• Telemedicine
  • 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:

    The efficacy of remote healthcare compared to in-person careHow doctors are reimbursed for telemedicine servicesEthical 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.

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    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.

  • Uganda’s got a new telemedicine service

    Makerere University College of Health Sciences and the Rotary Club of Kampala North are testing video conferencing equipment to improve healthcare services around the country. According to allAfrica, the video-conferencing equipment is a distance learning community platform for health centers, medical workers, patients, students and lecturers around the country to access and exchange information related to health care provision.

    Bob John the head of ICT at the College of health sciences explains the process. "We created local area networks and supplied computers at health centers where we installed digital libraries. Even without connections outside, health workers can learn by distance learning. A doctor can be seated here and he calls doctors from USA or Makerere University to discuss a case or a lecturer at Makerere university, can use the facility to supervise students in the field without going to the field," he said.

    He explained that students, nurses and doctors in rural areas who find themselves with difficult cases can consult with senior doctors from Mulago hospital or foreign collaborating institutions for alternative opinions. This allows doctors to deal with the case locally rather than transferring patients to Mulago as is the case currently.

    Mr. Jayesh Asher, from Rotary International, is confident that this is among the best projects they have ever implemented in an African country because the technology is able to deliver the latest information regarding healthcare provision to health workers in rural areas who need constant training to save lives. "This is a project whose impact stretches to rural areas where health workers need these latest techniques to save every mother who is giving birth and save the child," he said.

    The new services has been very well received in Tanzania. Hopefully it will be the same in Uganda.

  • 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.