In what circumstances is telemedicine appropriate in the developing world?

Rapid implementation of telemedicine in Neurology during the COVID-19 pandemic: Challenges in King Abdulaziz Medical City-Jeddah

Telemedicine is defined as the remote medical practice of delivering healthcare services to the underserved using information and communication technology. It encompasses a wide range of medical activities, including diagnosis, treatment, disease prevention, and education. The coronavirus disease of 2019 (COVID-19) pandemic has caused significant social dislocation, negative economic impact, and a major change in medical practice in Saudi Arabia. Telemedicine has rapidly moved to the frontline of healthcare practice due to the demand for prevention and mitigation strategies. It has been encouraged and facilitated with huge government support. Herein, we describe the virtual clinical practice of the neurology department at King Abdulaziz Medical City-Jeddah in response to the COVID-19 pandemic. This narrative review is an urgent call to improve the perception and knowledge of both medical personnel and patients concerning telemedicine and to support the utilization of advanced information and communication technology.

The Brief Review on Telemedicine: New Dream in Developing Countries

: In the new modern world, technology has a remarkable role in human life and affects all aspects of it. Indeed, the need for rapid counteractions, especially in medical requirements, can lead to interesting innovations. Telemedicine was disregarded for being an unwieldy, unreliable, and unaffordable technology. Rapidly evolving telecommunications and information technologies have provided a solid foundation for telemedicine as a feasible, dependable, and useful technology. Telemedicine has been conceived as an integrated system of healthcare delivery that employs telecommunications and computer technology as a substitute for face-to-face contact between provider and client. It has the potential for ameliorating seemingly intractable problems in healthcare such as limited access to care among segments in the population, especially the geographically disadvantaged, uneven quality of care, and cost of inflation. Its true merit has yet to be determined by systematic empirical studies. In another survey, the authors defined telemedicine as a branch of e-health, which works by communication networks and delivers healthcare and medical educations from remote locations. The main aim of telemedicine is to overcome the improper distribution of human and fundamental resources. Telemedicine could be considered from the viewpoint of two basic conditions: (1) as an alternative way for emergency services in remote locations and (2) it is a better option rather than conventional health services; for example, teleradiology for rural hospitals. It can result in appropriate availability of health services and acceptable efficiency. However, this aspect of medicine was considered in the late 1990, and then, developing countries have a long way for research about it.

Cardiac point of care ultrasound in resource limited settings to manage children with congenital and acquired heart disease

BACKGROUND

In resource limited settings, children with cardiac disease present late, have poor outcomes and access to paediatric cardiology programmes is limited. Cardiac point of care ultrasound was introduced at several Médecins Sans Frontières sites to facilitate cardiopulmonary assessment. We describe the spectrum of disease, case management and outcomes of cases reviewed over the Telemedicine platform.

METHODS

Previously ultrasound naïve, remotely placed clinical teams received ultrasound training on focussed image acquisition. The Médecins Sans Frontières Telemedicine platform was utilised for remote case and imaging review to diagnose congenital and acquired heart disease and guide management supported by a remotely situated paediatric cardiologist.

RESULTS

Two-hundred thirty-three cases were reviewed between 2016 and 2018. Of 191 who underwent focussed cardiac ultrasound, diagnoses included atrial and ventricular septal defects 11%, atrioventricular septal defects 7%, Tetralogy of Fallot 9%, cardiomyopathy/myocarditis 8%, rheumatic heart disease 8%, isolated pericardiac effusion 6%, complex congenital heart disease 4% and multiple other diagnoses in 15%. In 17%, there was no identifiable abnormality while 15% had inadequate imaging to make a diagnosis. Cardiologist involvement led to management changes in 75% of cases with a diagnosis. Mortality in the entire group was disproportionately higher among neonates (38%, 11/29) and infants (20%, 16/81). There was good agreement on independent review of selected cases between two independent paediatric cardiologists.

CONCLUSION

Cardiac point of care ultrasound performed by remote clinical teams facilitated diagnosis and influenced management in cases reviewed over a Telemedicine platform. This is a feasible method to support clinical care in resource limited settings.

Awareness, Views, Perceptions, and Beliefs of Pharmacy Interns Regarding Digital Health in Saudi Arabia: Cross-sectional Study

BACKGROUND

Digital health technologies and apps are rapidly advancing in recent years. It is expected to have more roles in transforming the health care system in this era of digital services. However, limited research is available regarding delivering digital health education in pharmacy and the pharmacy students' perspectives on digital health.

OBJECTIVE

This study aims to assess pharmacy interns' awareness of digital health apps in Saudi Arabia and their views regarding the coverage of digital health in the education of pharmacists. In addition, we assessed the interns' perceptions and beliefs about the concepts, benefits, and implementation of digital health in practice settings.

METHODS

A cross-sectional study using a web-based survey was conducted among pharmacy interns at Unaizah College of Pharmacy, Qassim University, Saudi Arabia. An invitation with a link to the web-based survey was sent to all interns registered at the college between January and March 2021.

RESULTS

A total of 68 out of 77 interns registered in the internship year participated in this study, giving a response rate of 88%. The mean total score for pharmacy interns' awareness of digital health apps in Saudi Arabia was 5.66 (SD 1.74; maximum attainable score=7). The awareness with different apps ranged from 97% (66/68) for the Tawakkalna app to 65% (44/68) for the Ministry of Health 937 call center. The mean total score for attitude and beliefs toward concepts and benefits of telehealth and telemedicine apps was 58.25 (SD 10.44; maximum attainable score=75). In this regard, 84% (57/68) of the interns believed that telehealth could enhance the quality of care, 71% (48/68) believed that it could help effectively provide patient counseling, and 69% (47/68) believed it could improve patients' adherence to therapy. In this study, 41% (28/68) believed that the current coverage of digital health in the curriculum was average, whereas only 18% (12/68) believed it was high or very high coverage. Moreover, only 38% (26/68) attended additional educational activities related to digital health. Consequently, the majority (43/68, 63%) were of the opinion that there is a high or very high need to educate and train pharmacists in the field of digital health.

CONCLUSIONS

Overall, the interns showed good awareness of common digital health apps in Saudi Arabia. Moreover, the majority of the interns had positive perceptions and beliefs about the concepts, benefits, and implementation of digital health. However, the findings showed that there is still scope for improvement in some areas. Moreover, most interns indicated that there is a need for more education and training in the field of digital health. Consequently, early exposure to content related to digital health and pharmacy informatics is an important step to help in the wide use of these technologies in the graduates' future careers.

WhatsApp Linking Lilongwe, Malawi to Los Angeles: Impacting Medical Education and Clinical Management

Background

Subspecialty expertise is often lacking in clinical environments in low-resource settings. As a result, medically complicated patients can receive suboptimal care, local clinicians can feel inadequately supported, and global health engagements can be difficult for medical trainees accustomed to more expert supervision at their home institutions.

Objective

We created WhatsApp Messenger discussion groups to connect subspecialists at the University of California, Los Angeles (UCLA) David Geffen School of Medicine with clinicians and rotating global health residents at Partners in Hope (PIH) Medical Center in Lilongwe, Malawi.

Methods

Case submitters and subspecialist respondents were surveyed about their experience in the discussion groups.

Findings

Over a three-year period, 95 cases were discussed in ten subspecialty groups, with dermatology and radiology/pulmonology receiving the most submissions. Participants were surveyed and reported excellent educational outcomes; large majorities of both case submitters (89%) and experts (71%) agreed or strongly agreed that the case discussions improved their medical education. The surveys also suggested positive impact on medical management decisions and patient outcomes. The major challenge to our intervention was low utilization of this resource by Malawian clinicians in comparison to medical residents. We hope to further address the barriers to participation and adapt the intervention to better support our Malawian colleagues.

Conclusion

Because the discussion groups are free to create and require very little maintenance, this intervention can be easily replicated at other institutions looking to augment their global health educational engagements and support their clinical partners abroad.

Diagnostic and interventional implications of telemedicine in Alzheimer's disease and mild cognitive impairment: A literature review

INTRODUCTION

Worldwide, life expectancy, and aging-related disorders as mild cognitive impairment (MCI) and Alzheimer disease (AD) are increasing, having a rising impact on patients' quality of life and caregivers' distress. Telemedicine offers many possibilities, such as remote diagnosing and monitoring of patients.

OBJECTIVE

The purpose of this study is to provide a narrative synthesis of the literature about the implementation of telemedicine for diagnosis, treatment, and follow-up of patients with AD and MCI and their caregivers.

METHODS

A systematic literature review was conducted on MEDLINE, EMBASE, and the Cochrane Library databases up to September 2018. MCI or AD diagnoses were the conditions of interest. We excluded other dementias.

RESULTS

Fifty-six articles met inclusion criteria. We identified two main categories: diagnosis group (DG) and follow-up/interventional group (FIG). Fifteen articles suggested how to make a remote or earlier diagnosis: four were case-control accuracy studies, nine were paired comparative accuracy studies, and two were prospective single-arm accuracy studies. Among these, four focused on MCI, six on AD, and five on both. Forty one focused on supporting patients during the stages of the disease (28 articles), patient's caregivers (nine articles), or both (four articles).

CONCLUSIONS

The rising use of telemedicine could actively improve AD and MCI patients' lives, reduce caregivers' burden, and facilitate an early diagnosis if patients live in remote places. However, as some studies report, it is relevant to take into account the emotional impact of telemedicine on patients and not only on the effectiveness.

Seven years of telemedicine in Médecins Sans Frontières demonstrate that offering direct specialist expertise in the frontline brings clinical and educational value

Background

Médecins Sans Frontières (MSF), a medical humanitarian organization, began using store-and-forward telemedicine in 2010. The aim of the present study was to describe the experience of developing a telemedicine service in low-resource settings.

Methods

We studied the MSF telemedicine service during the period from 1st July 2010 until 30th June 2017. There were three consecutive phases in the development of the service, which we compared. We also examined the results of a quality assurance program which began in 2013.

Results

During the study period, a total of 5646 telemedicine cases were submitted. The workload increased steadily, and the median referral rate rose from 2 to 18 cases per week. The number of hospitals submitting cases and the number of cases per hospital also increased, as did the case complexity. Despite the increased workload, the allocation time reduced from 0.9 to 0.2 hours, and the median time to answer a case decreased from 20 to 5 hours. The quality assurance scores were stable. User feedback was generally positive and more than 90% of referrers who provided a progress report about their case stated that it had been sent to an appropriate specialist, that the response was sufficiently quick and that the teleconsultation provided an educational benefit. Referrers noted a positive impact of the system on patient outcome in 39% of cases.

Conclusions

The quality of the telemedicine service was maintained despite rising caseloads. The study showed that offering direct specialist expertise in low-resource settings improved the management of patients and provided additional educational value to the field physicians, thus bringing further benefits to other patients.

Telemedicine's Potential to Support Good Dying in Nigeria: A Qualitative Study

OBJECTIVES

This qualitative study explores Nigerian health care professionals' concepts of good dying/a good death and how telemedicine technologies and services would fit the current Nigerian palliative care practice.

MATERIALS AND METHODS

Supported by the Centre for Palliative Care Nigeria (CPCN) and the University College Hospital (UCH) in Ibadan, Nigeria, the authors organized three focus groups with Nigerian health care professionals interested in palliative care, unstructured interviews with key role players for palliative care and representatives of telecom companies, and field visits to primary, secondary and tertiary healthcare clinics that provided palliative care. Data analysis consisted of open coding, constant comparison, diagramming of categorizations and relations, and extensive member checks.

RESULTS

The focus group participants classified good dying into 2 domains: a feeling of completion of the individual life and dying within the community. Reported barriers to palliative care provision were socio-economic consequences of being seriously ill, taboos on dying and being ill, restricted access to adequate medical-technical care, equation of religion with medicine, and the faulty implementation of palliative care policy by government. The addition of telemedicine to Nigeria's palliative care practice appears problematic, due to irregular bandwidth, poor network coverage, and unstable power supply obstructing interactivity and access to information. However, a tele-education 'lite' scenario seemed viable in Nigeria, wherein low-tech educational networks are central that build on non-synchronous online communication.

DISCUSSION

Nigerian health care professionals' concepts on good dying/a good death and barriers and opportunities for palliative care provision were, for the greater part, similar to prior findings from other studies in Africa. Information for and education of patient, family, and community are essential to further improve palliative care in Africa. Telemedicine can only help if low-tech solutions are applied that work around network coverage problems by focusing on non-synchronous online communication.

Healthcare Professionals' Perceptions of the Benefits and Challenges of a Teleconsultation Service in the Amansie-West District of Ghana

OBJECTIVES

A teleconsultation service was introduced in the Amansie-West District, Ghana, in 2010 linking health center-based community health nurses (CHNs) with a teleconsultation center (TCC) at the district hospital. This study aimed to assess healthcare professionals' perceptions of the benefits and challenges of this service and to identify possible areas for improvement.

MATERIALS AND METHODS

Qualitative semistructured interviews were conducted with eight CHNs and three TCC healthcare professionals to find their views on the benefits, challenges, and recommendations for improving the service. The data were analyzed using qualitative content analysis.

RESULTS

Interviewees were generally positive when describing the use of the teleconsultation service. They were of the opinion that the service had improved the quality of care at health centers, thus reducing the need to refer patients to the district hospital. Practical problems, such as inadequate information provided over the phone, delays in responding to calls, and the additional workload for teleconsultation staff, were viewed as important challenges to the success of the project. Interviewees identified several possible options for improving the service through extension to other levels of the healthcare system or by adding additional functionalities to their phones.

CONCLUSIONS

Teleconsultation services have the potential to improve quality of care in rural communities. However, practical problems in the operation of the service have to be taken seriously as they threaten sustainability of the intervention. Adequate training in phone-based clinical reporting appears to be essential. Teleconsultation staff should be compensated for additional workload through a reduction of other work-related tasks.

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.

In eHealth in India today, the nature of work, the challenges and the finances: an interview-based study

BACKGROUND

India is a country with vast unmet medical needs. eHealth has the potential to improve the quality of health care and reach the unreached. We have sought to understand the kinds of eHealth programmes being offered in India today, the challenges they face and the nature of their financing.

METHODS

We have adopted an interview-based methodology. The 30 interviews represent 28 organizations, and include designers, implementers, evaluators and technology providers for eHealth programmes.

RESULTS

A range of programmes is being run, including point-of-care in rural and urban areas, treatment compliance, data collection and disease surveillance, and distant medical education. Most programmes provide point-of-care to patients or other beneficiaries in rural areas. Technology is not a limiting factor but the unavailability of suitable health personnel is a major challenge, especially in rural areas. We have identified a few factors that help this situation. Financial sustainability is also a concern for most programmes, which have rarely been scaled up. There are recent for-profit efforts in urban areas, but no reliable business model has been identified yet. Government facilities have not been very effective in eHealth on their own, but collaborations between the government and non-profit (in particular) and for-profit organisations have led to impactful programmes.

CONCLUSIONS

It is unlikely that eHealth will have widespread and sustainable impact without government involvement, especially in rural areas. Nevertheless, programmes run solely by the government are unlikely to be the most effective.

The role of information technology in strengthening human resources for health

Purpose

– The purpose of this paper is to discuss innovative ways of addressing human resources for health (HRH) shortage in the Pacific, supported by a review of the literature and the Pacific Open Learning Health Network (POLHN), a programme created in response to the Pacific's HRH concern.

Design/methodology/approach

– A systematic search was conducted of English literature between 1990 and 2012. A number of key words, singly and/or in combination, were used to search for articles on ProQuest and PubMed. Original articles were identified and reference lists scrutinised to obtain additional literature. Due to the paucity of information, only narrative review was conducted and themes emerging from the literature identified and critically reviewed.

Findings

– There is a worldwide HRH shortage and a need to improve the skills of the health workforce to respond to changing population health needs. Continuing education (CE) through use of information technology (IT) is a means to strengthen HRH. POLHN is one example of an initiative to improve health worker skills and motivation. Technological change is increasingly common place in society. To make sense of these changes, practitioners can look for common themes in successful technological innovations of interactivity; information access, creation or sharing; communication; and simplicity. To ensure effective regulation of CE and IT there is a need to incorporate qualitative as well as quantitative measures, to prioritise the creation of quality, relevant, and appropriate resources and to facilitate access and active participation by health workers.

Originality/value

– The paper highlights the complexity of HRH shortage as a global problem, which demands multiple initiatives to respond to the shortage in the pursuit of skilled, equitable and just delivery of health services and distribution of health service providers. One initiative that has worked elsewhere is professional development of health professionals through the provision of CE using IT. Online learning offers a pathway to address HRH shortage and overcomes challenges posed by distance, limited infrastructure and in small remote communities. POLHN contributes to improved skills and knowledge among health professionals who can, as a result, deliver better health services in a region as geographically dispersed and isolated as the Pacific.

A hybrid approach to telepathology in Cambodia

We established a hybrid telepathology network at the Children’s Surgical Centre (CSC) in Cambodia, based on store-and-forward communication using iPATH and videoconferencing using Skype. We retrospectively analysed all data from the CSC stored on the iPATH server and reviewed the patient notes over an 8-month period. Of 115 patients for histopathology diagnosis during the study period, 38 cases were uploaded onto iPATH for further telemedicine discussion. The median number of days it took a specialist, other than the local one, to comment on the case on iPATH was 5 days (range 0–15). In three cases (8%) there was no reply from a specialist on iPATH. During the study period, seven clinical conferences were held, with an average of 6 cases (range 4–7) discussed at each conference. All 38 cases discussed had a final agreed diagnosis and firm management plans were made. Of the 24 cases where proactive management was advised, 17 patients followed through with the recommendations. Although the combination of video consultations and store-and-forward communication has not been used much before in the developing world, it has benefited patient care and outcomes at the CSC.

When access is an issue: exploring barriers to predictive testing for Huntington disease in British Columbia, Canada

Predictive testing (PT) for Huntington disease (HD) requires several in-person appointments. This requirement may be a barrier to testing so that at risk individuals do not realize the potential benefits of PT. To understand the obstacles to PT in terms of the accessibility of services, as well as exploring mechanisms by which this issue may be addressed, we conducted an interview study of individuals at risk for HD throughout British Columbia, Canada. Results reveal that the accessibility of PT can be a barrier for two major reasons: distance and the inflexibility of the testing process. Distance is a structural barrier, and relates to the time and travel required to access PT, the financial and other opportunity costs associated with taking time away from work and family to attend appointments and the stress of navigating urban centers. The inflexibility of the testing process barrier relates to the emotional and psychological accessibility of PT. The results of the interview study reveal that there are access barriers to PT that deter individuals from receiving the support, information and counseling they require. What makes accessibility of PT services important is not just that it may result in differences in quality of life and care, but because these differences may be addressed with creative and adaptable solutions in the delivery of genetic services. The study findings underscore the need for us to rethink and personalize the way we deliver such services to improve access issues to prevent inequities in the health care system.

Providing predictive testing for Huntington disease via telehealth: results of a pilot study in British Columbia, Canada

Predictive testing (PT) for Huntington disease (HD) usually requires several in-person appointments which acts as a barrier to testing for those from remote regions. This pilot study reports the use of telehealth PT to examine whether such telehealth testing improves access to HD PT while maintaining quality of care and support. Individuals underwent PT via the telehealth protocol or standard in-person protocol and were asked to complete surveys regarding their experience. Results reveal no significant differences between the in-person-tested and telehealth-tested groups with respect to quality of care, information, counselling and support. The majority of participants in both groups stated that pre-test counselling had provided them with sufficient knowledge about the advantages and disadvantages of undergoing testing, the opportunity to ask questions, and the ability to make an informed decision. The majority of participants in both groups were satisfied by the manner in which results were delivered and stated they had received sufficient information regarding the implications of these results. This study reveals that telehealth PT improves access while maintaining quality of care and support.

Successes and challenges in the implementation and application of telemedicine in the eastern province of Saudi Arabia

Telemedicine is the practice of healthcare using audio, video, and data communications. The aim of this study was to determine the perceptions of health professionals at hospitals adopting and not adopting telemedicine on its benefits and challenges, and their willingness to use it. The study was conducted at one hospital not adopting telemedicine and three hospitals adopting telemedicine. It was a cross-sectional descriptive study, and the target population was health professionals. Data collection methods included two paper-based questionnaires. Nonparametric statistical analysis and descriptive statistics were used. The study concluded that although telemedicine is promising and the Ministry of Health in Saudi Arabia has allocated a huge budget for e-health, the telemedicine modalities used were very limited. The percentage of adoption of telemedicine by health professionals was low in comparison to the high interest of nonadopters. Nonadopters' perception of benefits was higher than that of adopters. The most frequently cited benefits among adopters were improving the quality of care, enhancing access to healthcare, and providing patient care and management. However, adopters' perceptions were low for other benefits such as easy use of the network, the use of store-and-forward telemedicine, and the ability to follow up after face-to-face contacts. The greatest barrier as perceived by health providers was the lack of knowledge about telemedicine. Dissemination of information about telemedicine and proper training of health professionals on its use are recommended.

Long-running telemedicine networks delivering humanitarian services: experience, performance and scientific output

OBJECTIVE

To summarize the experience, performance and scientific output of long-running telemedicine networks delivering humanitarian services.

METHODS

Nine long-running networks--those operating for five years or more--were identified and seven provided detailed information about their activities, including performance and scientific output. Information was extracted from peer-reviewed papers describing the networks' study design, effectiveness, quality, economics, provision of access to care and sustainability. The strength of the evidence was scored as none, poor, average or good.

FINDINGS

The seven networks had been operating for a median of 11 years (range: 5-15). All networks provided clinical tele-consultations for humanitarian purposes using store-and-forward methods and five were also involved in some form of education. The smallest network had 15 experts and the largest had more than 500. The clinical caseload was 50 to 500 cases a year. A total of 59 papers had been published by the networks, and 44 were listed in Medline. Based on study design, the strength of the evidence was generally poor by conventional standards (e.g. 29 papers described non-controlled clinical series). Over half of the papers provided evidence of sustainability and improved access to care. Uncertain funding was a common risk factor.

CONCLUSION

Improved collaboration between networks could help attenuate the lack of resources reported by some networks and improve sustainability. Although the evidence base is weak, the networks appear to offer sustainable and clinically useful services. These findings may interest decision-makers in developing countries considering starting, supporting or joining similar telemedicine networks.

Experience with low-cost telemedicine in three different settings. Recommendations based on a proposed framework for network performance evaluation

Background

Telemedicine has been used for many years to support doctors in the developing world. Several networks provide services in different settings and in different ways. However, to draw conclusions about which telemedicine networks are successful requires a method of evaluating them. No general consensus or validated framework exists for this purpose.

Objective

To define a basic method of performance measurement that can be used to improve and compare teleconsultation networks; to employ the proposed framework in an evaluation of three existing networks; to make recommendations about the future implementation and follow-up of such networks.

Methods

Analysis based on the experience of three telemedicine networks (in operation for 7–10 years) that provide services to doctors in low-resource settings and which employ the same basic design.

Findings

Although there are many possible indicators and metrics that might be relevant, five measures for each of the three user groups appear to be sufficient for the proposed framework. In addition, from the societal perspective, information about clinical- and cost-effectiveness is also required. The proposed performance measurement framework was applied to three mature telemedicine networks. Despite their differences in terms of activity, size and objectives, their performance in certain respects is very similar. For example, the time to first reply from an expert is about 24 hours for each network. Although all three networks had systems in place to collect data from the user perspective, none of them collected information about the coordinator's time required or about ease of system usage. They had only limited information about quality and cost.

Conclusion

Measuring the performance of a telemedicine network is essential in understanding whether the network is working as intended and what effect it is having. Based on long-term field experience, the suggested framework is a practical tool that will permit organisations to assess the performance of their own networks and to improve them by comparison with others. All telemedicine systems should provide information about setup and running costs because cost-effectiveness is crucial for sustainability.

A telemedicine network to support paediatric care in small hospitals in rural Tanzania

We reviewed our experience with the Tanzanian Telemedicine Network in supporting paediatric care at 40 small, rural hospitals in the country. The network began operating in 2008. Store and forward telemedicine was provided via the open source software iPath. The 33 volunteer consultants were based in several countries, although most of them had practical experience in Tanzania. During the first three years of network operation there were 533 referrals. There were 159 paediatric cases (median age five years). Three paediatric specialists provided most consultations (64%), but other specialists provided recommendations when required. The response time was usually less than two days (median 6 h; inter-quartile range 2-24 h). A precise recommendation was not always provided, but since all consultants had an intimate knowledge of the state of health services in Tanzania, their advice was usually well adapted to the local circumstances of the hospitals. Referral to a higher level of care was recommended in 26 cases (16%). A simple web-based telemedicine system combined with email alerts is feasible in remote locations in Tanzania, even where fast Internet connections are not available.