in resource consumption is not exponential hence manageable even in the long run.  

As a matter of fact, fingerprinting as a record matching and identification methodology is widely known and used. Nonetheless, its penetration and usage, particularly in the healthcare industry, is still on the low. This is usually attributed to the intricacies in the healthcare workflow and other care processes that make it’s implementation a little bit tricky. Unlike other sectors like banking, Immigration, and security where the usage and implementation of biometrics is pretty straight forward, in healthcare the terrain assumes a different and tricky trajectory. Patient privacy and confidentiality concerns have always been cited as major issues to the implementation of this technology in the sector. Furthermore, ethical concerns surrounding the appropriate use of biometrics have also been of great concern, especially in resource-poor settings where data protection acts may not be comprehensive enough to protect patients as we push for biometrics integration in the healthcare industry. This is also true for advanced economies and that’s why states like Illinois in the USA had to pass an additional privacyact on top of HIPAA to cater for biometric implementations in their jurisdiction. Therefore addressing privacy and ethical concerns is crucial as we push for this technology in the healthcare industry. Other challenges to the implementation of biometrics include; (a) Sometimes you might require more than one finger to improve accuracy especially in populations where people’s palms are affected by the nature of their work, e.g. ironsmith workers usually have worn out palms; (b) if security is not ensured then client’s fingerprints may be compromised and used for the wrong reasons, and (c) people’s perception of biometrics being linked to crime scene investigations could also pause as a challenge to the implementation and acceptance of the technology.

So why biometrics in healthcare?

To ensure patient safety, the right care must be administered to the right patient. This, therefore, calls for proper and meticulous patient identification before administering care. Patient identification sometimes referred to as patient matching is the ability to match a patient to their record either situated in an Electronic Medical Records System (EMRs) or another medium such as a patient card. Failure to correctly match patients before care leads to errors that sometimes even lead to death in the worst-case scenario.

A report published in 2016 indicated that in the United States alone, about 195,000 deaths occur each year because of medical errors, with 10 of 17 being the result of identity errors. Preventing patient identification errors has been and still is an area of significant research.

While much progress has been made in this area, there is still more work and effort needed, patient identification errors can occur in every healthcare setting, during the encounter especially if due diligence is not done. Nonetheless, these errors are preventable, and to achieve this, biometrics could just be the answer, healthcare entities looking forward to providing the most secure and uniquely identifiable end-user authentication while providing the best inpatient and staff experience are considering Biometrics for the solution.

Despite the intricacies in the health settings workflow and not forgetting the challenges to the implementation of biometrics mentioned earlier, fingerprint biometrics matching and identification is actually feasible and implementable in these settings. Since people are used to fingerprinting in other sectors like banking and aviation, chances are high that this technology will be embraced and acceptable to the users (patients) in this domain if adopted and of course, keeping user concerns like patient privacy, confidentiality, and others in check.

Patients often lose or misplace their patient cards, which usually contain patient identification information and other pertinent details, in the event that the card lost as is always the case, patient identification becomes cumbersome, time-consuming and counterproductive to the care process. However, if fingerprints are used, then you are sure the patient will be identified in real-time and this will significantly reduce the time of the encounter which in the end improves efficiency.

References

https://www.csoonline.com/article/3339565/what-is-biometrics-and-why-collecting-biometric-data-is-risky.html

https://www.recogtech.com/en/knowledge-base/5-common-biometric-techniques-compared#:~:text=Fingerprint%20recognition%20and%20iris%20scanning,are%20also%20gaining%20in%20popularity.

https://www.tandfonline.com/doi/full/10.1080/11287462.2020.1773063

http://www.biometricsdirect.com/Biometrics/laws/HIPAA.htm

Article by: Noah k. Jaafa,
HELINA Association.

A Snap Shot of ‘Successful’ Telemedicine Implementations in Low and Middle-Income Countries

What is a successful telemedicine implementation?

A telemedicine implementation can be deemed to be successful when it is fully integrated into healthcare delivery such that it is and no longer viewed as ‘telemedicine’ (Mars and Scott, 2017). This is best exemplified by radiology in many developed countries, where the term ‘teleradiology’ is seldom used and imaging and communication over networks using radiology information systems and picture archiving systems is simply the norm for diagnostic imaging or radiology services. But in order to reach this stage, what characteristics must a telemedicine implementation have that makes it most likely to be successful?

Around the world, many telemedicine projects have been introduced and quickly abandoned (Schwamm et al., 2017; Wade et al., 2016) often due to a lack of continued funding commitment and lack of an overall strategy! Over 20 years ago seven principles were proposed to increase the chances for successful development of telemedicine (Yellowlees, 1997). These, and other principles for success, have evolved to include activities such as strategy development, needs assessment, business cases, and plans, readiness assessment, implementation plans, change management interventions, and ongoing monitoring and evaluation (Mars and Scott, 2017).

The Momentum Thematic Network for the Advancement of Telemedicine Adoption in Europe produced a blueprint of how to move telemedicine interventions from proof of concept to scale-up while making them sustainable. The 18 critical success factors for telemedicine deployment, have been laid out in four subgroups; context (cultural readiness, consensus on advantages of telemedicine); people (good leadership, the involvement of healthcare professionals, patients-centric, and technology-friendly); plan (pull resources, address client needs, business plan, change management plan, legislation, and assure technology can be scaled-up); and run (apply legal and security guidelines, involve legal and security experts, ensure telemedicine users are privacy-aware, availability of technology and e-Health infrastructure, monitoring services in place and procurement process) (Momentum blueprint, 2015). Greenhalgh et al. highlighted an important factor not addressed by Momentum, but noted in earlier literature, that if an innovation or setting under which the innovation has been introduced is complex then it is less likely to be successfully adopted, scaled-up, spread, and sustained (Greenhalgh et al., 2017).

Examples of telemedicine in developing countries

Telemedicine is used globally, but the extent and sophistication in developed countries contrasts with applications in developing countries. In developed countries, there has been continued growth in the use of telemedicine despite a need for heavy investment towards infrastructure. On the other hand, in developing countries telemedicine has mostly been used for tele-education as well as improving adherence to HIV/AIDs treatment using mHealth services (Combi et al., 2016; Hamine et al., 2015).

The RAFT (Réseau en Afrique Francophone pour la Télémédecine) telemedicine network started in Mali in 2001, then extended to other French, English and Portuguese speaking countries in West Africa but has also extended to Bolivia and Nepal. The network uses a very small aperture terminal (VSAT) in some remote areas for e-learning services and videoconferencing at minimal bandwidth to physicians located in the rural and remote areas of developing countries. Among the services under the RAFT network are continuous medical education (CME) courses, access to medical information, and teleconsultation in terms of second opinion from the distant experts (Bediang et al., 2014; Randriambelonoro et al., 2018).

Telemedicine and Telehealth in Latin America and the Caribbean (LAC)

In 1925, the use of telehealth started in LAC when the Maynard Columbus hospital sent a telegram requesting an antitoxin to battle a diphtheria epidemic that was affecting the local community (5G Americas, 2016).  Application of e-health in LAC is growing and has a great potential to address the challenges facing the health sector in this region by providing equitable, efficient, and effective ways to improve access and timely care (Fernández and Oviedo, 2011). Many telemedicine projects exist in LAC to address the severe shortage of HWs (Scott and Mars, 2015).  Therefore, advances in telehealth will improve the health system while speeding diagnosis and treatment and in addition, overcome geographical barriers, facilitate services and improve the quality of healthcare in LAC regions (5G Americas, 2016). Farach et al. examined e-health use for accessing underserved populations in several LAC countries (Colombia, Chile, Peru, Barbados, Haiti, Mexico, and Guatemala), with projects addressing communicable and non-communicable diseases as well as juvenile bullying (Farach et al., 2015). Perhaps the LAC country with the most widespread and sustained telemedicine application is in Brazil.

In 2007, a teleconsultation service within an existing national university and research network was implemented in Brazil linking clinicians (Pessoa et al., 2016). In Brazil teleconsultation is restricted by law to HW – to – HW communication and the patient is not permitted to be involved in the consultation except in an emergency, or for tele-assistance and telemonitoring (Garcia et al., 2015). HWs are able to connect with each other and also many telehealth centers are accredited (Moura, 2016). In addition, the Brazilian HWs have continued to benefit from Technology Enhanced Learning (TEL) through distance education (Oliveira et al., 2016).

Several telehealth systems exist in Brazil, such as HealthNet (teleconsultation); INDU (tele-education); dataNUTES (management); and SMART (monitoring); with a telehealth ontology through the integrated interface (Santana da Silva et al., 2016). Due to the increasing prevalence of the cardiovascular disease, a TeleECG solution was implemented in the city of Belo Horizonte to improve the healthcare services as well as reduce waiting time for cardiovascular services. Reporting on 1,954 consultations over 5 months in 2009, results showed that the use of the teleconsultation system had an important potential to reduce patients’ referral (78%), that the teleconsultation seemed to be adequate to the user’s need, as only 8% of users related that the teleconsultation did not answer their question and that 95% of users were satisfied or very satisfied with the system (Alkmim et al., 2015).  This service has now dealt with over two million cases (Chazard et al., 2015).

Telemedicine in Middle East and Asia

Jaber et al. reviewed telemedicine and telehealth activity and research in Saudi Arabia, Jordan, Kuwait, Syria, and Iraq (Jaber et al., 2014). They concluded that while telemedicine activity existed, barriers to its expansion and adoption were primarily a lack of awareness and knowledge about telehealth implementations, difficulty in application, and lack of time to adopt initiatives. More recently, individual research activity has been highlighted, including telemental health and teleaudiology (Al-Abri et al., 2016; Jefee-Bahloul, 2014).

In India, telemedicine started in 1976 with the satellite instructional television experience that connected several rural villages to provide education on hygiene and adult education (Bhaskaranarayana et al., 2009) and has developed due to the expansion of the ICT industry  (Mishra et al., 2011). The ISRO (Indian Space Research Organization) spearheaded the development of telemedicine and tele-education which has been of social benefit in India. In 2000, ISRO provided the world’s largest VSAT (Very Small Aperture Terminal) network connecting village hospitals. This type of technology has been used extensively in India connecting different hospital centers for teleconsultation and tele-education (Ramkumar and Selvakumar, 2016). Using space technology and satellite communications, ISRO has built and operated modern communication, remote sensing (ETtech, 2018), and meteorological satellites that have been used to connect qualified and specialized health professionals to the rural population in India (Bhaskaranarayana et al., 2009). Telemedicine has been used to offer services like; ophthalmology, retinal screening, tele-emergency, telestroke, telerehabilitation, and epileptology. Other areas that have benefited from telemedicine are teleradiosurgery, teleneuropathology and neurosciences. The Apollo Telemedicine Networking Foundation (ATNF) is the oldest and largest multispecialty telemedicine network in India, and in 2013 alone, 306,170 teleconsultations were done in the Aravind Eye System including 190,878 new and 115,292 review consultations (Ganapathy, 2014). Under the Government of India Pan African e-Network project, ATNF has delivered over 200 CME lectures to doctors in neurosciences and also to villagers in rural Tamilnadu via Internet-enabled village resource centers (Ganapathy and Ravindra, 2008).

The Pan-African e-Network (PAeN) project is an Indian Government contribution in collaboration with the African Union to provide tele-education, telemedicine, e-commerce, e-governance, resource-mapping, and metrological services to the people in Africa. The aim of this project was to create significant linkages for tele-education and tele-medicine, Internet, video-conferencing, and VoIP services, making available the facilities and expertise of some of the best universities and super-specialty hospitals in India to the people of Africa. Although aimed at all African countries, tele-Education learning centers have been set-up in 5 Regional University Centres in Africa, namely, Kwame Nkrumah University of Science and Technology, Ghana; Makerere University, Uganda; Yaounde University, Cameroon; Alexandria Faculty of Commerce, Egypt; and Chancellor College, Zomba, Malawi (Pan African e-Network Project, 2013). During the permanent executive committee meeting in Addis Ababa (African Union, 2018), the PAeN’s infrastructure and management of the project was transferred from the Indian Government to the African Union Commission which has already has identified ways of making use of the PAeN infrastructure for further add-on services which will be beneficial for Internet infrastructural development on the continent.

Skandarajah et al. evaluated an automated tablet-based mobile microscope as an adjunct for telehealth-based oral cancer screening (Skandarajah et al., 2017).  The tablets successfully collected images of sufficient quality to enable remote diagnoses in concordance with existing techniques. India has also implemented a toll-free helpline connecting HWs in the rural areas to access specialized medical care and professional services (Hegde et al., 2018) in management of hypertension and diabetes (Jindal et al., 2017) and a tele-diagnostic community-based hearing screening for children (Ramkumar et al., 2018).

In Bangladesh, a study that explored the knowledge, attitude and practices on eHealth of doctors in Dhaka hospital found that, of the 112 respondents, 50% had average knowledge and only 26%  had good knowledge of eHealth,  90% had a favorable attitude while patient follow-up and diagnosis were identified as the common eHealth practices (Parvin and Shahjahan, 2016). An advanced telehealth model was implemented to provide healthcare services for the rural people of Bangladesh. The model was successfully tested with patients of Marie Stopes hospital in Dhaka and demonstrated visualization of real-time data with the expert doctors (Prodhan et al., 2018). Another study conducted among university students in Bangladesh about the impact of Web 2.0 such as Facebook and Twitter on health information-seeking behaviors indicated that web-based health information seeking and sharing behaviors influence health-related decision making (Islam et al., 2017). Whilst for Sri-Lanka, a dengue surveillance system called Mo-BUZZ was developed and launched. An assessment of the usage and impact of the system showed a slow but positive uptake of the system (Lwin et al., 2017).

Hussain (2015) documented the history of eHealth initiatives (telehealth, telemedicine, and mHealth ) in Pakistan, that have evolved since 1990 and which started as small projects under public-private partnerships and donor funding. According to Khoja (2017), Roshan Telecommunication setup a telehealth link connecting hospitals in three Afghanistan provinces, Kandahar, Bamiyan, and Badakhshan to Aga Khan University Hospital in Karachi, Pakistan. The author reported that close to 20,000 patients have received treatment and nearly 6,000 teleconsultations and teleradiology sessions conducted. A telehealth solution for mental health was also implemented and this enabled primary care workers in rural areas to consult with those in urban communities to provide better access to healthcare (Khoja et al., 2016). In addition, Zahid et al. (2017) showed that those in those in the rehabilitation field had knowledge of ICT, which presents an opportunity for Pakistan to implement telehealth like telerehabilitation services for consultation, assessment, and therapy. In The Philippines, an Asian e-Health Information Network (AeHIN) was formed as a way of building capacity in the public and private health sector in support of patient care and public health (Marcelo and Marcelo, 2016).

Telemedicine in sub-Saharan Africa

Although countries in sub-Saharan Africa have benefited from telemedicine and telehealth projects with non-government organizations, government, and private entities providing financial, logistical and clinical support (Sundin et al., 2016),  few have scaled to full potential often remaining at the pilot level or proof of concept (Kiberu et al., 2017). mHealth has been implemented to serve multiple purposes as follows: (1) communication tool for behavior change, (2) clinic appointment or medication reminders, (3) monitoring and management of diseases and pandemic, (4) data collection and tracking, (5) enhanced communication among health professionals or between patients and providers, (6) education for health professionals or patients (Kallander et al., 2013), as well as for management of chronic diseases (Watkins et al., 2018) and telemedicine (Mars and Scott, 2017). mHealth interventions using short messaging services have improved adherence to antiretroviral therapy and tuberculosis (TB) treatment completion (Hermans et al., 2017). Likewise, technology support for TB treatment adherence using a smart pillbox improved TB treatment outcomes and lowered costs per patient and the burden on the limited resources (Broomhead and Mars, 2012).

In 1999, South Africa (SA) launched a National Telemedicine System (Jack and Mars, 2013). This has led to several telehealth initiatives in SA, for instance; dermatology, pathology, radiology, and ophthalmology, etc. (Mars, 2013). Several mHealth interventions have been used to improve HIV/AIDs and TB treatment adherence exists in SA (Maraba et al., 2018; Nachega et al., 2016). Guidelines have been developed to facilitate the practice of telepsychiatry. These were based on research and international evidence delivery of psychiatric services (Chipps et al., 2012a). After several years and some difficulty (Kekana et al., 2010), the Health Professionals Council of South Africa (HPCSA) has recently published General Ethical Guidelines for the Good Practice in Telemedicine in SA (HPCSA, 2016; Kekana et al., 2010; Mars and Jack, 2010)

The University of KwaZulu-Natal has been broadcasting lectures by videoconference and sending recorded videos of lectures to different African countries since 2001, with over 40 h of interactive sessions broadcast per week by 2010. These have covered postgraduate and more recently undergraduate training in over thirty medical specialties, nursing, medical informatics, and telemedicine (Mars, 2012). This has been shown to meet the academic needs of rural-based and African students with minimum impact on service delivery and substantial time and cost savings (Chipps et al., 2012b). For instance, an evaluation of the evidence on telepsychiatry and video conference-based education revealed that implementation of the telepsychiatry outreach model improved access to mental healthcare (Chipps et al., 2012a).

Social media platforms have also gained use in healthcare. WhatsApp technology has been reported in developing countries in the form of chat groups at hospital departments to provide updates on patient admissions, telehealth second opinion, changes in treatment plans and theatre scheduling, etc. (Mars and Scott, 2016). WhatsApp use has reduced unnecessary referrals, optimized use of scarce resource allocation, aided pre-hospital communication and facilitated CME (Martinez et al., 2018). A mHealth technology in Kenya has been used to remotely monitor malaria rapid diagnostic testing by community health workers for purposes of quality improvement (Laktabai et al., 2018) while in Ghana such technology has done well for hypertension control (Nichols et al., 2017) and access to sexual and reproductive health (SRH) services among the adolescents (Rokicki and Fink, 2017).

Although Botswana is classified as an upper-middle income country, the country still has a struggling healthcare system (World Bank Botswana, 2018). Despite continued scarcity of human and technology resources, the Botswana – University of Pennsylvania Partnership (BUP) piloted four mobile telehealth projects for cervical cancer screening, radiology, oral medicine and dermatology. The pilot projects were a success, and the m-Learning platform at BUP (through the University of Botswana, School of Medicine) enabled patients and healthcare workers to gain access to healthcare resources (Littman-Quinn et al., 2013). In another study Witt et al. (2016) demonstrated use of smart devices (tablets) in rural Botswana where there was only intermittent Internet access. The findings showed that the tablets are relevant in providing access to current medical information resources. An implementation evaluation on the use of television white space (TVWS) to provide bandwidth and connectivity to clinics in the rural areas of Botswana showed that TVWS has the potential to strengthen healthcare delivery in resource poor settings by providing reliable Internet connectivity (Chavez et al., 2016).

In Uganda, telehealth initiatives started in 1984 when clinical case conferencing was broadcast between Canada, Uganda, and Kenya by audio conferencing (House et al., 1987). In Tanzania, an SMS reporting tool was used to rapidly collate and monitor data (location, sex, age, and clinical condition) on Lymphatic filariasis (LF) in real-time. The approach of identifying, recording, and mapping patients’ data was reported to be feasible with the potential for scale-up in LF endemic urban settings (Mwingira et al., 2017). In 2012, Rwanda implemented an SMS-based system to improve maternal and child health (MCH) using RapidSMS. The pilot, which lasted for a year in Musanze district, indicated that the use of mobile phone could improve emergency care but requires a well-organized community structure in a low resource setting (Ngabo et al., 2012).

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