• Telemedicine
  • A telehealth review sets out benefits and challenges

    With Africa’s emphasis on telehealth and mHealth, a review by the US Department of Health and Human Services (HSS) “E-Health and Telemedicine,” offers valuable insights into benefits and challenges. Africa’s health systems can use it as a comparator for their programmes.

    It sees telehealth offering a way to increase healthcare access and improve health outcomes and reduce costs. It’s seen as beneficial for people in rural and remote areas and helping people with chronic diseases who need to manage their conditions.

    Developments in telecommunications, such as better high resolution imaging and broadband have accelerated telehealth’s use and availability. The increasing prevalence of mobile computers such as iPads and smartphones, linked to the Internet has enabled online, remote consultations between doctors and patients.

    The study deals with four basic telehealth types:

    Live synchronous video for two-way interaction between people and health professionalsStore-and-Forward: Transmission (SFY) of videos and digital images such as x-rays and photos through a secure electronic communications systemRemote Patient Monitoring (RPM) for personal health and medical data collection from people, transmitted to a provider in a different locationmHealth, using smartphone apps for better  health and well-being.

    Four telehealth challenges are:

    Reimbursement and its variability, so still a challenge in the US after many years of expanding telehealthLicencing and regulation, a challenge for AfricaAccreditation of, and privileges for, telehealth providesBroadband connectivity, a big, widespread challenge for Africa.

    An important perspective from the study’s how an accumulation of telehealth over many years has resulted in a set of issues that now need co-ordinating. In 2017, the US’s embarking on a legislative programme for telehealth. Its aim’s to improve co-ordination. It’s an initiative that Africa’s health systems should consider, especially with its expansion of the telehealth’s mHealth component that may be leading to proliferation.

  • Telehealth’s a cost centre

    Creating business models for telehealth and other types of eHealth’s often seen as an important part of eHealth strategy. Another view’s that most eHealth’s a healthcare resource alongside health workers, medicines and healthcare facilities, so a healthcare cost centre rather than a new service line.

    A survey by a team from University of New Mexico Health Sciences Center in Albuquerque, and published in Telemedicine and e-Health, found cost centres are the main approach in the US. The choice’s important because it can affect telehealth’s sustainability/ There’s also a lack of comparative studies about how successful telehealth centres function.

    The study compared the business models of ten successful telehealth centres. It identified five general approaches to sustainability:

    GrantsTelehealth network membership feesIncome from providing clinical servicesCharges per encounterOperating as a cost centre.

    It seems that telehealth centres start-up as healthcare provider cost centres, but it’s not a simple as picking one model. The team found that most centres use a mix of approaches. Its conclusion’s that telehealth centres should stay as cost centres for their healthcare organisations.

    Adopting this approach can save Africa’s health system much agonising over business models. It can be a protracted process, and in the medium term often incomplete because setting telehealth’s income streams can take several years after services have started, so a cost centre is the most realistic. mHealth services can be seen in the same way too. A sound business case for investment’s more important for setting sustainability than alluring, independent business models that see telehealth and mHealth as a separate healthcare enterprise.

    For developers and suppliers, it’s different. They need clear business models that ensure commercial success for their products and services. They need to know that healthcare providers and afford and sustain their innovations.

  • Telehealth’s marching on

    In the Atlas of eHealth country profiles for 2015 from WHO, African countries had 33% coverage for telehealth.  This’s encouraging in the context of a report by Drs Dorsey and Topol in the New England Journal of Medicine that summarises how telehealth’s evolving from clinics to homes and overcoming its barriers and limitations to offer potential for better healthcare. It suggests telehealth can expand medicine’s reach in remote areas and for several socio-economic groups.

    They identify three telehealth trends:

    Shift in focus from increasing access to convenience and lower costsExpansion beyond acute conditions such as stroke, to chronic care managementRoles away from hospitals and clinics to patient homes and mobile devices.

    Telehealth organisations now offer online visits at less than $50 instead of a more expensive 20-minute appointment with a doctor of two hours, including travel time.

    A challenge’s setting up telehealth reimbursement is time consuming. This has echoes of telemedicine reimbursement in the early years of the century. Most stakeholders agreed it needed doing, but decisions and implementation took several years and caused financial stresses for some suppliers and impeded adoption by some healthcare providers.  

    They foresee a future in which wide smartphones enable a range of diagnostic and monitoring capabilities, combined with patient-generated, real-world data, including from sensors. All these will help doctors to deal with patients remotely. There’s a big but. The digital divide’s the biggest issue. Elderly, lower income and less educated people are less likely to have the technical means to access telehealth. These are often in groups with more ill-health than average. 

    All this looks good for Africa. All it needs to do now is step up its 33% coverage to more than 50% in the short term and keep the investment momentum into the medium term.

  • Telehealth evidence report can guide Africa’s plans

    Africa’s telehealth plans extend across telemedicine and numerous types of mHealth. Telehealth: Mapping the Evidence for Patient Outcomes From Systematic Reviews from the USA’s Agency for Healthcare Research and Quality (AHRQ) and its Evidence-based Practice Centers (EPC) has assembled evidence that Africa’s health systems can use to move their mHealth programmes on.

    The key messages are:

    Telehealth research literature’s vast and varied, with hundreds of systematic reviews and thousands of use studies across various clinical conditions and healthcare functionsThere’s sufficient evidence to support the telehealth’s effectiveness for specific uses with some types of patients, including:Remote monitoring of patients with chronic conditionsCommunication and counselling for patients with chronic conditionsPsychotherapy as part of behavioural healthFor these telehealth applications, research should shift its focus to ways of promoting extended and wider implementation and address barriersMore systematic reviews may help some initiatives, such as consultation and maternal and child health, where primary studies are available but haven’t been synthesisedFor other uses, such as triage for urgent care, managing serious paediatric conditions, patient outcomes for teledermatology and the integration of behavioural and physical health, where telehealth’s cited as offering value, but has limited primary evidence, suggesting more studies are neededFuture research should assess the use and impact of telehealth in new healthcare models, implementation and practices so telehealth’s value can be assessed across the healthcare continuum.

    Distribution of the clinical focus across included systematic reviews was:

    %Mixed chronic conditions  25Cardiovascular disease21Diabetes14Behavioural health12Respiratory disease9Physical rehabilitation8Intensive care units or surgery support5Burn care2Dermatological conditions2Preterm births2

    The strongest findings on benefits were in remote monitoring for cardiology and respiratory diseases. Both had several studies identifying potential benefits. Acfee’s approach is that potential benefits usually exceed probable benefits.

    The final conclusion’s that “There are important areas within telehealth with substantial evidence that can support broader implementation and spread.” There are also other areas where evidence is minimal. Africa’s health systems need both findings to take beneficial telehealth and mHealth investment decisions.

  • Some telehealth may make a bit of an impact

    Not all eHealth offers substantial benefits. A UK study using qualitative interviews and reported in the Journal of Medical Internet Research (JMIR) found mixed evidence for the benefits of telehealth for two chronic conditions. For depression, the study identified moderate effectiveness. It was partial for Cardiovascular Disease (CVD) risk. These findings are important for Africa’s eHealth.

    The team ran two linked Randomised Controlled Trials (RCT) to test the Healthlines Service for depression and high CVD risk. The telehealth service comprised regular phone calls from non-clinical, trained health advisers who followed standardised scripts generated by interactive software. They facilitated patients’ self-management by supporting them to use web-based resources and supporting them to optimise medication, improve treatment adherence and encourage healthier lifestyles. Participants comprised 21 health workers and 24 patients.

    Some patients said telehealth had improved outcomes, but, contextual issues in patients’ lives and some problems with implementation may have reduced the benefits’ scale. Patients with depressions said their lives and preferences affected engagement with the intervention. Their busy and complex lives adversely affected their ability to engage. Some patients preferred to deal with a therapist instead of an advisor for their cognitive behavioural therapy.

    Patients’ with high CVD risk said their motivations adversely affected the intervention. Some had joined to gain general health improvement or from altruism rather than to make lifestyle changes needed to address their specific risk factors. Also, implementation wasn’t optimal in the early part of the CVD risk trial due to technical difficulties and the need to adapt the intervention for its practical use.

    Enthusiastic and motivated health workers providing continuity of intervention delivery tailored to individual patients’ needs were seen as important for patients’ engagement with telehealth. It wasn’t delivered consistently, especially in the trial’s early stages. There was a lack of active engagement from primary care too.

    While the study team supported telehealth’s conceptual model, it said that it may be possible to increase its effectiveness by incorporating human factors into the services. This finding offers a valuable approach for Africa’s systems’ eHealth, which is much more than just health ICT.

  • AMA approves telemedicine guidelines

    While many doctors have already adopted telemedicine enthusiastically, for some, using telemedicine can be problematic. To help, after three years of consideration, the American Medical Association has finalised its guidance on using telemedicine. It’ll be set out in in Opinion E-5.025, Physician Advisory or Referral Services by Telecommunication so doctors can have clarity and certainty about the appropriate use of audio-video technologies to connect with and treat patients remotely.

    A core requirement’s that doctors have access to the relevant information they need to make well-grounded recommendations for each of their patients. The main themes of the guidance are  that doctors should:

    Inform prospective patients about the limitations of the telemedicine relationship and servicesAdvise them about the potential need for follow-up care as indicatedEncourage patients who have existing primary care providers to inform their doctors about their receipt of telemedicine consultations and services, even if subsequent, direct care isn’t needed immediatelyBe proficient in using relevant technologies.Recognise the limitations of the technologies and take appropriate steps to overcome or address themPrudently perform appropriate diagnostic evaluations or prescribe medications by:Establishing each patient’s identityConfirming that the telemedicine services are appropriate for their individual situation and medical needsEvaluating the indication, appropriateness and safety of any prescriptive medication in accordance with best practices and state prescriptive formulariesSufficiently documenting the clinical evaluation and prescription and medical recordObtain appropriately documented informed consent to using the distinctive features of telemedicine in addition to information about the specific medical issues and treatment optionsTake appropriate steps to preserve continuity of care, including consideration of the preservation of information and accessibility to it by subsequent providers.

    The time taken to produce the guidance reveals the underlying complexity of eHealth. The AMA’s work provides a valuable starting point for Africa’s health systems to develop their own approaches. When they’ve agreed their own clinical guidance, it can be added to each country’s eHealth regulations.

  • Prisoners and prisons need eHealth too

    When prisoners need to visit hospitals, the cost and disruption’s considerable. Prison guards have to pull out of routine, scheduled duties. Other prison guards have to provide cover for the rota gaps, security risks need mitigating. Transport needs to be arranged and paid for, and prisoners may have to spend hours waiting. The change of scenery may be a benefit for them, but it’s not a constructive way of accessing avoidable hospital visits.

    One way to minimise visits to specialists in hospitals may be to have more prison doctors, though this is rarely an option. Attracting and retaining enough doctors and nurses to work in prisons is a continuous challenge. In African countries, with a huge deficit in healthcare professionals, it’s hardly an option.

    A solution’s to maximise eHealth. The relative opportunities for Africa are promising. The International Centre for Prison Studies has data on countries’ prison populations. It shows that an average rate for African countries is about 118 per 100,000 population, about 69% of the average rate of all countries of 171.

    Meeting the health and healthcare need for Africa’s prisoners can rely on more eHealth. Telemedicine and mHealth services are viable for them, with mobile phones provided with security requirements. EHRs that extend across the whole prison service offer opportunities to avoid duplicated tests and reconstructed medical histories.

    A study in Telemedicine and e-Health shows how telemedicine helps to treat prisoners with diabetes. The team from SUNY Upstate Medical University in Syracuse included telemedicine visits at 15 prisons in New York State. There were 106 male diabetic prisoners and one endocrinologist. A primary care physician was treating each prisoner. Patients with the highest levels showed the greatest results, with a drop of 1.3%. There were gains in blood pressure and lipid controls too.

    A conclusion is that telemedicine can resolve transport and security requirements for doctor visits and access to specialists, and improve prisoners’ health. It can avoid costs for both the prison services and health systems, so should find a place in African countries eHealth strategies.

  • Are critical success factors telemedicine's big challenge

    All change has Critical Success Factors (CSF). Momentum Thematic Network, a European Commission project aiming to mainstream telemedicine, has identified 18 generic CSFs for telemedicine. They’re derived from an analysis of recent telemedicine practices, and are:

    Check that there is cultural readiness towards telemedicine Ensure leadership through a champion Identify a compelling need Put together the resources needed for deployment and sustainability Address the needs of the primary client(s) Involve healthcare professionals and decision makers Prepare and implement a business plan Prepare and implement a change management plan Put the patient at the centre of the service Establish that the service is legal Ask advice from legal, ethical, privacy and security experts Apply relevant legal and security guidelines Ensure that telemedicine doers and users have "privacy awareness" Ensure that the ICT and eHealth infrastructures needed are in place Ensure that the technology is user-friendly Monitor the service Maintain good practices in vendor relations Guarantee that the technology has the potential for scale-­up, so think big.

    These are valuable for Africa’s health systems to adopt, but they’re not enough. Acfee’s approach adds a few extra CSFs, which apply to all types of eHealth. They are:

    In addition to CSF2, not all champions are eHealth leaders, so political, clinical and executive eHealth leaders are needed In addition to CSF7, rigorous business cases and business models are needed, especially as telemedicine sustainable reimbursement and financing often lags behind telemedicine implementation In addition to CSF8, effective project management and healthcare transformation are needed in addition to the plan In addition to CSF10, regulation’s important In addition to monitoring in CSF16, evaluation’s important to ensure Monitoring and Evaluation (M&E) New technologies offer new telemedicine opportunities, so need a planning to avoid the excessive effects of obsolescence Effective project management and healthcare transformation are needed Cyber-security’s essential Risks need evaluating and mitigating.

    Momentum has other documents that support telemedicine and can help Africa’s health systems. They include:

    Validated blueprint Case studies of successful telemedicine implementations in Europe Test methodology Strategy and management Organisational implementation and change management Legal, regulatory and security issues Technical infrastructure and market relations.

    For African countries, sustainability is a common challenge. Like all types of eHealth, each telemedicine project needs its own model.

  • eHealth's vital for better elderly care

    Populations are aging. Africa’s may be at a slower rate than the rest of the world, but it has an opportunity to use eHealth to transform its healthcare for its elderly patients.

    An article in The Economist says reliance on hospital care can be reduced by equipping people’s homes and rehabilitation services with monitoring equipment. It suggests that health systems have been slow in these types of transformation. This hints at an opportunity for Africa’s health systems to jump ahead and manage demand in a way that sustains the limited hospital resources for very ill patients.

    In the UK’s NHS, a project at Airedale Hospital that’s placed telemedicine services in nursing and care homes has reduced hospital admissions by more than a third. Nurses used it to triage patients. It’s a model for Africa’s eHealth strategies.

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    Image from www.prometheonpharma.com

  • Brazil's doctors use telehealth to treat Zika

    WHO describes Zika as an “emerging mosquito-borne virus” first identified in Uganda in 1947. It now seems to be taking hold with serious implications. NPR has a post about an initiative in Brazil to combat it using an existing telehealth service.

    It was originally designed as a telehealth programme for paediatric cardiology. Now, specialist doctors in Brazil’s state of Paraiba on the North-East coast are using it to help infants with possible Zika-related birth problems, such as microcephally, a congenital condition of an abnormally small head associated with incomplete brain development.

    One of Brazil’s big challenges in dealing with Zika is logistics. Dispersed communities, weak infrastructure and unequal healthcare access combine to make it difficult for parents to seek the help they need.

    Dr Sandra Mattos, a paediatric cardiologist, designed the telehealth service, and uses it to assess her patients through her laptop. It’s part of her Heart Network of 22 regional hospitals with over 100 doctors involved. Her telehealth initiative can deal with congenital heart defects and brain defects too.

    She can access hospital rooms across Paraiba and see the status of patients and decide if actions needed. It extends into communities too. Three echo taxis deliver specialised equipment to facilities in three remote rural communities and provide links to specialists in regional hospitals.

    Local health workers are trained to operate the equipment, and specialist doctors are on hand to review the data. It supports decisions about which babies need to be seen in person and which ones don't. Two benefits are better access for patients and avoiding over-full clinics in the regional hospitals. 

    Can Africa’s health systems use their existing telehealth services in the same way to fight Zika? If they can’t, Paraiba demonstrates the opportunities to develop and use new telehealth programmes.