Laurent Bonnardot

In what circumstances is telemedicine appropriate in the developing world

Objectives To review papers reporting actual experience with telemedicine in developing countries and to summarize their findings, including the strength of the evidence. Design A retrospective review was conducted. Study quality was assessed. Setting Four commonly-used electronic databases. Main outcome measures Study quality scores. Results From a total of 202 potential articles, 38 relevant papers were identified. Thirty-four articles (89%) reported clinical experience and 14 articles (37%) reported the use of telemedicine for educational purposes. The quality of the reports was rather weak (median quality-score 3, on a scale 0–9); only one study, rated at 7, fell into the high quality score band. The fact that almost all studies reported positively in favour of telemedicine suggests a publication bias. Of the 38 articles, 15 (39%) reported the use of real-time telemedicine and 25 (66%) reported the use of asynchronous, or store-and-forward, telemedicine. Email was the most commonly reported modality (half of all studies). Conclusion Some of the longer established telemedicine operations have developed into substantial networks. The review suggests that great potential exists for telemedicine in the developing world. However, some caution is required in future telemedicine work if telemedicine exemplars are to be produced which can be widely copied.

The Development of a Multilingual Tool for Facilitating the Primary-Specialty Care Interface in Low Resource Settings: the MSF Tele-Expertise System

In 2009, Médecins Sans Frontières (MSF) started a pilot trial of store-and-forward telemedicine to support field workers. One network was operated in French and one in English; a third, Spanish network was brought into operation in 2012. The three telemedicine pilots were then combined to form a single multilingual tele-expertise system, tailored to support MSF field staff. We conducted a retrospective analysis of all telemedicine cases referred from April 2010 to March 2014. We also carried out a survey of all users in December 2013. A total of 1039 referrals were received from 41 countries, of which 89% were in English, 10% in French, and 1% in Spanish. The cases covered a very wide range of medical and surgical specialties. The median delay in providing the first specialist response to the referrer was 5.3 h (interquartile range 1.8, 16.4). The survey was sent to 294 referrers and 254 specialists. Of these, 224 were considered as active users (41%). Out of the 548 users, 163 (30%) answered the survey. The majority of referrers (79%) reported that the advice received via the system improved their management of the patient. The main concerns raised by referrers and specialists were the lack of support or promotion of system at headquarters’ level and the lack of feedback about patient follow-up. Because of the size of the MSF organization, it is clear that there is potential for further organizational adoption.

Nucleating the development of telemedicine to support healthcare workers in resource-limited settings: a new approach

Collegium Telemedicus (CT) offers a new approach to the problem of starting a store-and-forward telemedicine network for use in low resource settings. The CT organization provides a no-cost template to allow groups to start a network without delay, together with a peer-support environment for those operating the networks. A new group needs only to supply a Guarantor (who accepts responsibility for the work of the network) and a Coordinator (who operates the telemedicine network, allocating cases and ensuring that they are responded to). Communication takes place via secure messaging, which has several advantages over plain email, e.g. all the data are stored centrally, which means that they can be read from a hand-held device such as a smart phone, but do not need to be stored on that device. Users can access the system with a standard web browser. In the first three months, seven networks were established on the CT system by university groups in the US, the UK, Australia and New Zealand, and by a large, multinational humanitarian organisation. In the most active network, there were 86 telemedicine cases in the first three months, i.e. an average submission rate of 7 cases/week. The CT system appears to fulfil its aim of assisting doctors who wish to help colleagues in other countries by improving their access to specialist opinions, while allowing them to maintain control over the new networks use and development. The long term aim of the CT organization is to provide a means of improving the quality of health care at the point of delivery in low resource settings.

Store-and-forward telemedicine for doctors working in remote areas

For doctors working in remote areas, access to medical specialists is crucial in order to provide patients with the best possible health care. Telemedicine is now widely used to obtain second opinions from consultants and is a mainstay of the organization of health care in Antarctica. Taking advantage of our extreme geographical isolation on a polar station, we tested the possibilities for obtaining specialist advice by telemedicine based on email. Two virtual case reports with one question each were sent to six correspondents: two non-governmental organizations (NGOs), two personal acquaintances and two institutions. Initial email replies were received between 13 hours and 7 days later. There were three kinds of reply: well argued and well adapted to our situation (one NGO); argued but not well adapted to our situation (one NGO, one acquaintance and one institution); and a short reply without argument (one acquaintance). Contacting personal acquaintances was not as reliable as we had expected. The best support was provided by one of the NGOs whose efficiency was based on the use of an automatic message-handling system and a team of specialists well trained in giving advice to isolated doctors. This NGO demonstrated how a store-and-forward telemedicine system can be efficient and reliable; the study also highlighted some limitations in other methods of obtaining specialist advice.

Assessing the quality of teleconsultations in a store-and-forward telemedicine network

Store-and-forward telemedicine in resource-limited settings is becoming a relatively mature activity. However, there are few published reports about quality measurement in telemedicine, except in image-based specialties, and they mainly relate to high- and middle-income countries. In 2010, Médecins Sans Frontières (MSF) began to use a store-and-forward telemedicine network to assist its field staff in obtaining specialist advice. To date, more than 1000 cases have been managed with the support of telemedicine, from a total of 40 different countries. We propose a method for assessing the overall quality of the teleconsultations provided in a store-and-forward telemedicine network. The assessment is performed at regular intervals by a panel of observers, who – independently – respond to a questionnaire relating to a randomly chosen past case. The answers to the questionnaire allow two different dimensions of quality to be assessed: the quality of the process itself and the outcome, defined as the value of the response to three of the four parties concerned, i.e., the patient, the referring doctor, and the organization. It is not practicable to estimate the value to society by this technique. The feasibility of the method was demonstrated by using it in the MSF telemedicine network, where process quality scores, and user-value scores, appeared to be stable over a 9-month trial period. This was confirmed by plotting the cusum of a portmanteau statistic (the sum of the four scores) over the study period. The proposed quality-assessment method appears feasible in practice, and will form one element of a quality assurance program for MSF’s telemedicine network in future. The method is a generally applicable one, which can be used in many forms of medical interaction.

Teledermatology in low-resource settings: the MSF experience with a multilingual tele-expertise platform

Introduction: In 2010, Médecins Sans Frontières (MSF) launched a tele-expertise system to improve the access to specialized clinical support for its field health workers. Among medical specialties, dermatology is the second most commonly requested type of tele-expertise. The aim of the present study was to review all MSF teledermatology cases in the first 4 years of operation. Our hypothesis was that the review would enable the identification of key areas for improvement in the current MSF teledermatology system. Methods: We carried out a retrospective analysis of all dermatology cases referred by MSF field doctors through the MSF platform from April 2010 until February 2014. We conducted a quantitative and qualitative analysis based on a survey sent to all referrers and specialists involved in these cases. Results: A total of 65 clinical cases were recorded by the system and 26 experts were involved in case management. The median delay in providing the first specialist response was 10.2 h (IQR 3.7–21.1). The median delay in allocating a new case was 0.96 h (IQR 0.26–3.05). The three main countries of case origin were South Sudan (29%), Ethiopia (12%), and Democratic Republic of Congo (10%). The most common topics treated were infectious diseases (46%), inflammatory diseases (25%), and genetic diseases (14%). One-third of users completed the survey. The two main issues raised by specialists and/or referrers were the lack of feedback about patient follow-up and the insufficient quality of clinical details and information supplied by referrers. Discussion: The system clearly delivered a useful service to referrers because the workload rose steadily during the 4-year study period. Nonetheless, user surveys and retrospective analysis suggest that the MSF teledermatology system can be improved by providing guidance on best practice, using pre-filled referral forms, following-up the cases after teleconsultation, and establishing standards for clinical photography.

Teleradiology Usage and User Satisfaction with the Telemedicine System Operated by Médecins Sans Frontières

Médecins Sans Frontières (MSF) began a pilot trial of store-and-forward telemedicine in 2010, initially operating separate networks in English, French, and Spanish; these were merged into a single, multilingual platform in 2013. We reviewed the pattern of teleradiology usage on the MSF telemedicine platform in the 4-year period from April 2010. In total, 564 teleradiology cases were submitted from 22 different countries. A total of 1114 files were uploaded with the 564 cases, the majority being of type JPEG (n = 1081, 97%). The median file size was 938 kb (interquartile range, IQR 163–1659). A panel of 14 radiologists was available to report cases, but most (90%) were reported by only 4 radiologists. The median radiologist response time was 6.1 h (IQR 3.0–20). A user satisfaction survey was sent to 29 users in the last 6 months of the study. There was a 28% response rate. Most respondents found the radiologist’s advice helpful and all of them stated that the advice assisted in clarification of a diagnosis. Although some MSF sites made substantial use of the system for teleradiology, there is considerable potential for expansion. More promotion of telemedicine may be needed at different levels of the organization to increase engagement of staff.

Telemedicine in Low-Resource Settings

Telemedicine is a fuzzy term with several synonyms (telehealth, e-health, etc), which cover a wide range of topics, all concerning the delivery of health care at a distance. “Health care” itself is a broad concept, encompassing diagnosis and treatment of patients, education of staff, patients, and the general public, and administrative activities, such as collecting public health data, as well as research. All of these may be assisted by judicious use of telemedicine. The main advantage of telemedicine is that it can improve access to health care, often by increasing the speed with which a specialist opinion can be obtained (e.g., tele-stroke) or by reducing the need to travel (e.g., teledermatology); in certain disciplines, evidence has also been obtained that telemedicine is cost-effective (1). Much of the experience with telemedicine in the last 20 years has concerned its application in high-income countries. In contrast, there has been relatively little use of telemedicine in low-income countries, which is surprising in view of the difficulties of accessing health care there. In those countries where telemedicine has been trialed, it seems to have worked well and a small number of programs have provided services for periods of 10 years or more (2). These long-running telemedicine programs have mainly used store-and-forward methods, although there has been some limited use of real-time video. The present Research Topic focuses on Telemedicine in Low-Resource Settings, environments where it is always a challenge to provide patients with the best level of health care. The term “low-resource settings” covers most low-income countries, and also includes regions in middle- or high-income countries where under-served populations have difficulties in accessing specialists. The Research Topic documents real, practical experience with the use of telemedicine in low-resource settings and identifies research problems of current interest. This collection of articles shows the rich diversity of applications for telemedicine. Examples come from all over the world and from a range of clinical settings and medical specialties. Mobile phones have great potential in the delivery of health care in low-resource settings. Patterson (3) developed a mobile-phone app to enable non-doctors to diagnose episodes as epileptic. In a pilot trial with health workers in Nepal who used the app in small numbers of patients, there were no false diagnoses. This represents a potential method of empowering health workers to help the millions of people in the resource-poor world with untreated epilepsy. Ndlovu et al. (4) conducted trials with mobile-phone telemedicine in Botswana, in four medical specialties: radiology, oral medicine, dermatology, and cervical cancer screening. The benefits reported by pilot project users were sufficient to convince the government to scale up the program, which is now in progress. Both senior management support and local “ownership” of the program are thought to be important for future success. Piette et al. (5) also reported on the importance of collaborating with the local ministry of health when scaling up a mobile telemedicine application in Bolivia. All these experiences reinforce the need to develop telemedicine by scaling it up from pilot projects, to do so in collaboration with local healthcare workers (rather than trying to impose telemedicine from above) and to enlist the support of the appropriate ministry of health. One of the longer-running examples of telemedicine used in low-resource settings is the RAFT network, which provides both educational and clinical services to centers in Africa and South America (6). The educational activities include the weekly delivery of video-lectures for continuing and postgraduate medical education. Much of this early video delivery depended on the use of satellite links, which are relatively expensive, and in recent years the RAFT program has begun to make use of low-bandwidth Internet connections. In South Africa, a tele-education network evolved from a failed government telemedicine program (7). Over 1000 h of videoconferenced lectures are delivered each year in KwaZulu-Natal, using ISDN transmission. Finally, the EHAS group has provided video-based telemedicine services in South America (8). In order to secure sufficient bandwidth for the delivery of video, they have developed long-range WiFi transmission. An alternative method of transmitting video for telemedicine is to make use of free or low-cost web-based tools. For example, Jefee-Bahloul (9) conducted a pilot trial of telepsychiatry in Jordan using Skype, while Adambounou et al. (10) used the file transfer facilities of the LogMeIn web service for tele-ultrasound between Togo and France. It is clear from these reports that video telemedicine is possible in low-resource environments, but it is also the case that non-real-time (store-and-forward) telemedicine is more common in these settings, not only because it is usually cheaper but also because the non-synchronous nature of the interaction between the parties makes it easier to organize. The longest-running such network is probably operated by the US military in the Pacific, which has used email and web-based communication in the Pacific Island Health Care Project since the late 1990s. As Person reports (11), teleconsultation has enabled local treatment in the Pacific islands, without necessarily requiring transfer to the major medical center on Hawaii; many of the cases were pediatric. Andronikou (12) reviewed his experience of pediatric teleradiology with three different store-and-forward programs. He concluded that teleradiology offers the potential to alleviate radiologist shortages in under-served areas, but that there are many challenges to designing an adequate process. Medecins Sans Frontieres (MSF), an organization that works mainly in low-resource settings, developed its own telemedicine tool based on the Collegium Telemedicus model (13). The aim was a system that would improve the primary-specialty care interface and allow their field doctors to obtain an expert opinion within a few hours, wherever they were located in the world. Based on a retrospective analysis and user survey, Bonnardot et al. (14) provide a general overview of the system and the user perceptions of it. The three main specialties used in the network are radiology, pediatrics, and dermatology, which were reviewed by Halton et al. (15), Delaigue et al. (16), and Martinez Garcia et al. (17), respectively. The MSF experience, and that of others reported here, suggests that store-and-forward networks are clinically useful, sustainable, and potentially cost-effective. It is also clear that there is still lingering skepticism from some healthcare staff about the adoption of telemedicine into routine practice. Apparently, telemedicine is sometimes viewed as a threat or a competitor to conventional ways of working. Yet, telemedicine is simply another tool for assisting in the delivery of health care, and in low-resource settings there is often no other way to access the required resources. As telemedicine matures to become a routine service in low-resource settings, it will become increasingly important to evaluate the quality of service being delivered and to demonstrate that this is being maintained. There is almost no published work about quality assurance in this context, and the present Topic contains three papers, which explore different aspects of this new area (18–20). While providing initial demonstrations of feasibility, each raises a number of questions for future research. In summary, this e-book provides vignettes illustrating (largely successful) telemedicine projects of widely different kinds in various low-resource settings. It is worth noting that solutions that are found to overcome the huge constraints imposed by low-resource settings may also be useful in middle- or high-income countries. The common themes are that success depends on expanding from small pilot projects using a “bottom-up” approach with engagement of local health workers, yet also requires senior management and government support. The research agenda for the future requires us to document the cost-effectiveness of these programs, and as telemedicine matures, to demonstrate that quality improvement activities can be incorporated in the same way as is done in many other areas of health care. We can expect that in the future, the use of telemedicine – practising health care at a distance – will become a norm. Indeed, we expect that it will become so common as to be unremarkable, that the prefix tele- will disappear, and that all telemedicine work will be considered as part of usual practice.

Assessing the Quality of Teleconsultations in a Store-And-Forward Telemedicine Network - Long-Term Monitoring Taking into Account Differences between Cases.

We have previously proposed a method for assessing the quality of individual teleconsultation cases; this paper proposes an additional step to allow the long-term monitoring of quality. The basic scenario is a teleconsultation system (aka an e-referral system or a tele-expertise system) where the referrer posts a question about a clinical case, the question is relayed to an appropriate expert, and the chosen expert provides an answer. The people running this system want assurances that it is stable, i.e., they want routine quality assurance information about the “output” from the “process.” This requires two things. It needs a method of assessing the quality of individual patient consultations. And it needs a method for taking into account differences between patients, so that these quality assessments can be compared longitudinally. Building on the previously proposed methodology, the present paper proposes two techniques for measuring the difficulty posed by a particular teleconsultation. The first is an indirect method, similar to a willingness to pay economic estimation. The second is a direct method. Using these two methods with real data from a telemedicine network showed that the first method was feasible, but did not produce useful results in a pilot trial. The second method, while more laborious, was also feasible and did produce useful results. Thus, when output quality is measured, an allowance can be made for the characteristics of the case submitted. This means that fluctuations in output quality can be attributed to variations in the process (network) or to variations in the raw materials (queries submitted to the network). Long-term quality assurance should assist those providing telemedicine services in low-resource settings to ensure that the services are operated effectively and efficiently, despite the constraints and complexities of the environment.

Quality assurance of teleconsultations in a store-and-forward telemedicine network - obtaining patient follow-up data and user feedback

User surveys in telemedicine networks confirm that follow-up data are essential, both for the specialists who provide advice and for those running the system. We have examined the feasibility of a method for obtaining follow-up data automatically in a store-and-forward network. We distinguish between follow-up, which is information about the progress of a patient and is based on outcomes, and user feedback, which is more general information about the telemedicine system itself, including user satisfaction and the benefits resulting from the use of telemedicine. In the present study, we were able to obtain both kinds of information using a single questionnaire. During a 9-month pilot trial in the Médecins Sans Frontières telemedicine network, an email request for information was sent automatically by the telemedicine system to each referrer exactly 21 days after the initial submission of the case. A total of 201 requests for information were issued by the system and these elicited 41 responses from referrers (a response rate of 20%). The responses were largely positive. For example, 95% of referrers found the advice helpful, 90% said that it clarified their diagnosis, 94% said that it assisted with management of the patient, and 95% said that the telemedicine response was of educational benefit to them. Analysis of the characteristics of the referrers who did not respond, and their cases, did not suggest anything different about them in comparison with referrers who did respond. We were not able to identify obvious factors associated with a failure to respond. Obtaining data by automatic request is feasible. It provides useful information for specialists and for those running the network. Since obtaining follow-up data is essential to best practice, one proposal to improve the response rate is to simplify the automatic requests so that only patient follow-up information is asked for, and to restrict user feedback requests to the cases being assessed each month by the quality assurance panel.