• Telemedicine
  • 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.

  • Does Africa need telemedicine regulations?

    Clarity on the place of telemedicine isn’t always clear. Some doctors are content to use it without specific regulations, others want clarity on how it fits with the traditional patient and doctor relationships and encounters.

    The USA’s District of Columbia has started formal consultation on telemedicine regulations. There are 14. They may help Africa’s telemedicine to move into a regulated environment. A generalised summary’s:

    To use telemedicine, a license to practice medicine’s required, but with some exceptions in existing laws and regulations, and a requirement to comply with regulations in the jurisdictions where the telemedicine provider’s and patients are physically located Doctors’ medical decisions using telemedicine must adhere to the same standards of care as decision in face to face encounters with patients Patient evaluations are needed that meet the requirements in existing standards before providing recommendations or making treatment decisions for patients except when performing interpretive services Doctors must ensure that interpretive services do not result in clinically significant loss of data from image acquisition through transmission to final image display Doctors practicing telemedicine shall: Obtain and document patient consent, except for interpretive services Create and maintain adequate medical records Follow requirements of existing laws and regulations for confidentiality of medical records and disclosure of medical records Adhere to other existing relevant laws, requirements and prohibitions Doctors shall perform patient evaluations to establish diagnoses and identify underlying conditions or contraindications to recommended treatment options before providing treatment or prescribing medication Licensed doctors may rely on patient evaluations performed by another licensed doctor if the former is providing cover for the latter If doctor-patient relationships don’t include prior in-person, face-to-face interactions with patients, doctors shall use real-time auditory communications or real-time visual and auditory communications to allow a free exchange of protected health information between patients and the doctors performing the patient evaluation Licensed telemedicine practitioners shall have the current, minimal technological capabilities to meet all standard of care requirements in order to use telemedicine to deliver services or treatment Adequate security measures shall be implemented to ensure that all patient communications, recordings and records remain confidential Written policies and procedures shall be maintained when using email for doctor-patient communications, and these shall be evaluated periodically to make sure they are up to date in addressing: Privacy, to assure confidentiality and integrity of patient-identifiable information Responsibilities of all health care personnel, including doctors, who process messages Hours of operation and availability Types of transactions permitted electronically Required patient information to be included in communications, such as patients’ names, identification numbers and types of transactions Archival and retrieval of patient records Quality oversight mechanisms All relevant patient-doctor emails and other patient-related electronic communications shall be stored and filed in patients’ medical records Patients shall be informed of alternate forms of communications between them and doctors for urgent matters All licensees shall be subject to the requirements of health and healthcare laws and regulations.

    It’s a start for Africa’s telemedicine regulations where health systems haven’t started down this road. Like the District of Columbia recognises, consultation with the medical profession’s the vital first step. Other stakeholders can make contributions too. Having agreed telemedicine regulations, a follow-up’s to ensure effective implantation and compliance.

  • Telemedicine's effective with some children's conditions

    Evidence for telemedicine’s effectiveness has been growing, and steadily assembling over the last 20 years or so. An example’s NHS England and its Telemedicine Evidence. More’s still needed to guide Africa’s health system’s business cases. 

    A study in Paediatrics says that data’s limited about the clinical reliability of telemedicine in evaluating seriously ill children. It’s challenging because telemedicine’s mainly visual, precluding hands-on, physical examinations. 

    Studies have already evaluated observation in assessing febrile children and children in respiratory distress. They’ve validated observations that detect underlying illness as predictive and reliable. The latest study seeks to determine the inter-observer reliability of telemedicine observations, compared with bedside observations. 

    Two types of groups were established. One comprised 132 children aged 2months to 3 years old, presenting with fevers. They were evaluated using the Yale Observation Scale. There were 145 patients aged 2 months to 18 years in the group presenting with respiratory symptoms, and evaluated by using the Respiratory Observation Checklist of signs of respiratory distress derived from validated studies. Telemedicine services for these two groups used commercially available tablet devices providing two-way, live-streamed images with audio. 

    For both groups, the comparison with their control groups showed consistencies. The Yale Scale groups had a good, positive correlation of +0.81 between bedside and telemedicine observers. The study team say this’s a strong agreement. The correlation for the Respiratory Checklist groups was seen as excellent at +0.85 for the impression of respiratory distress, and good, at +0.6, for most of the other Checklist measures.

    The study concludes that telemedicine, using commercially available telecommunications equipment, is reliable for assessing febrile children and children with respiratory distress. These findings offer a sound baseline for Africa’s health systems to pursue increased and sustainable investment in this role for telemedicine.

  • Ten telehealth questions you should ask

    Digital health is on the rise as eHealth, mHealth and telehealth services are being implemented across the globe. Telehealth is being adopted by major health systems, health plans and employers to deliver more immediate access to care and reduce costs to organisations and the people and patients they serve. This widespread adoption is being driven largely by consumers who want telehealth services and more personalised care. A survey by American Well, a telemedicine provider, found that 65% of consumers want to use telehealth and 7% would consider leaving their primary care physician for one that offered telehealth, says an article in Healthcare IT News.

    The lure of telehealth for hospitals and providers isn’t solely about the risk of losing patients. It’s also about gaining market share. For hospitals and providers, telehealth enables more frequent connections with existing patients and the capacity to reach new patients in new markets. It also offers a tool to improve healthcare and coordination. 

    When new technology changes the healthcare model, there are questions and fears. Dr Peter Antall, American Well’s Chief Medical Officer Medical Director of the national medical network Online Care Group, compiled the top ten questions providers ask when they’re considering telehealth. These are:

    How does it work? Is it legal? How can I get paid for using telehealth? Which use cases or conditions should I treat with telehealth? How do I examine a patient? How do I go about building a programme? What is the liability? What kind of results can I expect to see? What’s the best medium for practicing telehealth? Why should I do telehealth?

    These are important questions for anyone considering telehealth services. African countries are no exception. Answers to these critical questions will ensure they have the insights needed to make informed decisions about telehealth services and make sure they’re right for them. Other important financing questions will help with budgeting and planning for affordability and sustainability.

  • Telemedicine benefits prisoners and prisons

    Africa’s eHealth initiatives have to deal specifically with its wide range of geographic, demographic and health communities. Prisoners are one of these, and often aren’t mentioned in eHealth strategies. Both prisoners and prisons can benefit from eHealth, especially telemedicine that can avoid costly, high-security visits to hospitals that can delay treatments and disrupt prison staffing levels. World Prison Brief and the Institute for Criminal Policy Research say there’s about a million people in Africa’s jails, so it’s a large community.

    The Pew Charitable Trusts’ been examining telemedicine’s potential. Its report includes a review of prisoners’ healthcare in Texas and the University of Texas Medical Branch (UTMB) that provides most of the prisoners healthcare. UTMB provides about 127,000 telemedicine consultations a year with inmates, many for primary care or mental health needs. All five state prisons in Wyoming also provide telemedicine services, with some 440 total telemedicine visits a year. Healthcare providers also use telemedicine to consult specialists at another hospital.

    The business case for telemedicine for prisoners is straightforward. It has direct cost and health benefits that can contribute to affordability. Despite this, Pew found the similar obstacles to adoption that prevail in general healthcare, such as a lack of high-speed broadband connections.

    Users have also highlighted the need for doctors to be on site for some hands-on diagnoses and treatments. This can help them to understand the unique world of prison life and culture that their patients occupy.

    While Africa has many other eHealth priorities, it’s important to include prisoners in their chosen initiatives. The lessons and benefits can help to use eHealth for other communities.

  • Tele-ICU delivers massive benefits in the US

    Not all eHealth’s good eHealth, it seems. In the USA, EHRs, telemedicine and mHealth initiatives are being scrutinised for not delivering their promised benefits. Instead of increasing efficiency, cutting costs and decreasing delays, many eHealth initiatives are doing the opposite, costing hospitals millions and frustrating doctors and nurses.

    But, a recent report in the American Journal of Critical Care says it isn’t all bad. It shows that telemedicine is improving the way care is provided in the Intensive Care Units (ICU). It’s also reported in an article in Healthcare IT News.

    The study shows most ICU nurses are noticing improved productivity and collaboration. More than 1,200 nurses responded to the online survey. About 79% agreed tele-ICU systems help nurses to improve patient care. Some 75% agreed it improves job performance.

    There are about 45 tele-ICUs that connect more 200 hospitals and 6,000 beds in the USA. It's estimated between 800 to 1,000 nurses practice in tele-ICUs and another 16,000 interface with these units. 

    Tele-ICU uses audio or visual technology, or a combination of both, to monitor critical care remotely in ICUs. It provides data on patients’ vital signs, physiological status and laboratory and diagnostic test results and helps healthcare professionals to make faster and better decisions

    Most ICU nurses found telemedicine beneficial: 

    63% said tele-ICU enables faster work performance 66% saw improvement in collaboration 64% found it improved job performance 60% said it improves communication 60% said it helps with nursing assessments.

    Respondents said the biggest benefits to tele-ICU is the ability to monitor vital sign trends, provide medical management, enhance patient safety and detect unstable physiological status in patients.

    Despite the massive benefits the report found, the impact of tele-ICUs is still limited. The biggest barriers are staff attitudes, audio and video problems and the belief that telemedicine interferes with care. The report says "These findings can be used to further inform the development of competencies for tele-intensive care nursing." Healthcare organisations can "match the tele-intensive care nursing practice guidelines of the American Association of Critical-Care Nurses and highlight concepts related to the association's standards for establishing and sustaining healthy work environments." 

    For Africa’s health systems, tele-ICU offers a new area of eHealth investment. The returns look promising.