Telemedicine, synonymous with electronic Health, is a health-care delivery concept that enables distant patients especially in rural areas to be examined by the physicians using telecommunications technologies. In low resource settings, the majority of population dwells in rural areas that represent the largest patient base of variety of health issues such as access to basic healthcare, doctors, and treatment and telemedicine using different technologies is proving extremely viable and feasible solution reaching out to rural population and bridging disparity in quality and access to healthcare between urban and rural regions because of convergence of Information Technology Communication (ICT) and Healthcare.
This scientific survey paper sought to review and describe the telemedicine technologies aiding the practice of telemedicine in low resource. Evidence extracted from the reviewed studies were analysed through a narrative synthesis which suggests a multi-sectoral approach for the use of technologies in implementing and practising telemedicine. A review of the technological infrastructure development supporting the use of different technologies is made.
In low resource settings, technologies commonly used support both synchronous (Real-Time) and asynchronous (Store-and- Forward) telemedicine systems, though technologies for store-and-forward (asynchronous) telemedicine ” which does not require sophisticated videoconferencing technologies ” being clinically useful, sustainable and potentially cost-effective are adopted. Mobile phones, internet, e-mails are technologies commonly in use, while videoconferencing technologies are also coming up. Technological infrastructure – are still a challenge in most low resource settings as the existing infrastructures are either obsolete or do not exit and the transmission capacity is inadequate for telemedicine.
Key Words: Telemedicine, Telemedicine Technologies, ICT, synchronous, asynchronous, Teleconferencing, Internet, e-Health, Healthcare, Low resource setting, Technological Infrastructure.
In low resource settings, the rural population struggles to avail the amenities of modern healthcare. The use of technologies – Information Communication Technologies (ICT) – has made a tremendous impact on rural population in terms of enabling access to healthcare via telemedicine which various initiatives have been undertaken to connect rural population with healthcare facilities. Technology (both soft- and hardware) has simplified telemedicine by which patients can be examined, investigated, monitored, and treated, with the patient and the doctor located at different places. Telemedicine services being used in radiology, cardiology, ophthalmology, pathology, teleeducation, disease surveillance, second opinion, telementored procedure, homecare, disaster and disease management, remote consultation, second opinion and electronic medical record keeping all require use of technologies.
The different technologies can be applied in four different domains of telemedicine:
The main aspects on the infrastructure side cover the pure ICT technological infrastructure (such as teleconferencing, mobile smart phones, internet, emails, satellite broadband, mobile cloud system, all with their accessories – ) as well as any other generic infrastructure such as power supply, water supply. However, the use of technology in provision of telemedicine and eHealth from urban centres or from other countries is hampered by the lack of communications infrastructure, with no landline phone or broadband internet connection, little or no mobile connectivity, and often not even a reliable electricity supply.
To examine the different technologies that can be used to aid the practice of Telemedicine in a low resource setting. To examine the different technological infrastructure to support the use of telemedicine technologies in a low resource setting.
The mobile smart phones have great potential in the delivery of health care in low-resource settings. Patterson (Patterson V, 2014) 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. In Uganda, a computer Science student developed an app that can be used as a rapid diagnostic tool for malaria. Ndlovu et al. 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.
It allows open access to a global-communication environment. Within this open global network, a heterogeneous set of activities and technologies is bringing about a new environment for a wide spectrum of personal and professional interactions. It is estimated that, of the 70 million web users seeking health and health care information, many were looking for information on specific diseases, including, in decreasing order of magnitude, depression, allergies or sinus conditions, cancer, bipolar disorders, arthritis or rheumatism, high blood pressure, migraine, anxiety disorders, heart disease, and sleep disorders (American Telemedicine Association, 1999). The spectrum of Internet services in health care ranges from posted information about health issues and treatment modalities to the provision of professional services, including diagnosis, treatment, and drug prescriptions..Major categories of web health services are the following:
A recent study documented alarming levels of misinformation and inaccuracy on health web sites, making it not an absolute site to trust for correct health information.
Advances in computer science have created very large data repositories, substantially enhanced visualization, and the integration of multiple media operating from a single platform. Extensive image, audio, and text information can be stored and retrieved at the points of origin and care, in addition to computer-aided remote clinical manipulation.
Its use in telemedicine has been reported to be an efficient method of delivering online health services to patients at a distance and is often described as a low-cost form of telemedicine especially in asynchronous (Store “and- Forward) telemedicine. The functionalities of webmail application are: all incoming emails are automatically scanned and flagged if they contained pre-defined keywords, email cases can be triaged and assigned to a particular clinician, auditing tools ensure cases are answered in a timely fashion, full patient history can be viewed online, complex cases can be flagged by the clinician, ensuring a supervisor endorses the response, before it is sent to the client. (Liam Caffery et al, 2008). In radiology, for example, images taken can be emailed to a radiologist who interprets them and emails the report back.Television and radio systems: These are used to broadcast health messages in many low resource settings such as Uganda (Stephen R. Isabalija et al, 2011)
This involves real-time, live interactive high-definition video and audio communication between the specialist at a distance and the health care provider at the remote hospital. It requires videoconferencing equipment like Webcam, a telecommunications connection, and 24/7 technical assistance when needed (Ryhan Ebad, 2013). Example of teleconferencing technology used in low-resource settings is the RAFT network, which provides both educational and clinical services to centres in Africa and South America (Bediang G et al, 2014). It is clear from these reports that video telemedicine is possible in low-resource environments as low broadband internet is coming available.Web portals are being increasingly used as a resource for store and forward telemedicine and to access electronic medical records, including picture archiving communication systems images (Moya et al, 2010).
It is an Internet based computing model which enables convenient, on-demand network access to shared resources, software and information which is provided to computers and other devices.’ (Ragent and Leach, 2010). The main advantage of cloud computing is that it increases productivity and decreases the cost of Information Technology (IT). Cloud computing can provide various types of services such as Software as a Service, Platform as a Service and Infrastructure as a Service (Baize, 2011). Cloud computing embraces new opportunities of transforming healthcare delivery into a more reliable and sustainable manner by taking advantage of the real-time, on-site monitoring capability of Android mobile device and the abundant computing power of the cloud. Recently, many mobile-based medical monitoring devices have been developed with the capability of processing certain types of physiological signals (J. Oresko, et al, 2010) The acquired physiological signals will be transferred to a cloud service environment to perform desired, computation-intensive algorithmic signal processing. The processed results, recognized abnormalities, or diagnostic alarms will be automatically archived in the cloud or sent to the mobile devices owned by patients, physicians, or emergency teams. This application mode can be of particular significance to patients whose physiological signals need to be monitored continuously.
Can be used to establish telemedicine in such areas as low resource settings. Example, the Satellite African eHEalth vaLidation (SAHEL) in Kenya and Senegal, provides self-contained, solar-powered internet terminals to rural villages for use by community nurses for collaboration with distant health centres for training, diagnosis and advice on local health issues (Company brochure, 2016).
This covers the pure ICT technological infrastructure as well as any other generic infrastructure such as power supply, water supply- which can limit utilization of telemedicine in low resource settings due to: poor-quality electricity and water supplies poor-quality telephone services; isolation and lack of continuing medical education (CME) for health care staff; and poor supervision of health care staff. In rural regions of developing countries, communication media mainly include voice (typically, via a VHF transceiver) and text (typically, via e-mail messages. Low resource settings in Africa, the Americas, and South-East Asia cited infrastructure as one of the greatest barriers to telemedicine.
A literature search was conducted to identify papers reporting the technologies being used to aid the practice of telemedicine and also the technological infrastructure supporting its use in low resource settings.
The databases: Google, PubMed, Researchgate, Medline were searched and one World Health Organisation book and data were extracted from the full text of the articles and book and analysed through a narrative synthesis.
A total of 30 articles were searched. In 28 (93.3%) articles, it is shown that technologies are being used to aid the practice of telemedicine in low resource settings, especially the asynchronous (Store-and-Forward) for being clinically useful, sustainable and potentially cost-effective, while the synchronous (Real-Time) telemedicine is also being adopted.All the articles (100%) acknowledge that the use of telemedicine technologies in low resource settings has made a tremendous impact on rural population in terms of enabling access to healthcare via telemedicine which various initiatives have been undertaken to connect rural population with healthcare facilities.All the articles (100%) identify Infrastructure and 17 (56.7%) of the articles identify little human resource ” few technical staff- as barriers to adoption and use of telemedicine technologies in low resource settings
There is an increasing uptake of the use of different technologies in the practice of telemedicine low resource settings such that in the near future, it is obvious that telemedicine technologies will play a significant role in completely revolutionalizing the entire health care industry, a substantial transformation that will strengthen the effectiveness and efficiency of healthcare delivery. With the advancement in cutting edge technology it will be lot easier to extend affordable health care in distant location and reach out to such remote communities, telemedicine is proving to be saving lives, offsetting shortages of general practitioners and medical specialists, providing medical consultation to heath care professionalsAs the use of telemedicine technologies 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. Infrastructure is still one of the greatest barriers to adoption and use of telemedicine technologies in low resource settings.
Support and strengthen the existing technologies for asynchronous telemedicine while adopting and developing the technologies for synchronous telemedicine.Provide, improve and sustain the technological infrastructure to support the technologies used in the practice of telemedicine in low resource settings.Train the necessary human resources to handle the relevant technologies used in telemedicine in low resource settings.