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

Comparing effects and application of telemedicine for different specialties in emergency medicine using the Emergency Talk Application (U-Sim ETA Trial)

Telemedicine as a technology can support processes in the field of emergency medicine (EM) including therapies and diagnostics, but technically is often based on hardware solutions for local EM structures, especially when involving the field of pre-hospital EM. By developing an open-source, data protection compliant solution (EU GDPR and HIPAA) as well as using standardized web and open-source based technology the Emergency Talk Application (ETA) can be used as a technology that can connect emergency medical providers and include already available regional structures. By actively involving patients and connecting these with emergency or urgent care physicians ETA can be used not only as a teleconsultation system for paramedics and physicians, but in a wider network. Randomised simulation trial, comparing EM scenarios from the field of internal medicine, trauma and neurology. Participants were qualified as certified paramedics or emergency physicians (EP). Paramedics performed as ambulances crews and involved an EP if needed via ETA as Tele-Emergency Physicians (TEP). EP participated from a device of their choice, while being able to stay within their clinical workspace. From 141 scenarios 129 used ETA. Significant differences were found for the length of scenarios, duration of time the TEP was on scene, TEP arrival after scenario start, duration until TEP was called and the duration until a diagnosis was made. Also a strong positive and significant correlation between duration of the scenario and the time a TEP was bound could be described. Telemedicine is a technology that is increasingly used in the field of EM. Improving the use of telemedicine by using up-to date technology while allowing an integration of available technical and human resources is a challenge in the field of emergency medicine especially with its regional but also broad medical variety. When using one technical solution, understanding that different cases need a different medical and also telemedical approach can help in the understanding and improving therapies, diagnostics but also the involved processes and solutions. Such results are not only relevant for healthcare providers but especially by law and decision makers as to which type of solution could be introduced in each regional setting.

Auditing the Audits: A Systematic Review on Different Procedures in Telemedicine

Telemedicine is a process of delivering health care using information and communication technologies. Audit and feedback (A&F) constitute a systematic intervention that is aimed at collecting data, which are subsequently compared with reference standards and then returned to health care operators through feedback meetings. The aim of this review is to analyse different audit procedures on and by mean of telemedicine services and to identify a practice that is more effective than the others. Systematic searches were performed in three databases evaluating studies focusing on clinical audits performed on and by means of telemedicine systems. Twenty-five studies were included in the review. Most of them focused on telecounselling services with an audit and a maximum duration of one year. Recipients of the audit were telemedicine systems and service users (general practitioners, referring doctors, and patients). Data resulting from the audit were inherent to the telemedicine service. The overall data collected concerned the number of teleconsultations, service activity, reasons for referral, response times, follow-up, reasons why treatment was not completed, technical issues, and other information specific to each telemedicine service. Only two of the considered studies dealt with organizational aspects, and of these, only one analysed communicative aspects. The complexity and heterogeneity of the treatments and services provided meant that no index of uniformity could be identified. Certainly, some audits were performed in an overlapping manner in the different studies, and these show that although attention is often paid to workers' opinions, needs, and issues, little interest was shown in communicative/organizational and team dynamics. Given the importance and influence that communication has in teamwork and care settings, an audit protocol that takes into account intra- and extra-team communication processes could be essential to improving the well-being of operators and the quality of the service provided.

Digital Transformation in Healthcare: Technology Acceptance and Its Applications

Technological innovation has become an integral aspect of our daily life, such as wearable and information technology, virtual reality and the Internet of Things which have contributed to transforming healthcare business and operations. Patients will now have a broader range and more mindful healthcare choices and experience a new era of healthcare with a patient-centric culture. Digital transformation determines personal and institutional health care. This paper aims to analyse the changes taking place in the field of healthcare due to digital transformation. For this purpose, a systematic bibliographic review is performed, utilising Scopus, Science Direct and PubMed databases from 2008 to 2021. Our methodology is based on the approach by Wester and Watson, which classify the related articles based on a concept-centric method and an ad hoc classification system which identify the categories used to describe areas of literature. The search was made during August 2022 and identified 5847 papers, of which 321 fulfilled the inclusion criteria for further process. Finally, by removing and adding additional studies, we ended with 287 articles grouped into five themes: information technology in health, the educational impact of e-health, the acceptance of e-health, telemedicine and security issues.

Satisfaction of healthcare workers and patients regarding telehealth service in a hospital in Peru

OBJECTIVES.

To evaluate the level of satisfaction of healthcare workers and patients with the telehealth service of the Hospital III Regional Honorio Delgado (HRHD), as well as the maturity level of the telehealth service implementation.

MATERIALS AND METHODS.

Cross-sectional, observational study conducted from October to December 2021. The satisfaction of healthcare workers and patients was assessed with the Glaser et al. survey and the Telemedicine Satisfaction Questionnaire (TSQ), respectively. The level of service maturity was assessed using the Pan American Health Organization's instrument for measuring the maturity level of healthcare institutions implementing telemedicine service.

RESULTS.

A total of 129 responses were obtained from healthcare workers. Non-physician professionals' satisfaction with the telehealth service was higher than that of physicians (72.5% vs. 18.3%). Of 377 patients, 77.6% stated they were satisfied with the service. Regarding the maturity level, the HRHD telemedicine service had 32% of items in null status, 40.8% in started, 25.2% in advanced, and 2% in ready conditions.

CONCLUSIONS.

Physician satisfaction was lower than that of other health professionals. Patients had a moderate-high satisfaction. The maturity level of telehealth implementation in HRHD was oriented towards a null or initiated level. Decision-makers need to consider user satisfaction for the telehealth implementation and the follow-up.

Remote Healthcare During the COVID-19 Pandemic: Findings for Older Adults in 27 European Countries and Israel

The COVID-19 pandemic exacerbated issues regarding access to healthcare for older people, by far the most vulnerable population group. In particular, older adults avoided seeking medical treatment for fear of infection or had their medical treatments postponed or denied by health facilities or health professionals. In response, remote medical services were recognized as an essential adjustment mechanism to maintain the continuity of healthcare provision. Using the SHARE Corona Survey data, we estimate logistic and multilevel regression models for the remote care of 44,152 persons aged 50 and over in 27 European countries and Israel. Our findings suggest that those aged 80+ were the least likely to use remote healthcare. However, women, better educated individuals, older adults who lived in urban areas, those with no financial strain, and active Internet users used remote medical consultations more often. Those who reported poor or fair health status, two or more chronic diseases, or hospitalization in the last 12 months were significantly more likely to use remote healthcare. Furthermore, remote medical consultations were more frequent for those who had their healthcare postponed or went without it due to fear of coronavirus infection. Finally, older adults used remote care more frequently in countries with less healthcare coverage and lower health expenditures. Health systems should prioritize vulnerable groups in maintaining continuity in access to healthcare, despite the availability of remote care. Policymakers should improve telemedicine regulation and offer incentives for providers of remote healthcare services by adapting reimbursement policies. Remote medical care could play an important role in maintaining healthcare access for older adults and increasing health systems' preparedness in future health emergencies.

Healthcare Providers’ Satisfaction with Implementation of Telemedicine in Ambulatory Care during COVID-19

Introduction: Telemedicine has become a critical aspect of healthcare provision during the coronavirus pandemic (COVID-19). However, healthcare providers’ utilization of and satisfaction with telemedicine technologies could have a significant impact on the quality of care provided to patients during COVID-19. The current study explores the key factors that could affect healthcare providers’ satisfaction with telemedicine in ambulatory care during the pandemic. Objectives: This research study aims at identifying the factors that could influence the healthcare providers’ satisfaction level with the use of telemedicine in ambulatory care services in Saudi Arabia during COVID 19. Methods: This is a descriptive quantitative cross-sectional study. The research team has utilized the Service Quality Model (SERVQUAL) to assess the healthcare providers’ satisfaction with telemedicine in ambulatory care through a questionnaire that was adapted from previous studies. This questionnaire includes the following dimensions: tangibility, reliability, responsiveness, assurance, and empathy. It was distributed to all ambulatory care physicians in a public hospital-based ambulatory health center in Eastern Region, Saudi Arabia. Results: The study findings showed that Saudis are significantly more satisfied with telemedicine compared to non-Saudis. Age, gender, experience, medical specialty, and computer literacy skills were not found to have any significant effects on the level of the provider’s satisfaction. Conclusion: This research provides new insight and understanding of the relationship between the frequent use of the health information system and the level of physician satisfaction. This major finding puts more emphasis on the importance of education and training when it comes to the adoption of telemedicine through the frequent use of health information systems and applications. These encouraging findings provide a vital piece of information for healthcare organizations interested in a further adoption of telemedicinal practices and applications.

Repostioning of Telemedicine in Cardiovascular World Post-COVID-19 Pandemic

Background

During the COVID-19 pandemic, telemedicine is a quickest expanding service solution to provide improved access to sophisticated healthcare that is efficient, cost-effective, and time-consuming.

Methods

This analysis is evaluated on the basis of several studies that look at the history, benefits, various techniques, challenges, uses, and impact of telemedicine in the treatment of heart failure and cardiac rehabilitation as during COVID-19 outbreak.

Results

Patients avoided or refused medical treatment during COVID-19 pandemic despite the risk of illness and the threat of infections spreading. Telemedicine has become a non-traditional form of care delivery due to better access and high-end technologies such as virtual consultations, face-to-face video, smartphone visits, two-way text communication, distant patient history, and distal characteristic assessment. Remote monitoring can help manage cardiovascular disease risk factors and increase patient participation in blood pressure, heart failure data, and workout or other activity progress.

Conclusion

Based on the findings of past studies, we can infer that telemedicine is still an emerging subject in the treatment and management of cardiovascular disease. Telemedicine and similar technologies will also revolutionize healthcare services by expanding their reach and providing a big pool of database for better research and analysis.

Developing telemedicine in Emergency Medical Services: A low-cost solution and practical approach connecting interfaces in emergency medicine

Background:

In Germany, the number of calls for Emergency Medical Services (EMS) are increasing, while the number of general practitioners and hospitals are decreasing, resulting in a growing demand and workload for emergency physicians and paramedics. Furthermore, an aging population with increasingly complex medical histories, present emergencies in which a more detailed assessment and therapies are urgently needed. Therefore, common EMS systems need to find solutions to handle these problems.

Methods:

We used a user-focused five-step approach to define a technological solution: Research of current systems, definition of goals and requirements, development of concept, test series and evaluation, evaluation of costs and benefits.

Results:

Development of a holistic telemedical concept to connect in-hospital clinical emergency physicians and paramedics on the scene, by implementing and connecting systems that are already partially being used in common EMS in Germany. By using live audio and video communication, including vital signs between the two, a system can be established by keeping costs low, affordable and at the same time protecting patient data in line with General Data Protection Regulation.

Conclusion:

Implementing technologies in a practical specialty like Emergency Medicine with a user-focused approach demonstrates that the hurdle for integration into established routines can improve current processes. Evaluation of costs and usability is a main driver to define success of such concepts and can improve if such systems can be developed to be used in larger networks.

A scoping review of the use of e-learning and e-consultation for healthcare workers in low- and middle-income countries and their potential complementarity

OBJECTIVE

Although the provision of e-learning (EL) training for healthcare workers (HCWs) and provider-to-HCW e-consultation (EC) is considered useful for health outcomes, research on their joint use is limited. This scoping review aimed to create an overview of what is currently known in the literature about the use and implementation of EC and EL by HCWs in LMICs and to answer the question of whether there is evidence of complementarity.

MATERIALS AND METHODS

Scientific databases were searched and peer-reviewed papers were reviewed systematically according to predefined inclusion/exclusion criteria. Data were extracted including the study focus (EC/EL), year of publication, geographical location, target population, target disease(s) under study, type(s) of study outcomes, and article type.

RESULTS

A total of 3051 articles were retrieved and screened for eligibility, of which 96 were kept for analysis. Of these, only 3 addressed both EL and EC; 54 studies addressed EL; and 39 addressed EC. Most studies looked at gain in knowledge/skills usability, efficiency, competence, and satisfaction of HCW, or barriers/challenges to implementation. Descriptive studies focused on the application of EL or EC for targeting specific health conditions. Factors contributing to the success of EC or EL networks were institutional anchoring, multiple partnership, and capacity building of local experts.

CONCLUSIONS

Our review found an important gap in the literature in relation to the complementary role of EL and EC for HCWs in LMICs evidenced by outcome measures. There is an important role for national and international academic institutions, learned medical societies, and networks to support regional experts in providing EL and EC for added value that will help the clinical performance of HCWs and improve health outcomes.

"A decade's worth of work in a matter of days": The journey to telehealth for the whole population in Australia

Introduction

Internationally the COVID-19 pandemic has triggered a dramatic and unprecedented shift in telehealth uptake as a means of protecting healthcare consumers and providers through remote consultation modes. Early in the pandemic, Australia implemented a comprehensive and responsive set of policy measures to support telehealth. Initially targeted at protecting vulnerable individuals, including health professionals, this rapidly expanded to a “whole population” approach as the pandemic evolved. This policy response supported health system capacity and community confidence by protecting patients and healthcare providers; creating opportunities for controlled triage, remote assessment and treatment of mild COVID-19 cases; redeploying quarantined or isolated health care workers (HCWs); and maintaining routine and non-COVID healthcare.

Purpose

This paper provides a review of the literature regarding telephone and video consulting, outlines the pre-COVID background to telehealth implementation in Australia, and describes the national telehealth policy measures instituted in response to COVID-19. Aligned with the existing payment system for out of hospital care, and funded by the national health insurance scheme, a suite of approximately 300 temporary telehealth Medicare-subsidised services were introduced. Response to these initiatives was swift and strong, with 30.01 million services, at a cost of AUD $1.54 billion, claimed in the first six months.

Findings

This initiative has been a major policy success, ensuring the safety of healthcare consumers and healthcare workers during a time of great uncertainty, and addressing known financial risks and barriers for health service providers. The risks posed by COVID-19 have radically altered the value proposition of telehealth for patients and clinicians, overcoming many previously encountered barriers to implementation, including willingness of clinicians to adopt telehealth, consumer awareness and demand, and the necessity of learning new ways of conducting safe consultations. However, ensuring the quality of telehealth services is a key ongoing concern.

Conclusions

Despite a preference by policymakers for video consultation, the majority of telehealth consults in Australia were conducted by telephone. The pronounced dominance of telephone item numbers in early utilisation data suggests there are still barriers to video-consultations, and a number of challenges remain before the well-described benefits of telehealth can be fully realised from this policy and investment. Ongoing exposure to a range of clinical, legislative, insurance, educational, regulatory, and interoperability concerns and solutions, driven by necessity, may drive changes in expectations about what is desirable and feasible – among both patients and clinicians.

Lights and Shadows of the Perception of the Use of Telemedicine by Romanian Family Doctors During the COVID-19 Pandemic

Introduction

Telemedicine has emerged as a critical technology to mitigate SARS-CoV-2 infection. We aim in this work to explore how general practitioners (GPs) perceived the use of telemedicine, recently recognized and reimbursed by the Public Health Insurance House (PHIH) for primary care (PC) provision.

Methods

A cross-sectional study was performed in 2020 in one county of Romania using an anonymous questionnaire that assessed physicians' perceptions regarding teleconsultation, reliability in tele-decision, remote pathology management, pregnant women's surveillance, patients' satisfaction with telemedicine, the need for its further reimbursement. Bivariate correlation was used to measure associations between the investigated issues.

Results

More than a quarter of GPs (28.6%) found it easier to address patients' healthcare needs remotely, while 60.7% considered time-consuming teleconsultations compared to face-to-face visits. Tele-diagnostic uncertainty was expressed by 64.3% of physicians, and a quarter were confident in tele-decisions. Almost half of GPs (43%) observed patients' satisfaction with tele-visits, while half said patients encountered difficulties using technology. A large percentage of doctors (62.5%) perceived that patients felt as well treated by virtual as in-person visit and 91.1% suggested post-pandemic reimbursement. The results of the bivariate correlation showed that physicians who perceived positive patient feedback on telemedicine were more supportive of subsequent reimbursement.

Conclusion

This study showed the GPs' positive perception of the use of telemedicine. Its adoption in PC has shed light on the shadows of the pandemic. The time-consuming nature of teleconsultations, uncertainty in tele-decisions, patients' difficulties in using technology were seen as shadows of telecare. However, most of the GPs surveyed agreed with the need for further reimbursement. Future work should focus on innovative solutions for integrating telemedicine as complementary form of PC, the need for telemedicine-based training for GPs to improve capacity building, and patients' perceptions of virtual care, helping to build trust and satisfaction.

Mobile Health Strategies to Tackle Skin Neglected Tropical Diseases With Recommendations From Innovative Experiences: Systematic Review

Background

Neglected tropical diseases (NTDs) represent a diverse group of 20 communicable diseases that occur in tropical and subtropical areas in 149 countries, affecting over 1 billion people and costing developing economies billions of dollars every year. Within these diseases, those that present lesions on the skin surface are classified as skin NTDs (sNTDs). Mobile health interventions are currently being used worldwide to manage skin diseases and can be a good strategy in the epidemiological and clinical management of sNTDs.

Objective

We aimed to analyze existing evidence about mobile health interventions to control and manage sNTDs in low- and middle-income countries (LMICs) and make recommendations for what should be considered in future interventions.

Methods

A systematic review was conducted of the MEDLINE, Embase, and Scopus databases over 10 years up to April 30, 2020. All types of clinical studies were considered. Data were synthesized into evidence tables. Apps were selected through a comprehensive systematic search in the Google Play Store and Apple App Store conducted between March 20 and April 15, 2020.

Results

From 133 potentially relevant publications, 13 studies met our criteria (9.8%). These analyzed eight different interventions (three SMS text messaging interventions and five app interventions). Six of the 13 (46%) studies were community-based cross-sectional studies intended to epidemiologically map a specific disease, mainly lymphatic filariasis, but also cutaneous leishmaniasis, leprosy, and NTDs, as well as sNTDs in general. Most of the studies were considered to have a high (5/13, 39%) or moderate (4/13, 31%) risk of bias. Fifteen apps were identified in the Google Play Store, of which three were also in the Apple App Store. Most of the apps (11/15, 73%) were targeted at health care professionals, with only four targeted at patients. The apps focused on scabies (3/15, 20%), lymphatic filariasis (3/15, 20%), cutaneous leishmaniasis (1/15, 7%), leprosy (1/15, 7%), yaws and Buruli ulcer (1/15, 7%), tropical diseases including more than one sNTDs (3/15, 20%), and NTDs including sNTDs (2/15, 13%). Only 1 (7%) app focused on the clinical management of sNTDs.

Conclusions

All mobile health interventions that were identified face technological, legal, final user, and organizational issues. There was a remarkable heterogeneity among studies, and the majority had methodological limitations that leave considerable room for improvement. Based on existing evidence, eight recommendations have been made for future interventions.

Patterns of skin cancer and treatment outcomes for patients with albinism at Kisangani Clinic, Democratic Republic of Congo

BACKGROUND

People with albinism (PWA) are at increased risk of photodamage and skin cancer. In many parts of Africa, there is a significant lack of knowledge regarding albinism which can lead to societal stigma, discrimination, and persecution from an early age. In the Democratic Republic of Congo (DRC), there is limited clinical data on PWA and skin cancer. We aim to better understand sociodemographics, risk factors, clinical features, and outcomes of this population.

METHODS

Patients with a diagnosis of albinism and skin cancer presenting to Kisangani Albino Clinic were enrolled.

RESULTS

Of 205 PWA, 61 patients were diagnosed with skin cancer with a mean age of 26.5 years. Common occupations were student (45.6%) or unemployed (26.4%). Discrimination was experienced from close contacts (24.4%) and society (67.4%). A majority (88.5%) had never used sunscreen, only 4.9% used fully sun protective clothing, and 90.2% spent 4 or more hours in the sun daily. Skin cancers had a mean size of 3.8 cm and were most commonly located on the face (47.7%). Squamous cell carcinoma was the most common histopathological diagnosis. Most patients underwent excision, and 90.2% had clinical clearance of tumors at a mean follow-up of 5.7 months.

CONCLUSION

People living with albinism in the DRC experience a high rate of nonmelanoma skin cancers at a young age and additionally face a number of psychosocial challenges. This study represents the first attempt to analyze a cohort of patients with albinism from the DRC and serves to increase awareness of this vulnerable population.

Evaluating diverse electronic consultation programs with a common framework

Background

Electronic consultation is an emerging mode of specialty care delivery that allows primary care providers and their patients to obtain specialist expertise without an in-person visit. While studies of individual programs have demonstrated benefits related to timely access to specialty care, electronic consultation programs have not achieved widespread use in the United States. The lack of common evaluation metrics across health systems and concerns related to the generalizability of existing evaluation efforts may be hampering further growth. We sought to identify gaps in knowledge related to the implementation of electronic consultation programs and develop a set of shared evaluation measures to promote further diffusion.

Methods

Using a case study approach, we apply the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) and the Quadruple Aim frameworks of evaluation to examine electronic consultation implementation across diverse delivery systems. Data are from 4 early adopter healthcare delivery systems (San Francisco Health Network, Mayo Clinic, Veterans Administration, Champlain Local Health Integration Network) that represent varied organizational structures, care for different patient populations, and have well-established multi-specialty electronic consultation programs. Data sources include published and unpublished quantitative data from each electronic consultation database and qualitative data from systems’ end-users.

Results

Organizational drivers of electronic consultation implementation were similar across the systems (challenges with timely and/or efficient access to specialty care), though unique system-level facilitators and barriers influenced reach, adoption and design. Effectiveness of implementation was consistent, with improved patient access to timely, perceived high-quality specialty expertise with few negative consequences, garnering high satisfaction among end-users. Data about patient-specific clinical outcomes are lacking, as are policies that provide guidance on the legal implications of electronic consultation and ideal remuneration strategies.

Conclusion

A core set of effectiveness and implementation metrics rooted in the Quadruple Aim may promote data-driven improvements and further diffusion of successful electronic consultation programs.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3626-4) contains supplementary material, which is available to authorized users.

Long-Range Diagnosis of and Support for Skin Conditions in Field Settings

Skin diseases are a significant cause of morbidity and mortality worldwide; however, access to dermatology services are critically limited, particularly in low- to middle-income countries (LMIC), where there is an overall shortage of physicians. Implementation of long-range technological support tools has been growing in an effort to provide quality dermatology care to even the most remote settings globally. eHealth strategies can provide realistic healthcare solutions if implemented in a feasible and sensitive way, customizing tools to address the unique needs and resource limitations of the local setting. This article summarizes the various types of telemedicine and mobile health (mHealth) tools and their practical applications and benefits for patient care. The challenges and barriers of teledermatology are discussed, as well as steps to consider when implementing a new teledermatology initiative. eHealth arguably offers one of the most flexible and realistic tools for providing critically needed access to dermatology skills in underserved LMICs.

The Development of Complex Digital Health Solutions: Formative Evaluation Combining Different Methodologies

Background

The development of digital health solutions for current health care settings requires an understanding of the complexities of the health care system, organizational setting, and stakeholder groups and of the underlying interplay between stakeholders and the technology. The digital health solution was founded on the basis of an information and communication technology platform and point-of-care devices enabling home-based monitoring of disease progression and treatment outcome for patients with rheumatoid arthritis (RA).

Objective

The aim of this paper is to describe and discuss the applicability of an iterative evaluation process in guiding the development of a digital health solution as a technical and organizational entity in three different health care systems.

Methods

The formative evaluation comprised the methodologies of contextual understanding, participatory design, and feasibility studies and included patients, healthcare professionals, and hardware and software developers. In total, the evaluation involved 45 patients and 25 health care professionals at 3 clinical sites in Europe.

Results

The formative evaluation served as ongoing and relevant input to the development process of the digital health solution. Through initial field studies key stakeholder groups were identified and knowledge obtained about the different health care systems, the professional competencies involved in routine RA treatment, the clinics’ working procedures, and the use of communication technologies. A theory-based stakeholder evaluation achieved a multifaceted picture of the ideas and assumptions held by stakeholder groups at the three clinical sites, which also represented the diversity of three different language zones and cultures. Experiences and suggestions from the patients and health care professionals were sought through participatory design processes and real-life testing and actively used for adjusting the visual, conceptual, and practical design of the solution. The learnings captured through these activities aided in forming the solution and in developing a common understanding of the overall vision and aim of this solution. During this process, the 3 participating sites learned from each other’s feed-back with the ensuing multicultural inspiration. Moreover, these efforts also enabled the consortium to identify a ‘tipping point’ during a pilot study, revealing serious challenges and a need for further development of the solution. We achieved valuable learning during the evaluation activities, and the remaining challenges have been clarified more extensively than a single-site development would have discovered. The further obstacles have been defined as has the need to resolve these before designing and conducting a real-life clinical test to assess the outcome from a digital health solution for RA treatment.

Conclusions

A formative evaluation process with ongoing involvement of stakeholder groups from 3 different cultures and countries have helped to inform and influence the development of a novel digital health solution, and provided constructive input and feedback enabling the consortium to control the development process.

The Collaborative Role of North American Departments of Pediatrics in Global Child Health

Appeals for health equity call for departments of pediatrics to improve the health of all children including those from underserved communities in North America and around the world. Consequently, North American (NA) departments of pediatrics have a role in global child health (GCH) which focuses on providing health care to underserved children worldwide. In this review, we describe how NA departments of pediatrics can collaboratively engage in GCH education, clinical practice, research, and advocacy and summarize best practices, challenges, and next steps for engaging in GCH in each of these areas. For GCH in low- and middle-income countries (LMICs), best practices start with the establishment of ethical, equitable, and collaborative partnerships with LMIC communities, organizations, and institutions engaged in GCH who are responsible for the vast majority of work done in GCH. Other best practices include adequate preparation of trainees and clinicians for GCH experiences; alignment with local clinical and research priorities; contributions to local professional development and ongoing monitoring and evaluation. Challenges for departments include generating funding for GCH activities; recruitment and retention of GCH-focused faculty members; and challenges meeting best practices, particularly adequate preparation of trainees and clinicians and ensuring mutual benefit and reciprocity in NA-LMIC collaborations. We provide examples of how departments have overcome these challenges and suggest next steps for development of the role of NA departments of pediatrics in GCH. Collaborative implementation of best practices in GCH by LMIC-NA partnerships can contribute to reductions of child mortality and morbidity globally.

Ethics of emergent information and communication technology applications in humanitarian medical assistance

New applications of information and communication technology (ICT) are shaping the way we understand and provide humanitarian medical assistance in situations of disaster, disease outbreak or conflict. Each new crisis appears to be accompanied by advancements in humanitarian technology, leading to significant improvements in the humanitarian aid sector. However, ICTs raise ethical questions that warrant attention. Focusing on the context of humanitarian medical assistance, we review key domains of ICT innovation. We then discuss ethical challenges and uncertainties associated with the development and application of new ICTs in humanitarian medical assistance, including avoiding harm, ensuring privacy and security, responding to inequalities, demonstrating respect, protecting relationships, and addressing expectations. In doing so, we emphasize the centrality of ethics in humanitarian ICT design, application and evaluation.

State of global pediatric neurosurgery outreach: survey by the International Education Subcommittee

OBJECTIVE Neurosurgical services are increasingly recognized as essential components of surgical care worldwide. The degree of interest among neurosurgeons regarding international work, and the barriers to involvement in global neurosurgical outreach, are largely unexplored. The authors distributed a survey to members of the American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS) Joint Section on Pediatric Neurosurgery to assess the state of global outreach among its members and to identify barriers to involvement. METHODS An internet-based questionnaire was developed by the International Education Subcommittee of the AANS/CNS Joint Section on Pediatric Neurosurgery and distributed to pediatric neurosurgeons via the AANS/CNS Joint Section email contact list. Participants were surveyed on their involvement in global neurosurgical outreach, geographic location, nature of the participation, and barriers to further involvement. RESULTS A 35.3% response rate was obtained, with 116 respondents completing the survey. Sixty-one percent have performed or taught neurosurgery in a developing country, and 49% travel at least annually. Africa was the most common region (54%), followed by South America (30%), through 29 separate organizing entities. Hydrocephalus was the most commonly treated condition (88%), followed by spinal dysraphism (74%), and tumor (68%). Most respondents obtained follow-up through communications from local surgeons (77%). Seventy-one percent believed the international experience improved their practice, and 74% were very or extremely interested in working elsewhere. Interference with current practice (61%), cost (44%), and difficulty identifying international partners (43%) were the most commonly cited barriers to participation. CONCLUSIONS Any coordinated effort to expand global neurosurgical capacity begins with appreciation for the current state of outreach efforts. Increasing participation in global outreach will require addressing both real and perceived barriers to involvement. Creation and curation of a centralized online database of ongoing projects to facilitate coordination and involvement may be beneficial.

Improving health-care delivery in low-resource settings with nanotechnology: Challenges in multiple dimensions

In the two decades after 1990, the rates of child and maternal mortality dropped by over 40% and 47%, respectively. Despite these improvements, which are in part due to increased access to medical technologies, profound health disparities exist. In 2015, a child born in a developing region is nearly eight times as likely to die before the age of 5 than one born in a developed region and developing regions accounted for nearly 99% of the maternal deaths. Recent developments in nanotechnology, however, have great potential to ameliorate these and other health disparities by providing new cost-effective solutions for diagnosis or treatment of a variety of medical conditions. Affordability is only one of the several challenges that will need to be met to translate new ideas into a medical product that addresses a global health need. This article aims to describe some of the other challenges that will be faced by nanotechnologists who seek to make an impact in low-resource settings across the globe.

A retrospective study on how primary care providers manage specialists' recommendations after an e-consultation

Introduction:

E-consultations are asynchronous text-based consultations between providers which can facilitate patient access to timely specialty care. In contrast to traditional face-to-face consults, conveying and completing recommendations of the specialist is the responsibility of the referring provider. This presents a new workflow for primary care providers who have multiple options (face-to-face, telephone, letter, secure message) to communicate the e-consultation recommendations. This study examines how primary care providers are managing this new workflow.

Methods:

We performed a retrospective random sampling of e-consultations with individual medical record review and classified e-consultations by type of recommendation, how recommendations were communicated to patients, and whether recommendations were carried out.

Results:

We randomly selected 220 e-consultations in 13 different specialties for review. In all, 85% of e-consultations contained recommendations for referring providers. Recommendations on medication(s) were most common (35%) followed by recommendations on ordering laboratory tests (29%). In all, 25% of the time e-consultants gave multiple possible courses of action for referring providers to choose from. Patient notification of recommendations was found for 192 (87%) of e-consultations with providers performing the notification 63% of the time and nursing staff performing the notification 37% of the time. The communication back to the patients included communication via nurse telephone calls (37%), provider telephone calls (23%), secure messages (24%), face-to-face visits (11%), and by written correspondence (5%).

Discussion:

Managing recommendations from e-consultations results in a new workflow for primary care providers. Healthcare institutions that utilize e-consults should be aware of this new workflow. Further study is needed to determine best practices for this task that is now increasing in primary care.

The Map and the Territory: An Ethnographic Study of the Low Utilisation of a Global eHealth Network

Recent years were marked by the implementation of many eHealth projects using information and communication technologies to provide health services in developing countries. While generating great expectations, these projects remain poorly documented and available data suggest high failure rates. This raises a practical question: How are such eHealth networks to be effectively designed and implemented? This paper addresses this question. Specifically, it presents an ethnographic study of the Pan-African e-Network, a project which connects many hospitals all across India and Africa, providing medical teleconsultations and distance learning services. The study investigates the low utilisation of the network, an issue undermining its potential and efficiency. Factors contributing to this situation include communication barriers, the presumed ego of doctors, poor awareness of the project, and a lack of flexibility to work with the specificities of the connected sites. Above all, these factors point towards a dichotomous approach across the project's design and implementation, and taking two distinct yet related forms: (a) an ontological divide between technical and ‘non-technical’ domains; (b) a political sorting out of what is and what is not the project, aimed at neutralising and accounting for heterogeneous processes and practices. In both cases, low utilisation reveals tensions between processes of closure and control, and the openness of a life that will not be contained. Ultimately, this paper intends to destabilise binary modes of thinking as they crystallise oppositions between design and implementation, project and context, technical and social worlds, efficacy and improvisation, mastery and unruliness, map and territory.

A retrospective analysis of medical record use in e-consultations

Introduction

Under certain circumstances, e-consultations can substitute for a face-to-face consultation. A basic requirement for a successful e-consultation is that the e-consultant has access to important medical history and exam findings along with laboratory and imaging results. Knowing just what information the specialist needs to complete an e-consultation is a major challenge. This paper examines differences between specialties in their need for past information from laboratory, imaging and clinical notes.

Methods

This is a retrospective study of patients who had an internal e-consultation performed at an academic medical centre. We reviewed a random sample of e-consultations that occurred in the first half of 2013 for the indication for the e-consultation and whether the e-consultant reviewed data in the medical record that was older than one year to perform the e-consultation.

Results

Out of 3008 total e-consultations we reviewed 360 (12%) randomly selected e-consultations from 12 specialties. Questions on management (35.8%), image results (27.2%) and laboratory results (25%) were the three most common indications for e-consultation. E-consultants reviewed medical records in existence more than one year prior to the e-consultation 146 (40.6%) of the time with e-consultants in the specialties of endocrinology, haematology and rheumatology, reviewing records older than one year more than half the time. Labs (20.3%), office notes (20%) and imaging (17.8%) were the types of medical data older than one year that were reviewed the most frequently overall.

Discussion

Management questions appear to be the most common reason for e-consultation. E-consultants frequently reviewed historical medical data that is older than one year at the time of the e-consultation, especially in endocrinology, haematology and rheumatology specialties. Practices engaging in e-consultations that require transfer of data may want to include longer time frames of historical information for those specialties.

User Feedback on the MSF Tele-Expertise Service After a 4-Year Pilot Trial - A Comprehensive Analysis

We surveyed all users of the Médecins Sans Frontières (MSF) tele-expertise service, approximately four years after it began operation. The survey contained 50 questions and was sent to 294 referrers and 254 specialists. There were 163 responses (response rate 30%). There were no significant differences between the responses from French and English users, so the responses were combined for subsequent analysis. Most of the responders were doctors (133 of 157 who answered that question), and most had completed field missions for MSF, i.e., both specialists and referrers. The majority stated that the system was user friendly and that they found it self-explanatory (i.e., they did not need to be shown how to use it). Almost all the referrers found that the telemedicine advice that they received was helpful, changed diagnosis and management, and/or reassured the patient. Similar feedback came from the specialists, who also felt that there was educational value for the field doctor. Although there was general satisfaction with the service, the survey identified various problems. The main concerns of the referrers were the lack of promotion of the system at headquarters' level, and the main concerns of the specialists were the lack of feedback about patient follow-up. Nonetheless, both referrers and specialists recognized the benefits of telemedicine in improving patient management, providing education, and reducing isolation in the field.

Early e-consultation face-to-face conversions

Introduction

E-consultations are asynchronous, text-based consultations. The specialist e-consultant answers clinical questions in a similar way to a standard consultation but the questions and answers are sent electronically. The e-consultant has access to some or all of the medical record but does not have contact with the patient. Although e-consultations are meant to substitute for face-to-face (F2F) consultations, a significant proportion of e-consultations are converted to F2F consultations.

Methods

We examined e-consultation content from a sample of e-consultations that had subsequent F2F visits in the same specialty as the e-consultation within 28 days of the e-consultation.

Results

Out of 5115 e-consultations, there were a total of 547 (10.7%) early F2F conversions. One hundred and fifty-one e-consultations with subsequent early F2F conversions were reviewed in eight specialties. In 64% of the F2F conversions, specialists recommended the F2F consultations. In 75% there were complex diagnostic or treatment considerations. In only 1% was there a sense of medical urgency or a stated need for physical examination.

Discussion

E-consultations convert to F2F consultations primarily at the request of the specialist. Diagnostic and treatment complexity appear to be the main reasons. We found little evidence that patients decided independently to get a F2F visit or that specialists needed a F2F visit to perform a physical examination. Although e-consultations might not be a complete substitute for F2F consultations, they may serve as an entry level consultation that could be supplemented by a video consultation as needed for cases with more diagnostic and treatment complexity.

Interactive telemedicine: effects on professional practice and health care outcomes

BACKGROUND

Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care.

OBJECTIVES

To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation).

SEARCH METHODS

We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions.

DATA COLLECTION AND ANALYSIS

For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes.

MAIN RESULTS

We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups.

AUTHORS' CONCLUSIONS

The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.

Interactive telemedicine: effects on professional practice and health care outcomes

BACKGROUND

Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care.

OBJECTIVES

To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation).

SEARCH METHODS

We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions.

DATA COLLECTION AND ANALYSIS

For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes.

MAIN RESULTS

We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups.

AUTHORS' CONCLUSIONS

The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.

A national teleradiology programme in Mali: implementation and results

We reviewed the national teleradiology programme in Mali to establish whether it improved diagnosis for patients and improved the referring doctor's ability to give an accurate diagnosis. The teleradiology programme connected the University Hospital in Bamako to all seven regional hospitals in Mali and one private health clinic. The pilot phase began in 2005 in three hospitals. Initially the implementation involved connections via broadband, but subsequently satellite antennae were provided at three remote hospitals in the north. Between 2005 and 2013, X-ray and mammogram images from 5628 patients were read by teleradiology. Radiologists provided the sole diagnosis for 29% of cases (i.e. the referrer did not make a diagnosis) and altered the regional doctor's diagnosis in 12% of cases. The proportion of cases for which the regional doctor gave no diagnosis decreased from 93% to 24% over the same period, indicating an increase in the doctors' confidence and incentive to test their own diagnosis. The percentage of cases for which regional doctors made an inaccurate diagnosis decreased to 3% in 2013. Use of the teleradiology service varied widely between hospitals. Successful implementation depended on local ownership of a network, which was developed in close collaboration with hospital leadership, national radiologists and other healthcare personnel.

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.

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.

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 network's 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.

Integration of e-consultations into the outpatient care process at a tertiary medical centre

An e-consultation is an asynchronous consultation performed by a specialist without a face-to-face patient visit. E-consultations have been available to primary care providers at the Mayo Clinic for several years. We reviewed e-consultations performed by specialists at the Mayo Clinic for the first six months of 2013. We included only "internal" e-consultations, originating from within the Rochester practice. During the study period a total of 3242 e-consultations were completed at the Mayo Clinic. After excluding those relating to patients who did not give research consent, 3008 e-consultations remained. We categorized our internal e-consultations into eight types. The most frequently used types were the first e-consultation processes to be implemented: the primary care to specialist e-consultation and the specialist to specialist e-consultation, accounting for 74% of the total. As these two types of e-consultation became widely used, the staff discovered that the e-consultation process could be adapted to meet specific practice needs and six more e-consultation types emerged. For example, intra-specialty e-consultations and surgical e-consultations accounted for 16% of the total. E-consultations appear to have improved access to specialists, and they are integrated into care processes when timely expert opinions are needed. As e-consultations evolve, it will be important to develop a standard, well-defined terminology to compare outcomes of these processes across practices.

A web-based telemedicine system for low-resource settings 13 years on: insights from referrers and specialists

BACKGROUND

One way to tackle health inequalities in resource-poor settings is to establish links between doctors and health professionals there and specialists elsewhere using web-based telemedicine. One such system run by the Swinfen Charitable Trust has been in existence for 13 years which is an unusually long time for such systems.

OBJECTIVE

We wanted to gain some insights into whether and how this system might be improved.

METHODS

We carried out a survey by questionnaire of referrers and specialists over a six months period.

RESULTS

During the study period, a total of 111 cases were referred from 35 different practitioners, of whom 24% were not doctors. Survey replies were received concerning 67 cases, a response rate of 61 per cent. Eighty-seven per cent of the responding referrers found the telemedicine advice useful, and 78% were able to follow the advice provided. As a result of the advice received, the diagnosis was changed in 22% of all cases and confirmed in a further 18 per cent. Patient management was changed in 33 per cent. There was no substantial difference between doctors and non-doctors. During the study period, the 111 cases were responded to by 148 specialists, from whom 108 replies to the questionnaire were received, a response rate of 73 per cent. About half of the specialists (47%) felt that their advice had improved the management of the patients. There were 62 cases where it was possible to match up the opinions of the referrer and the consultants about the value of a specific teleconsultation. In 34 cases (55%) the referrers and specialists agreed about the value. However, in 28 cases (45%) they did not: specialists markedly underestimated the value of a consultation compared to referrers. Both referrers and specialist were extremely positive about the system which appears to be working well. Minor changes such as a clearer referral template and an improved web interface for specialists may improve it.

Design and customization of telemedicine systems

In recent years, the advances in information and communication technology (ICT) have resulted in the development of systems and applications aimed at supporting rehabilitation therapy that contributes to enrich patients' life quality. This work is focused on the improvement of the telemedicine systems with the purpose of customizing therapies according to the profile and disability of patients. For doing this, as salient contribution, this work proposes the adoption of user-centered design (UCD) methodology for the design and development of telemedicine systems in order to support the rehabilitation of patients with neurological disorders. Finally, some applications of the UCD methodology in the telemedicine field are presented as a proof of concept.

Feasibility of a clearing house for improved cooperation between telemedicine networks delivering humanitarian services: acceptability to network coordinators

Background

Telemedicine networks, which deliver humanitarian services, sometimes need to share expertise to find particular experts in other networks. It has been suggested that a mechanism for sharing expertise between networks (a ‘clearing house’) might be useful.

Objective

To propose a mechanism for implementing the clearing house concept for sharing expertise, and to confirm its feasibility in terms of acceptability to the relevant networks.

Design

We conducted a needs analysis among eight telemedicine networks delivering humanitarian services. A small proportion of consultations (5–10%) suggested that networks may experience difficulties in finding the right specialists from within their own resources. With the assistance of key stakeholders, many of whom were network coordinators, various methods of implementing a clearing house were considered. One simple solution is to establish a central database holding information about consultants who have agreed to provide help to other networks; this database could be made available to network coordinators who need a specialist when none was available in their own network.

Results

The proposed solution was examined in a desktop simulation exercise, which confirmed its feasibility and probable value.

Conclusion

This analysis informs full-scale implementation of a clearing house, and an associated examination of its costs and benefits.

Comparative performance of seven long-running telemedicine networks delivering humanitarian services

Seven long-running telemedicine networks were surveyed. The networks provided humanitarian services (clinical and educational) in developing countries, and had been in operation for periods of 5–15 years. The number of experts serving each network ranged from 15 to 513. The smallest network had a total of 10 requesters and the largest one had more than 500 requesters. The networks operated in nearly 60 countries. The seven networks managed a total of 1857 cases in 2011, i.e. an average of 265 cases per year per network. There was a significant growth in total activity, amounting to 100.3 cases per year during the 15 year study period. In 2011, network activity was 50–700 teleconsultations per network. There were clear differences in the patterns of activity, with some networks managing an increasing caseload, and others managing a slowly reducing caseload. The seven networks had published a total of 44 papers listed in Medline which summarized the evidence resulting from the delivery of services by telemedicine. There was a dearth of information about clinical and cost-effectiveness. Nevertheless, the services were widely appreciated by referring doctors, considered to be clinically useful, and there were indications that clinical outcomes for telemedicine patients were often improved. Despite a lack of formal evidence, the present study suggests that telemedicine can provide clinically useful services in developing countries.