Maurice Mars

Telehealth in audiology: The need and potential to reach underserved communities

Abstract Permanent hearing loss is a leading global health care burden, with 1 in 10 people affected to a mild or greater degree. A shortage of trained healthcare professionals and associated infrastructure and resource limitations mean that hearing health services are unavailable to the majority of the world population. Utilizing information and communication technology in hearing health care, or tele-audiology, combined with automation offer unique opportunities for improved clinical care, widespread access to services, and more cost-effective and sustainable hearing health care. Tele-audiology demonstrates significant potential in areas such as education and training of hearing health care professionals, paraprofessionals, parents, and adults with hearing disorders; screening for auditory disorders; diagnosis of hearing loss; and intervention services. Global connectivity is rapidly growing with increasingly widespread distribution into underserved communities where audiological services may be facilitated through telehealth models. Although many questions related to aspects such as quality control, licensure, jurisdictional responsibility, certification and reimbursement still need to be addressed; no alternative strategy can currently offer the same potential reach for impacting the global burden of hearing loss in the near and foreseeable future. Sumario La pérdida auditiva permanente es una importante carga para los cuidados de la salud a nivel mundial, con 1 de cada 10 personas afectadas en grado ligero o mayor. La escasez de profesionales entrenados en cuidados de la salud y de infraestructura asociada y la limitación de recursos determina que los servicios de salud auditiva no estén disponibles para la mayoría de la población mundial. La utilización de información y tecnología de la comunicación para los cuidados de la salud auditiva o teleaudiología, combinada con la automatización, ofrece oportunidades únicas para mejorar los cuidados clínicos, ampliar el acceso a los servicios y tener cuidados de salud auditiva costoefectivos y sustentables. La Teleaudiología ha demostrado un potencial significativo en áreas como las de educación y adiestramientio de profesionales de la salud auditiva, profesionales afines, padres y adultos con problemas auditivos; tamiz de problemas auditivos; diagnóstico de pérdidas auditivas y servicios de intervención. La conectividad global está creciendo rápidamente y ha aumentado de manera generalizada su distribución en comunidades con pocos servicios, en donde los servicios audiológicos pueden facilitarse a través de modelos de telesalud. No obstante, existen muchas dudas que deben resolverse y que están relacionadas con aspectos como control de calidad, regulación del ejercicio profesional, responsabilidad jurisdiccional, certificación y reembolso de servicios, pero no existe como alternativa ninguna otra estrategia que pueda ofrecer actualmente el mismo potencial, para impactar el peso global de las pérdidas auditivas en el futuro cercano o previsible.

Telemedicine and Advances in Urban and Rural Healthcare Delivery in Africa

Telecardiology holds great promise for Africa, from tele-echocardiography and tele-ECG s, to home monitoring and text messaging for medication adherence monitoring. The burden of disease is great and there is an extreme shortage of health professionals. Telemedicine can provide access to scarce specialist care, improve the quality of care in rural areas and reduce the need for rural patients to travel to seek medical attention. International cross border service can alleviate the shortage of doctors. But telecardiology, and telemedicine uptake in general, has been poor in Africa. Legal and ethical issues around local and cross border telemedicine have not been resolved. The literature was reviewed and obstacles to telemedicine in Africa and current telemedicine activities in Africa, are described. There are few sustained telemedicine services in Africa with the exception of tele-education. There is an expectation that mobile phones will facilitate a range of telemedicine activities in Africa. Africa needs telemedicine.

Global E-Health Policy: A Work In Progress

E-health (information and communication technology that facilitates health and health care) is expanding in developed, developing, and least-developed countries. E-healths ability to transcend sociopolitical boundaries holds the potential to create a borderless world for health systems and health care delivery. But the policy needed to guide e-health development is limited and just now emerging in developed countries. Whats needed to foster e-health growth in the developing world is thoughtful policy to facilitate patient mobility and data exchange, across both international borders and regional boundaries within countries.

Building the Capacity to Build Capacity in e-Health in Sub-Saharan Africa: The KwaZulu-Natal Experience

BACKGROUND Sub-Saharan Africa has a disproportionate burden of disease and an extreme shortage of health workers. There are already too few doctors to train doctors in specialities and sub-specialties. E-health is seen as a possible solution through distance education, telemedicine, and computerized health information systems but there are few people trained in e-health. We describe 12 years of experience at the University of KwaZulu-Natal (UKZ-N) in education and training in postgraduate medical disciplines, medical informatics, and telemedicine. MEDICAL EDUCATION Videoconferencing of seminars and grand rounds to regional training hospitals commenced in 2001 and has grown to 40 h of interactive conferencing taking place weekly during academic terms involving over 33,000 participants in 2010. Videoconferenced sessions are directly recorded to DVD and DVDs are sent to other medical schools in Africa that do not have the infrastructure to directly connect. E-HEALTH EDUCATION: Students and academic staff were initially sent to the United States for training in medical informatics and workshops were held in South Africa for people from sub-Saharan Africa. This led to the development of postgraduate academic programs in medical informatics and telemedicine at UKZ-N. African students were then brought to UKZ-N for training. The model was changed from UKZ-N to students and staff based at their home universities with the aim of building capacity in the staff at partner institutions so that they can in time offer their own e-health academic programs. CONCLUSIONS The need for capacity development in all aspects of e-health in sub-Saharan Africa is great and innovative solutions are required.

Hearing health-care delivery in sub-Saharan Africa – a role for tele-audiology

Hearing loss is the most prevalent chronic disability and a major contributor to the global burden of disease. Its effects are far-reaching and can lead to severely restricted developmental outcomes for children and limited vocational prospects for adults. The benefits of intervention are dramatic and can significantly improve developmental outcomes, especially in infants identified early. Hearing health-care services in developing regions such as sub-Saharan Africa are however severely limited, leaving affected individuals without access to secondary and tertiary intervention. Tele-audiology has potential for improved access to specialist hearing health services including identification, diagnosis and intervention. There has been limited experience so far with tele-audiology in industrialized countries. In the sub-Saharan region, the continued growth in Internet connectivity and general technological advances make tele-audiology an important approach to consider in the management of hearing loss. Pilot studies are warranted to investigate the potential obstacles to the widespread implementation of telehealth in the delivery of hearing health care in poorly-resourced communities, in line with World Health Organization initiatives.

Principles and Framework for eHealth Strategy Development

Significant investment in eHealth solutions is being made in nearly every country of the world. How do we know that these investments and the foregone opportunity costs are the correct ones? Absent, poor, or vague eHealth strategy is a significant barrier to effective investment in, and implementation of, sustainable eHealth solutions and establishment of an eHealth favorable policy environment. Strategy is the driving force, the first essential ingredient, that can place countries in charge of their own eHealth destiny and inform them of the policy necessary to achieve it. In the last 2 years, there has been renewed interest in eHealth strategy from the World Health Organization (WHO), International Telecommunications Union (ITU), Pan American Health Organization (PAHO), the African Union, and the Commonwealth; yet overall, the literature lacks clear guidance to inform countries why and how to develop their own complementary but locally specific eHealth strategy. To address this gap, this paper further develops an eHealth Strategy Development Framework, basing it upon a conceptual framework and relevant theories of strategy and complex system analysis available from the literature. We present here the rationale, theories, and final eHealth strategy development framework by which a systematic and methodical approach can be applied by institutions, subnational regions, and countries to create holistic, needs- and evidence-based, and defensible eHealth strategy and to ensure wise investment in eHealth.

Retrospective return on investment analysis of an electronic treatment adherence device piloted in the Northern Cape Province.

OBJECTIVE The return on investment (ROI) for utilizing the SIMpill electronic treatment adherence solution as an adjunct to directly observed treatment short-course (DOTS) is assessed using data from a 2005 pilot of the SIMpill solution among new smear-positive tuberculosis (TB) patients in the Northern Cape Province. The value of this cost minimization analysis (CMA), for use by public health planners in low-resource settings as a precursor to more rigorous assessment, is discussed. MATERIALS AND METHODS The retrospective analysis compares the costs and health outcomes of the DOTS-SIMpill cohort with DOTS-only controls. Hypothetical 5-year cash flows are generated and discounted to estimate net present values (NPVs). RESULTS Comparison between the DOTS-SIMpill pilot cohort and DOTS-only supported controls, for a hypothetical implementation of 1,000 devices, over 5 years, demonstrates positive ROI for the DOTS-SIMpill cohort based on improved health outcomes and reduced average cost per patient. The net stream is shown to be positive from the first year. Discounted NPV is ZAR 3,255,256 (US

Forensic telepsychiatry: a possible solution for South Africa?

493,221) for a cohort that would have started mid 2005 and ZAR 3,747,636 (US

Effectiveness and feasibility of telepsychiatry in resource constrained environments? A systematic review of the evidence

487,339) starting mid 2010. This is an ROI of 23% over the 5-year period. CONCLUSION The addition of electronic treatment adherence support technology can help to improve TB outcomes and lower average cost per patient by reducing treatment failure and the associated higher cost and burden on limited resources. CMA is an appropriate initial analysis for health planners to highlight options that may justify more sophisticated methods such as cost effectiveness analysis or full cost benefit analysis where a preferred option is immediately revealed. CMA is proposed as a tool for use by public health planners in low-resource settings to evaluate the ROI of treatment adherence technology postpilot and prior to implementation.

Telehealth in the developing world: current status and future prospects

OBJECTIVE South Africa has a shortage of facilities and psychiatrists to assess adjudicative competence of prisoners awaiting assessment under sections 77 to 79 of the Criminal Procedures Act of 1977. Various solutions have been proposed by the Department of Health. The recent linking of a Magistrates court and a prison by videoconferencing offers the opportunity to implement a forensic telepsychiatry service. The literature on forensic telepsychiatry for assessment of adjudicative competence was reviewed. METHOD The electronic databases, PubMed, Scopus, Cinahl and Google Scholar were searched for papers on forensic telepsychiatry. The inclusion criterion was papers reporting the use of videoconferencing for assessment of adjudicative competence or for assessment for referral out of the judicial system, by psychiatrists or psychologists. RESULTS 411 papers were found of which 13, published between 1997 and 2008 were relevant. The use of videoconferencing for forensic psychiatric assessment was reported from four countries. The courts in those jurisdictions have accepted the use of videoconferencing for assessment and no successful appeals have been mounted on the basis of the use of videoconferencing for assessment. User satisfaction has not been reported for assessing adjudicative competence. Forensic telepsychiatry has been found to be cost effective, improve access to scarce specialist skills and reduce transport of prisoners under guard to hospitals or psychiatrists to prisons. CONCLUSION There is nothing in the literature to suggest that a forensic telepsychiatry service is not feasible in South Africa and a pilot project is being planned.