Role of Telemedicine in Developed and Under-Developed Countries

by Farhan Khan MD, Fizah Sajjad Chaudhary MD, Muhammad Nadeem Yousaf MD and Syed Ahmad Chan Bukhari PhD

IEEE Internet Initiative eNewsletter, May 2017

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The American Telemedicine Association (ATA) defines telemedicine as the medical information exchange from one site to another via electronic communications to improve patients’ health status [1]. The term “telehealth” is closely associated with telemedicine and used to encompass a broader definition of remote healthcare that does not involve clinical services. The innovative idea of telemedicine may have existed centuries ago, however, Thomas Bird was the first one to introduce the term “telemedicine” in the 1970s [1]. Before the advent of the internet, telephone was the mainstay for sharing medical information in the 20th century [1]. Telemedicine, eHealth, eGovernment, eCommerce and eLearning are now part of 21st century life. It is about placing citizens in the epicenter to simplify, improve and facilitate their interactions with the healthcare personnel and this facility has the potential to transform healthcare infrastructure.  

Telehealth is emerging as a critical component of the healthcare crisis solution. It holds the promise to put an impact on some of the most challenging problems in the current healthcare system: cost effective delivery, distribution of limited providers, and access to care. Telemedicine depends on various factors such as economic, social and political. In developing countries, the healthcare facilities are limited due to lack of infrastructure, low ratio of physicians to population, substandard management, and conflicting policies. In 2011, the World Health Organization (WHO) reported that the average number of physicians in developing countries is 0.7-1.0/1000 population, while in the developed countries the ratio is 3-5/1000 population [2]. This data is not stratified into the number of physicians in rural and urban populations. In developing countries, unequal distribution of the healthcare facilities are serious concerns.

At present telemedicine is largely based on the two different kinds of technologies: asynchronous and synchronous. Asynchronous, which is also referred to as “store and forward,” is used to digitally transfer patients’ related medical data such as medical history, physical examination findings, diagnostic laboratory workup, and digital radiological images. A digital image is usually captured with a digital camera, which is later stored locally as well as shared by a computer to another location. This is typically used for non-emergent situations (when a diagnosis or consultation may be needed in the following 24 to 48 hours). Tele-radiology, tele-pathology and tele-dermatology [3] are a few examples of asynchronous telemedicine. In these cases, electronically stored radiologic images of computed axial tomography (CT) or magnetic resonance imaging (MRI) scans, digital photos of skin lesions or histologic pictures of pathologic lesions can be forwarded to physicians located remotely for diagnostics and their expert opinions. This can efficiently aid in allowing necessary diagnostics and treatment in time [4].

Synchronous telemedicine or two-way interactive television, is used as a ‘face-to-face’ consultation mechanism. Videoconferencing equipment is required at both locations to enable a ‘real-time’ communication [5].  With the proliferation of cheap telecommunication equipment and services. There is a possibility that the synchronous medicine will take over the asynchronous telemedicine to assist in the remote treatment process of the stroke, acute coronary syndrome, chronic infections diseases, diabetes mellitus and psychiatric conditions. There is a need for hardware requirements and standards to be developed in the context of the asynchronous telemedicine [6].

Many specialties are thriving in the U.S. by providing services through telecare.  At this time, there are over 200 telemedicine networks, with more than 3,500 service sites in the U.S. There is a need to expand services of telemedicine in developing countries. Statistics shows the number of psychiatrists per 1,000 population in Pakistan and India are 0.31 and 0.30 respectively, which are significantly low figures. These experts can provide services to the public via telemedicine. Many developing countries have inadequate healthcare because of inaccessible medical services and are suffering from a shortage of physicians and other healthcare professionals. Lack of resources, such as doctors, medical supplies and road infrastructure, are the few factors which make it difficult to deliver quality health services in rural areas. Often clinics and hospitals located in rural areas are not well equipped to accommodate the complexity of medical services.

In neurology, stroke is the most known disease and requires urgent care because of the in-time treatment requirement for the affected patient especially in developing areas where specialized stroke centers are not reachable. Tele-stroke (neurologists provide counseling remotely to treat the stroke patients) also provides high quality stroke care to the hospitals that lack expertise in providing appropriate stoke treatment [7]. In a survey on tele-neurology, George et al., concluded that over 85% of U.S. leading neurology departments are currently using or planning to implement tele-neurology in the near future to provide their services to underdeveloped and developing areas (8). The timely provision of treatments that effectively reverse the consequences of a stroke have risen from 15% to 85% due to the availability of tele-stroke programs [9]. Telehealth supporting Intensive Care Units (often called e-ICUs) is reducing mortality rates by 15 to 30% [7]. The instruction provided to the patients or healthcare providers over telecommunication devices has reduced the intra hospital mortality rate from 12.3 to 7.1% among patients of acute myocardial infarction (10).

Tele-radiology is another well-established entity of telemedicine [11, 12]. It provides interaction between radiologists and healthcare providers for timely interpretation of radiological images and, therefore, reduces the mortality rate by establishing prompt diagnosis and treatment. Tele-psychiatry or tele-mental health is a widely used entity of telemedicine in the modern era. Psychiatrists are providing mental healthcare and counselling sessions to remote areas via audio and video call sessions. These have proved to be the most acceptable to patients. Tele-psychiatry has increased the capacity of small healthcare centers with limited resources to manage psychiatric diseases.  Not only does tele-psychiatry minimize the consultation cost, but it also allows hospitals to accept a higher number of psychiatric patients in underdeveloped and developing areas.

Moreover, telemedicine offers great opportunity for underserved and developing countries, where the basic concern is to provide primary care. Telemedicine services have successfully improved the accessibility of physicians to evaluate, diagnose, treat and provide follow up care in economically underdeveloped areas. It also provides an opportunity for rural physicians to interact, discuss and improve skills. Telemedicine technology can also be used for teaching healthcare providers, residents, fellows and students in large academic institutes. The sharing of knowledge that occurs due to the inter-site collaboration may be formal or informal. This has shown to aid healthcare professionals in overcoming the professional isolation they may often face in remote areas and improve their skills and services they offer. Telemedicine services can provide efficient means of accessing tertiary care advice in underserved areas. Telemedicine can enable patients to seek treatment earlier and adhere better to their recommended treatment as well as improve the quality of life for patients with chronic conditions. A review meta-analysis by Mair and Whitten [13], includes 32 multiple studies on patients’ satisfaction with telemedicine, showing acceptable satisfaction levels of teleconsultation.

Additionally, telemedicine is a cost-effective approach compared to in-person visits of patients to medical centers. Quality care can be established in economically developing areas of the world through the availability of remarkable technology at a reduced cost (14-16). In urban or developed areas, hospital beds are mainly occupied by patients with chronic diseases, decreasing bed availability for other patients in need. Tele-healthcare can easily overcome these obstacles by offering remote monitoring and care to patients. A recent complete review with meta-analysis determined home based telehealthcare reduces the rate of hospitalization and emergency visits with chronic illnesses [17]. In the U.S., the national average for re-admission to hospitals following a heart failure episode is 20%, and telehealth monitoring programs have reduced this statistic to less than 4% [12]. Furthermore, numerous studies have revealed the promising effects of telemedicine in lowering the cost of healthcare [18-21]. The evidence-based systemic review [22] of home tele-monitoring for chronic diseases shows significant improvement in the readmission rate and cost of hospital care, in addition to the betterment in patients’ attitudes, behaviors and their medical conditions [22].

Conclusion:

Telemedicine is an emerging approach to providing healthcare services to patients in developing areas of the world. It enhances early diagnosis of emergency problems by specialty expert physicians, reduces mortality, and yields a positive health outcome of patients by enabling early specialty consultation, compliance to medication, and reduced missed appointments and operational costs of healthcare services. However, implementation of telemedicine in developing countries is challenging for healthcare providers and policy makers due to ignorance, poverty, cultural differences, unavailability of healthcare resources and lack of expertise. These challenges can be overcome by convincing policy makers to develop infrastructure for smooth implementation of telemedicine services.

References:

[1] Zundel KM. Telemedicine: history, applications, and impact on librarianship. Bulletin of the Medical Library Association. 1996;84(1):71-9.

[2] World Health Organization. World Health statistics 2011. 2011 [Available from: http://www.who.int/whosis/whostat/EN_WHS2011_Full.pdf.

[3] Mezrich RS, DeMarco JK, Negin S, Keller I, Schonfeld S, Safer J, et al. Radiology on the information superhighway. Radiology. 1995;195(1):73-81.

[4] Young JD, Badowski ME. Telehealth: Increasing Access to High Quality Care by Expanding the Role of Technology in Correctional Medicine. Journal of clinical medicine. 2017;6(2).

[5] Hayes T, Kinsella A, Brown NA, Perednia DA. The Telemedicine Information Exchange (TIE). Journal of telemedicine and telecare. 1996;2(1):20-7.

[6] Goetz CF. Health care professionals protocol for secure online transmission of patient data. Studies in health technology and informatics. 1999;64:65-72.

[7] Wechsler LR, Demaerschalk BM, Schwamm LH, Adeoye OM, Audebert HJ, Fanale CV, et al. Telemedicine Quality and Outcomes in Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2017;48(1):e3-e25.

[8] George BP, Scoglio NJ, Reminick JI, Rajan B, Beck CA, Seidmann A, et al. Telemedicine in Leading US Neurology Departments. The Neurohospitalist. 2012;2(4):123-8.

[9] California telehealth resource center. Why are Telemedicine and Telehealth so Important in Our Healthcare System? [Available from: http://www.caltrc.org/telehealth/why-are-telemedicine-and-telehealth-so-important-in-our-healthcare-system/.

[10] Oliveira MT, Jr., Paula LJ, Marcolino MS, Canesin MF. Executive summary - guideline on telecardiology in the care of patients with acute coronary syndrome and other cardiac diseases. Arquivos brasileiros de cardiologia. 2015;105(2):105-11.

[11] Giansanti D. Teleradiology Today: The Quality Concept and the Italian Point of View. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2017.

[12] Reponen J. Teleradiology: changing radiological service processes from local to regional, international and mobile environment: Oulun yliopisto; 2010.

[11] Giansanti D. Teleradiology Today: The Quality Concept and the Italian Point of View. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2017.

[12] Reponen J. Teleradiology: changing radiological service processes from local to regional, international and mobile environment: Oulun yliopisto; 2010.

[13] Mair F, Whitten P. Systematic review of studies of patient satisfaction with telemedicine. BMJ (Clinical research ed). 2000;320(7248):1517-20.

[14] Mair F, Whitten P. Systematic review of studies of patient satisfaction with telemedicine. BMJ (Clinical research ed). 2000;320(7248):1517-20.

[15] Sorwar G, Rahamn MM, Uddin R, Hoque MR. Cost and Time Effectiveness Analysis of a Telemedicine Service in Bangladesh. Studies in health technology and informatics. 2016;231:127-34.

[16] Arora M, Harvey LA, Hayes AJ, Chhabra HS, Glinsky JV, Cameron ID, et al. Effectiveness and cost-effectiveness of telephone-based support versus usual care for treatment of pressure ulcers in people with spinal cord injury in low-income and middle-income countries: study protocol for a 12-week randomised controlled trial. BMJ open. 2015;5(7):e008369.

[17] Beratarrechea A, Lee AG, Willner JM, Jahangir E, Ciapponi A, Rubinstein A. The impact of mobile health interventions on chronic disease outcomes in developing countries: a systematic review. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2014;20(1):75-82.

[18] Polisena J, Tran K, Cimon K, Hutton B, McGill S, Palmer K, et al. Home telehealth for chronic obstructive pulmonary disease: a systematic review and meta-analysis. Journal of telemedicine and telecare. 2010;16(3):120-7.

[19] Haesum LK, Soerensen N, Dinesen B, Nielsen C, Grann O, Hejlesen O, et al. Cost-utility analysis of a telerehabilitation program: a case study of COPD patients. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2012;18(9):688-92.

[20] Johnston B, Wheeler L, Deuser J, Sousa KH. Outcomes of the Kaiser Permanente Tele-Home Health Research Project. Archives of family medicine. 2000;9(1):40-5.

[21] Paré G, Poba-Nzaou P, Sicotte C, Beaupré A, Lefrançois É, Nault D, et al. Comparing the costs of home telemonitoring and usual care of chronic obstructive pulmonary disease patients: A randomized controlled trial. European Research in Telemedicine / La Recherche Européenne en Télémédecine. 2013;2(2):35-47.

[22] de la Torre-Diez I, Lopez-Coronado M, Vaca C, Aguado JS, de Castro C. Cost-utility and cost-effectiveness studies of telemedicine, electronic, and mobile health systems in the literature: a systematic review. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2015;21(2):81-5.

[23] Paré G, Jaana M, Sicotte C. Systematic Review of Home Telemonitoring for Chronic Diseases: The Evidence Base. Journal of the American Medical Informatics Association : JAMIA. 2007;14(3):269-77.


Syed Ahmad Chan Bukhari, PhDSyed Ahmad Chan Bukhari, PhD

Dr. Bukhari is a semantic data scientist, a tech consultant and an entrepreneur. He received his PhD in computer science from University of New Brunswick, Canada. He is currently working as postdoc associate at Yale University, School of Medicine and at National Center for Biotechnology Information (NCBI) under scientific visitor’s program. At Yale, he is working as part of two NIH-funded consortia, the Center for Expanded Data Annotation and Retrieval (CEDAR, http://metadatacenter.org) and the Human Immunology Project Consortium (HIPC, http://www.immuneprofiling.org). Dr. Bukhari specific research efforts are concentrated on several core problems from the area of semantic data management. On the standards side, his focus is on the development of metadata and data standards development, and improving data submission and reuse through the development of methods that leverage ontologies and semantic web technologies. As part of the AIRR community (AIRR, http://airr.irmacs.sfu.ca) data standards working group, Dr. Bukhari with his colleagues have introduced an initial set of  ontology-aware metadata recommendations for publishing AIRR sequencing studies. On the application side, his research aims are providing non-technical users with scalable self-service access to data, typically distributed and heterogeneous. Semantic technologies, based on semantic data standards and automated reasoning, alleviate many data access-related challenges faced by biologists and clinicians, such as data fragmentation, necessity to combine data with computation and declarative knowledge in querying, and the difficulty of accessing data for non-technical users. As an entrepreneur, Dr. Bukhari and his team is working on the development of a collaborative annotation toolkit for radiologist. His startup scaai labs (http://scaailabs.com) was in top-ten innovators list of 2015 contest at sillicon valley (http://www.globaltechsymposium.com/innovators.html). His research and entrepreneurial work has  been picked by the CBC Canada, PakWired, and UNB News.

Farhan Khan

Dr. Khan, MD is a Post-Doctorate Research Fellow in the Department of Neurology, Movement Disorders Division, Yale School of Medicine.

Muhammad Nadeem Yousaf

Dr. Muhammad Nadeem Yousaf, MD is a Post-Doctorate Fellow in the Department of Internal Medicine, Section Yale Digestive Diseases, Yale University, School of Medicine.

Fizah Sajjad Chaudhary

Dr. Fizah Sajjad Chaudhary, MD, The American University of Barbados.


Editor:

Dr. Kashif Saleem Dr. Kashif Saleem

Dr. Kashif Saleem is a research scientist, currently working at Center of Excellence in Information Assurance (CoEIA), King Saud University as an Assistant Professor, since 2012. He received his M.E. and Ph.D. degrees in Electrical Engineering from University Technology Malaysia in 2007 and 2011, respectively. He took professional trainings and certifications from the University of the Aegean, Massachusetts Institute of Technology (MIT), IBM, Microsoft, Cisco. He has authored several research publications that are presented and published in renowned conferences, books and top-tier journals. His professional services include Associate and Guest Editorships, Chair, TPC Member, Invited Speaker and reviewer for several journals, conferences and workshops. Dr.Saleem have acquired and is running funded scientific research projects in KSA, EU, and the other parts of the world. His research interest mainly includes data communication and security, intelligent algorithms, Biological inspired computing, for IoT, M2M Communication, WSN, WMN, MANET, Cyber-physical Systems.

 



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