• Telemedicine
  • Telemedicine’s as big a US priority as EHRs

    Telemedicine’s up with inpatient and outpatient EHRs for US eHealth investment priorities. A survey by Reaction Data found 33% of healthcare executive have it as their top priority, alongside 32 % who have EHRS for inpatients and outpatients as top. Nearly half the respondents work in standalone hospitals. About a third are ion Integrated Delivery Networks (IDN).

    About 20% have investment to support a payment initiative. The Medicare Access and CHIP Reauthorization Act 2015 (MACRA) is a new way to pay doctors who treat Medicare patients. CHIP’s the Children's Health Insurance Program.

    These eHealth priorities don’t convert directly into spending priorities across all types of healthcare organisations for the next twelve months. The top two are:

    IDNs      

    Inpatient EHRs 

    41%

     

    Outpatient EHRs               

    24%

    Standalone hospitals

    Inpatient and outpatient EHRs

    31%

     

    Population health management

    24%

    Hospital’s physician groups

    Information security

    50%

     

    Telehealth

    38%

    Independent physician groups

    Telehealth

    52%

     

    Information security

    33%


    With Africa’s different health and healthcare priorities and eHealth development stage, will mHealth feature in the top two or three short term priorities and spending plans? Will cyber-security be moving up the eHealth priority ladder?

  • Telemedicine performance can steer Africa’s programmes

    In the right setting, telemedicine’s worth it. For Africa’s remote communities, it can offer access to services and avoid long, and sometime wasted, journeys. A US study by NTCA–The Rural Broadband Association Anticipating Economic Returns of Rural Telehealth, identifies quantifiable and intangible benefits.

    The report identifies intangibles that include access to specialists, timeliness, comfort, transportation, provider benefits and improved outcomes. Its quantifiable benefits are transport cost savings, reduced loss of wages, hospital cost savings and increased revenues to local labs and pharmacies.

    For Africa’s rural communities, telemedicine can bring all these, but there are two big practical challenges. One identified in the report is rural telemedicine’s significant dependency on the future-proof, fibre-based broadband infrastructure. It’s seen as a challenge in the US, in Africa, it’s a longstanding technical and affordability challenge. Part of the solution may be in using smartphones and their networks for telemedicine.

    Increasing access for rural patients may result in a significant impact on stretched healthcare resources, especially specialists. This can be offset by reducing the unnecessary visits, but still likely to increase workloads. It’s not necessarily an insurmountable problem, but clarity on the implications is important to have in advance.

  • Samsung's launching new telemedicine features

    At the launch of Samsung Galaxy S8 and S8+ phones, the company announced the re-invention of its S Health app as "Samsung Health". An article in mobihealthnews says the upgrade includes tracking and social features already in S Health and  adds new features and a new user interface.

    Ask an Expert’s Samsung's most-popular feature. Users can connect via video to a doctor for US$59 without insurance. It includes real time insurance verification. 

    The app taps into American Well's system so users can see several doctors. The company says its network contains more than 1,200 certified, licensed doctors with an average of 10 to 15 years of clinical experience.

    "This isn’t telemedicine, this is a connected healthcare ecosystem,” American Well CEO and President Dr. Roy Schoenberg told MobiHealthNews. “And we’ve been building up so that it is bigger than anything we have done, and what Samsung is saying is, ‘I’m not going to build healthcare on my product, I’m going to tap into that ecosystem and open the door through technology that touches a lot of people.'”

    In addition to the telemedicine features, Samsung Health includes:

    • Access to lifestyle, food, and fitness trackers
    • A step leaderboard to compete with friends
    • A Discover feature for health content
    • Integration with connected health devices
    • Rewards for signing up with Ask an Expert or Health Insights, a feature that adds analytics and coaching to Samsung's health trackers. 

    The app will be available on all devices that run Android 4.4 and higher. Some older devices and devices in certain countries may not have access to all features. It highlights an important component of Africa’s drive towards Universal Healthcare (UHC).

  • Telemedicine saves time, cuts travel costs and improves air quality

    Telehealth policies continue to grow. Whether it actually reduces healthcare costs and improves outcomes is still a point of some contention. Researchers at University of California Davis (UCD) looked at how telehealth impacts patients at a basic level: driving costs.

    Spanning across two decades, the study, published in Value in Health, examines 18 years of UCD’s clinical records from 1996 to 2013, evaluating inpatient and outpatient interactive video visits for 19,246 patients.  Patients usually still visit their primary care doctor, but they also consult a UC specialist via video consultation. The cost savings were measured based on patient travel to a telemedicine center near their home versus traveling to UC Davis Health in Sacramento for specialty care.

    Telemedicine visits saved patients an aggregate of nearly nine years of travel time, five million miles and US$3 million in costs. For each individual, these numbers are a little more modest. Over the 20 year period, a patient could see an average cost savings of four hours of driving time, 278 miles and US$156 in direct travel costs.

    The UCD team researchers measured environmental impacts from the avoided car trips. Telemedicine helped saved almost 2,000 metric tons of carbon dioxide, 50 metric tons of carbon monoxide, 3.7 metric tons of nitrogen oxides and 5.5 metric tons of volatile organic compounds. It’s a big contributor to cleaner air, a factor often missing from previous evaluations.

    If the study paramaters were expanded to include rural areas that are underserved by medicine and reliable public transportation, the results are very different. The real costs of fuel, mileage and time are all measurable savings from telemedicine to patients. This is the case in many African countries, where people often have to walk long distances to reach a healthcare facility before waiting in queues for hours before being helped. These should combine into encouraging more patients to seek medical care. As telemedicine technology advances costs to patient will drop, reinforcing increasing access.

    African healthcare systems have a way to go before telehealth benefits can be realized and services be implemented on a large scale. Infrastructure, affordability and connectivity remain challenges.

  • Brazil looks set to expand telemedicine

    Market research report on Brazil’s telemedicine shows it’s likely to increase from $495.3 million in 2015 to $743.8 million in 2017. That’s about a 50% increase in two years. Research and Markets published its findings and also found that the country’s mHealth market revenue look set to grow from $446.8 million to $1.43 billion over the two years, more than three times its 2015 spend.

    Brazil’s teleradiology takes a huge market share, 98%. The remaining 2% is for specialist consultations and distance learning and education. mHealth is a different market. Its range’s broad, and includes some apps for telemedicine.

    Despite mHealth’s gigantic growth forecast, there are several investment barriers. Short life-cycles is one. Both wearable and apps, and across vital signs remote monitoring and chronic disease management, mHealth’s rapidly and constantly transforming its ecosystem with new value proposition and solutions. Dealing with these obsolescence costs creates affordability challenges.

    World Bank data shows Brazil’s Gross Domestic Product (GDP) per head as about US$8,539. An average for Africa’s about US$5,666. The extra 50% can make a big difference to eHealth affordability. Even so, Brazil’s forecast expansion’s huge, so Africa’s health systems may be able to see some significant growth.

  • WHO’s telehealth view is optimistic – unpacking the 3rd Global Survey on eHealth

    French and English speaking African countries have long associations with telehealth. Réseau en Afrique Francophone pour la Télémédecine (RAFT) Project involved Geneva University Hospital and Health On the Net Foundation in developing a network for eHealth in Africa. It started in 2000 and is now across four continents.

    Telehealth data from WHO Global Survey 2015 provided insights for Chapter 3 of the WHO and Global Observatory for eHealth (GOe) publication eHealth Report of the third global survey on eHealth Global diffusion of eHealth: Making universal health coverage achievable. The report deals with five telehealth types:

    1. Teleradiology
    2. Teledermatology
    3. Telepathology
    4. Telepsychiatry
    5. Remote patient monitoring.

    A country average was 3.7 telehealth programmes. At about 3.3, Africa had slightly fewer, about 90% of the global average. For the five telehealth types, Africa’s teleradiology in about two-thirds of countries has a score of some 60%, below the global rate of 75%. The other four types are below 45%, with telepsychiatry the lowest, about 20% of teleradiology’s rate.

    Telehealth evaluations are increasing in number. Criteria used to evaluate government-sponsored telehealth programmes were:

    Programme acceptance by providers
    73%
    Quality
    73%
    Access
    68%
    Programme acceptance by target groups
    64%
    Cost-effectiveness for providers
    55%
    Sustainability                    
    55%
    Health outcome
    50%
    Cost-effectiveness target groups
    46%

    Comprehensive evaluation using Cost-Benefit Analysis (CBA) could combine all these perspectives. It could also include efficiency and provide a direct link with telehealth financing. Global perspectives of barriers to telehealth investment may not match Africa’s, especially telehealth finance and infrastructure for connectivity:

    Importance        


    Very      
    Not
    Funding                
    <10%
    >70%
    Infrastructure  
    >10%
    >50%
    Priority                  
    <20%
    >40%
    Legal    
    >10%
    >40%
    Capacity
    >10%
    >40%
    Policy
    >20%
    <40%
    Cost-effectiveness
    >10%
    <40%
    Demand
    <20%    
    <40%
    Effectiveness
    >10%    
    <30%








    Since telehealth emerged on the scene, technology’s changed. The Internet and mHealth have created new and wider opportunities. Initiatives like Figure 1, described in an eHNA post, are changing its scope and range, and offer Africa’s health systems greater participation. 


  • Three things holding telehealth back

    Since telehealth and telemedicine first emerged on the eHealth scene, new tools, such as social media, SMS and mHealth have expanded its potential. In an article for Healthcare IT News, Dr Shivan Mehta, Director of Operations at the Penn Medicine Center for Health Care Innovation and author of Telemedicine's Potential Ethical Pitfalls, says it can forge a deeper connection with underserved populations, but achieving uniform, high-quality telehealth needs healthcare providers, vendors and ethicists to answer important questions. They include:

    1. The efficacy of remote healthcare compared to in-person care
    2. How doctors are reimbursed for telemedicine services
    3. Ethical standards for telehealth.

    None of these are new, hinting that they might be somewhat intractable issues. A version of the technology may go back as far as 1924, so it’s reasonable to expect that barriers may have been demolished by now, but it seems they haven’t.

    Concern that telemedicine could depersonalise doctor-patient relationships and compromise its pastoral role is valid. A telehealth plan that caters for patients’ special needs should minimise most doubts. Telehealth’s main contribution may be to meet some of the needs of underserved populations with few doctors in their communities, or who travel long distances to see a physician. This confirms its value for Africa’s health systems. It can also complement existing healthcare, again, beneficial for Africa.

    He sees two crunch issues in this context, efficacy and efficiency. Their components are providing acceptable quality by measuring the right outcomes by using technology that improves quality for everyone and enables health workers to interact with more patients. Achieving these needs telemedicine that’s directly integrated with high-quality clinical standards. Carena has developed a set of virtual practice guidelines to help.

    Telemedicine needs the highest ethical standards that match conventional medicine. Protecting privacy and confidentiality of patient data and patient exchanges with health workers and teams is paramount. It must ensure that no one’s off-screen or observing without patients’ consents, says the Dr David Fleming, co-director of the MU Center for Health Ethics at University of Missouri School of Medicine. He also highlights an equity issue of avoiding discrimination against patients who may be denied access to telemedicine venues because of logistics, cost or reimbursement barriers. Using mHealth may help to resolve this for some patients.

    If telehealth isn’t reimbursed fully, patients and doctors will be reluctant to use it. Fleming sees affordable and less complicated technology as part of the solution. It should run alongside better and more informed healthcare policies, strategies, plans and projects to deploy telehealth to under-served populations.

    Effective reimbursement underpins expansion. Scalability and readiness are affected by it. A random mix of reimbursement models and regulations inhibits progress. Clarity and consistency are the keys, identifying a need for Africa’s health systems to develop these in parallel to investment programmes.

  • Uganda's virtual doctors strengthen healthcare

    Uganda has only one doctor for every 25,000 people, below the WHO recommended combined ratio of 2.5 doctors, nurses and midwives per 1,000 patients. Mobile technology has emerged as a lifeline for many of these people who now have digital channels through which they can access medical professionals, says an article in ITWEB Africa.

    Mobile devices and social networks are steadily eliminating the problem of distance between urban areas, where many medical professionals are located, and remote regions, where there is a desperate need for medical treatment and services.  The Medical Concierge Group (TMCG), uses mobile technology and the Internet to bring patients and medical services together. Based in Kampala, TMCG runs a call centre service providing free access to doctors, pharmacists and other professionals, and anyone seeking consultation and information.

    The call centre uses Asterisk software for the voice service and call centre technology’s E1 cards that enables it to handle up to 60 simultaneous calls. RapidPro supports SMSs and can handle tens of thousand interactions per minute.

    Data collected from all the call centre’s stored on local servers and backed up in the cloud. Social networks such as WhatsApp and Facebook are the most popular first points of contact. Call centre services are geared for nationwide scale with the capacity to handle up to 8,000 voice calls a day, unlimited SMS messages and unlimited email, video chat and social media interactions.

    "Surveys show that 60-70% of the reasons that take people to hospital do not actually require them to go to hospital physically. Most of them can be resolved remotely by a medical professional's interpretation, reassurance and direction. Mobile technology and medical call centres in particular provide an avenue through which a small team of health professionals can serve a larger number of people without physically being present," explains Dr Davis Musinguzi, MD at TMCG.

    He says with preventative medicine at the forefront of healthcare programmes, the providing adequate medical information that empowers individuals to take charge of their health is vital. TMCG's approach is making several channels of communication available simultaneously to cater for the needs of all potential users. "The more the richness of the media communication, the more effective ... video is more effective than messaging, which is more effective than voice calling only. The challenge is with the limit of bandwidth and cost of internet to entirely rely on video thus messaging is the preferred option."

    The platforms are making a difference to health services, including emergency contraceptive advice, post-exposure prophylaxis for HIV and chronic illnesses such as diabetes and hypertension. TMCG says that the percentage of resolved health inquiries of users of the service currently stands at 98%, and the percentage reduction in the time spent accessing the same service through alternative/ traditional means is at 98% less time spent. There’s also been a reduction in the cost, with SMSs at an average of 100 UGX compared to 30,000 UGX for a traditional consultation fee plus transport costs.

    .

    TMCG plans to extend its services to other countries. It has confirmed plans to launch its operation with local partners in Kenya and Nigeria in 2017.

  • In-person teledermatology’s offers good quality healthcare

    Africa’s health systems accord a high priority to telemedicine as an important part of their eHealth plans. It provides a valuable service to remote communities. For teledermatology, a study by a US team, published in Telemedicine and eHealth, has two results. “The superiority of in-person consultations suggests the tendencies to order more biopsies or still see patients in-person are often justified in teledermatology and that high resolution uncompressed video can close the resolution gap between store-and-forward and live interactive methods.”

    There hasn’t been much teledermatology research comparing remote methods, and even less with two in-person dermatologist providing a baseline to compare remote methods. This controlled study of more than 200 patients evaluated each one three times in single clinical sessions. They were in person, using store-and-forward still photography and either high-definition uncompressed or compressed video.

    The study team says it’s the first research into using high definition video as a live interactive method. It compares in-person consultations with store-and-forward and two type of live interactive methods with different image qualities, lower resolution compressed or higher resolution uncompressed.

    It found that concordance and confidence were significantly better for in-person teledermatology than remote methods. Biopsy recommendations were lower too. Store-and-forward and higher resolution uncompressed video results were similar and both better than results for lower resolution compressed video. There were some variations in expertise between second and third year resident doctors.

    It seems that high-resolution uncompressed video’s more feasible teledermatology technology than other remote methods. It points Africa’s health systems to consider it as a component of their programmes and projects.

  • Telehealth reimbursements a persistent challenge

    As telehealth expands, reimbursement seems like a persistent loose end. It seems it’s hard to achieve. A meeting of US hospital CIOs at the College of Healthcare Information Management Executives (CHIME), and reported by Fierce Healthcare, concluded that reimbursement for telehealth services a persistent challenge. This has lessons for Africa’s telehealth initiatives.

    Cyndi Cahill, a consultant with Pursuit Healthcare Advisors, said adoption rates were very low, or non-existent for some healthcare providers because hospital CFOs want to see “butts in the bed.” As more types of telehealth become reimbursable, the trend’s slowly changing, but still has a long way to go. An example of the a reimbursement lag’s where Medicaid reimbursement for telehealth’s dependent on patients being in another medical facility, but there’s no financial incentives for telehealth treatments in patient’s homes.

    A constant feature of telehealth’s its technological expansion always ahead of healthcare’s reimbursement and financing models. A lesson for Africa’ health systems is the need to set in train financing and reimbursement models as part of telehealth projects, programmes and business cases. The goal’s to ensure that effective telehealth services are sustained.