As an invited Moderator for GHDonline, I have been fortunate to have three leading experts in the field of telemedicine join us for this Expert Panel, to be held from February 20th to March 2nd.
Our panelists are:
* Antoine Geissbuhler
* Richard Wootton
* Dr. Shariq Khoja
A short biographical background introduction on these participants will be posted on 13th February.
I would like to ask our panellists a few general questions to set the scene. As the discussion evolves, I hope you will all contribute your own questions for our panel as well:
1. What were the lessons learned in starting and continuing a telemedicine project in low resource settings?
2. Are there resources and ways for clinical staff and organizations to get involved in current telemedicine projects?
3. What has been shown to be the highest benefits of telemedicine and what still needs to shown as benefits?
 
We look forward to hearing everyone's thoughts when this Expert Panel begins on February 20th.

 
NGENZI Joseph Lune
Replied at 11:15 AM, 8 Feb 2012

I am working on the evaluation of a callaborative Learning using Telehealth
in Rwanda and abroad for health capacity builing and I am working in Higher
Learning Institution related to Health. If there is a way to link learners
in differents settings I will be glad for that.

Area of focus is

- E-health (Masters Level)
- Nursing (Bacher's degree)
- Dental therapy (Bacher's degree)
- Physiotherapy (Bacher's degree)
- Medical imaging (Advanced diploma)

We have the facilities and the bandwidth and we are looking for experience
sharing by abraod students

Thanks

Joseph

Joaquin Blaya, PhD
Replied at 5:58 PM, 8 Feb 2012

Hi Joseph,
Could you explain a bit more what you are looking for? Is it how to have
your students participate in the Panel? How to connect people to the class
you are doing? or something different?

Thanks,

Joaquín
___________________________________________________________________
Gerente de Desarrollo, eHealth Systems <http://www.ehs.cl/>
Research Fellow, Escuela de Medicina de Harvard <http://hms.harvard.edu/>
Moderador, GHDOnline.org <http://www.ghdonline.org/>

NGENZI Joseph Lune
Replied at 1:18 AM, 9 Feb 2012

Hi Joaquin,

May be we can take like an example linking Rwanda Students in Masters in
E-health to some Public Lecturer via Videoconference and get to know what
is happening elsewhere...initiate journal Club and share research interest
me too I am in the capacity of a student in telemedecine in developing
country.

Thanks

Joseph

Joaquin Blaya, PhD
Replied at 3:28 PM, 9 Feb 2012

Yes, now I understand. I think that is a good question for the members of
the Expert Panel once it starts on Feb. 20.

Joaquín
___________________________________________________________________
Gerente de Desarrollo, eHealth Systems <http://www.ehs.cl/>
Research Fellow, Escuela de Medicina de Harvard <http://hms.harvard.edu/>
Moderador, GHDOnline.org <http://www.ghdonline.org/>

A/Prof. Terry HANNAN
Replied at 3:48 AM, 12 Feb 2012

This update on this panel is a day earlier that anticpated. This is because we have already received replies to the opening of the panel and therefore indicates some people are anticipating this important topic discussion. An additional factor is that my clinical committments ths week mean that on the 13th I may inadvertently overlook this important posting.
1. What where the lessons learned in starting and continuing a telemedicine project in low resource settings?
2. Are there resources and ways for clinical staff and organizations to get involved in current telemedicine projects?
3. What has been shown to be the highest benefits of telemedicine and what still needs to shown as benefits?


Our three panellists are:

1. Antoine Geissbuhler is Professor of Medical Informatics and Chairman of the Department of Radiology and Medical Informatics at Geneva University, Director of the Division of Medical Informatics at Geneva University Hospitals, and President of the Health-On-the-Net Foundation. He is also President-elect of the International Medical Informatics Association (IMIA) and Vice-chair of the HIMSS Europe Governing Council.
His research is on the development of innovative, knowledge-enabled information systems at the hospital level, community healthcare informatics network, and at the global level with the Health-On-the-Net Foundation (http://www.hon.ch) and south-south telemedicine network in Africa (http://raft.hcuge.ch).


2. Richard Wootton is the head of research at the Norwegian Centre for Integrated Care and Telemedicine and was previously the director of research of the Centre for Online Health at the University of Queensland. He was responsible for a research trial of a novel telepaediatric service which was delivered to various hospitals in Queensland – the results were most encouraging and demonstrated substantial patient travel savings for the health care provider. He also developed a method of automatic message-handling used by the Swinfen Charitable Trust, a global support network for doctors working in hospitals in developing countries.



3. Dr. Shariq Khoja is the Director of the Aga Khan Development Network's eHealth Resource Centre, Assistant Professor at the Aga Khan University in Kenya, and adjunct faculty at the University of Calgary. Shariq Khoja is a physician by training, with a PhD in eHealth. His research interests focus on creating evidence and policies to guide the implementation of eHealth in developing countries. Dr. Khoja is leading the ‘PAN Asian Collaboration for evidence-based e-Health Adoption and Application (PANACeA)’, which supports researchers in 17 Asian countries to create evidence for eHealth implementation. He leads eHealth initiatives for the Aga Khan Development Network globally, has contributed extensively to literature, especially through the development and validation of eHealth readiness assessment tools for healthcare institutions.

In this update there is a resubmitting of the 3 initial questions asked of panel participants [A kind of reminder focus on the topic] and their short biosketchs.

A/Prof. Terry HANNAN
Replied at 3:24 PM, 19 Feb 2012

Today I am adding in 3 separate postings the responses of our three panelists to Q1 of this discussion.

A/Prof. Terry HANNAN
Replied at 3:24 PM, 19 Feb 2012

Prof. Antoine Geissbuhler.
In the process of setting up and growing the RAFT telemedicine network over the last 12 years, we have learned many lessons.
First lesson: a telemedicine network is first and foremost a network of people who trust each other and want to collaborate,. Capacity building and social engineering are thus very important.
Second lesson: long-term success is more likely when institutional anchoring (top-down approach) and routine use by professionals (bottom-up approach) are working simultaneously. A well-defined organization of the coordination at the national level is therefore essential.
Third lesson: a multi-lateral approach that promotes and values South-South collaboration enables more relevant tele-expertise, better adapted to the socio-economic reality of isolated healthcare settings. It also enables the emergence of innovative processes and tools that leverage on the existing infrastructure. The development of centers of excellence in the countries are important in order to provide long-term sustainability.
Fourth lesson: although technology is not a major issue, the cost of internet connections can kill you unless you are able to work on low-bandwidth. This still necessitates the development of custom, adapted, and finely-tuned software, as commercial solutions are rarely designed for such challenging infrastructures.

A/Prof. Terry HANNAN
Replied at 3:25 PM, 19 Feb 2012

Prof. R. Wootton.
My answer to this question is based on my involvement with the Swinfen Charitable Trust telemedicine network. This provides support (via web-based messaging) to doctors working in developing countries. It has been in operation for about 13 years.
My observation is that anyone can start a telemedicine project, but relatively few can sustain it beyond the first few years. The Swinfen project has been sustained by a core group of retired/semi-retired Board members. One challenge is that the Swinfen network is not anchored in an institution like a teaching hospital, which would make the recruitment of experts to manage the e-referrals much easier. On the other hand, it is operated as a charity and led by a high-profile figure in the House of Lords, which makes raising charitable donations easier. I believe that the central weakness of the work, which affects all similar telemedicine networks, is the absence of quantitative data on outcomes -- this is a serious research problem which the academic community has yet to face up to. Without proper evidence for effectiveness, it is unlikely that Ministries of Health and donor agencies will take telemedicine seriously.

A/Prof. Terry HANNAN
Replied at 3:26 PM, 19 Feb 2012

A/Prof. S. Khoja.
In my experience managing telehealth projects in number of countries in South and Central Asia and East Africa, I have seen high level of interest among health providers and managers to learn about the technology and benefits of telehealth, willingness to use telehealth for patient care and learning, eagerness to use telehealth for continuing education, and acceptance of new technology and innovation. Shortage of trained health providers in these countries, especially in remote areas, have made the decision makers realize the importance of using technology to access the limited resources. There are also several barriers to the use of telehealth in such settings, which include connectivity to use live telehealth, over-burdened staff with limited support, availability of training opportunities, and sustainability of telehealth programs without external funding.

A/Prof. Terry HANNAN
Replied at 5:21 PM, 20 Feb 2012

Today I am adding the responses of our three guest panelists to the second question posed to them on this discussion topic. The question asked was;
"Are there resources and ways for clinical staff and organizations to get involved in current telemedicine projects?"

A/Prof. Terry HANNAN
Replied at 5:22 PM, 20 Feb 2012

Prof.A.Geissbuhler.
There are various ways to get involved in projects such as the RAFT network. Our educational program committee defines thematic priorities each semester and issues a call for contributions. Experienced clinicians can participate by providing quality educational contents, adapted to the training needs of care professionals who practice in remote settings (not in teaching hospitals). They can also give some of their time to participate to virtual communities of experts who respond to online tele-expertise requests. Finally, institutions can also contribute on research and development projects, such as the development of new software or the evaluation of the impact of telemedicine tools on healthcare processes and outcomes.

A/Prof. Terry HANNAN
Replied at 5:22 PM, 20 Feb 2012

Prof.R.Wootton
Yes, there are several (at least eight) telemedicine networks that support health workers in developing countries, e.g. the RAFT project.

A/Prof. Terry HANNAN
Replied at 5:23 PM, 20 Feb 2012

A/Prof.S.Khoja.
With improving connectivity through both fixed lines and mobile technologies, most areas have some connectivity available to initiate store-and-forward or live telehealth. It is important for the planners of these programs to understand the resources well, which include human, financial, technology, and policies to ensure a successful telehealth program. In low-resource settings, usually low-cost and simple telehealth solutions have better chance of success in both short and long term. Sustainability of the programs remain an issue because of the low-capacity of clients to pay for the services, even if it saves them the cost of travel.

Neil Pakenham-Walsh
Replied at 12:55 AM, 21 Feb 2012

I facilitate a global discussion forum called Healthcare Information For All by 2015 (www.HIFA2015.org). Our group of 4500-plus health professionals, publishers and information specialists discusses health systems issues - *how* to improve the availability and use of healthcare knowledge. Some of our members are providers of telemedicine services. And some of us feel that it would be valuable if there was a global service for _any_ internet-connected health professional in a low-income country to have access to urgent expert advice from a global group of medical volunteer advisers. The Swinfen Trust does this, but only for individual pre-registered institutions. Is anyone aware of existing services that provide this for any healthcare professional, without institutional pre-registration? Clearly, email is not the ideal medium for urgent advice, but it could assist an isolated healthcare provider faced with a difficult situation who is unable to get adequate help from their seniors locally.

Neil Pakenham-Walsh, HIFA2015 Coordinator, www.hifa2015.org
Twitter @hifa2015

A/Prof. Terry HANNAN
Replied at 1:32 AM, 21 Feb 2012

Neil, your response to this discussion is most welcome. You raise several queries in your statements. Are you able to formulate specific questions to the three panelists and maybe address Prof. Richard Wootton for more detailed external assessment of the Swinfen project? He will provide "observations" as an external observer and evaluator. I believe those discussions will bring to light some interesting discussions on telemedicine and it's roles in health care delivery. Terry Hannan

Juanita Fernando
Replied at 3:23 AM, 21 Feb 2012

Hi all,

These are really interesting discussions and I'm learning a great deal.

I am a health informatics researcher at Monash University and convene the honours year for local and international medical students. I have a very real interest in personal mobile devices, m-health and e-health. I know my questions are slightly off topic, but I wondered whether the panelists might comment regarding the capacity for m-health to function as a "disruptive technology" in the context of global e-health movements, which seem tied to both fixed and portable computers (i.e. laptops). Or perhaps the distinction between devices is artificial or only "disruptive" in middle income countries? I find it difficult to define what m-health is and is not. Finally, I wonder what middle income countries might be able to learn from low-income countries who are already using m-health effectively.

Cheers

Juanita

Anna E. Schmaus
Replied at 3:32 AM, 21 Feb 2012

Neil, I would like to introduce the web-based telemedicine platform CampusMedicus to you. It can be used by doctors for exchanging knowledge, diagnoses, images and documents (store-and-forward).
It can also be used for live video conferences as well as for live videos from a microscope or any other device which has a c-mount thread. For a video conference you need a webcam and for live microscope or slit lamp images you need the CM-Cam, which is a special camera for web applications. Images from the live videos can be captured into a patient record, so that you have all relevant information of one patient available.

CampusMedicus comes with a web-based form generator which allows to create forms by drag-and-drop. These forms can be filled out for every case and the result can be exported.

CampusMedicus is used for
- Clinical Decision Support
- Teaching
- Epidemiology

CampusMedicus is easy to use. It also works in regions with low internet bandwidth because we developed it for those regions. Images can be captured with smart phones and will be sent to CampusMedicus.

Let me know if you or anybody else would like to have more information or would like to register. The Open Community is free of charge for doctors, no matter where they are from. If you would like to have a private community, a fee has to be paid for it.

I hope we can improve the exchange of knowledge with CampusMedicus.

www.campusmedicus.com/more

NGENZI Joseph Lune
Replied at 4:42 AM, 21 Feb 2012

Thanks me too I am learning a lot from this discussion.

I totally I agree with the first lesson that a Telemedecine network is network of people who trust one another. It make a difference if you have first the person involved fist by face to face. This add another value for the acceptance of the technology.

Is it possible to get involved in the project starting with tele education session.

Joseph

NGENZI Joseph Lune
Replied at 4:52 AM, 21 Feb 2012

How can measure the impact and the benefits of Telemedecine and teleeducation project is there some standards tools to be used.

Thanks

Joseph

A/Prof. Terry HANNAN
Replied at 5:15 AM, 21 Feb 2012

Joseph, all three panelists could provide a response to measurement. I know that Antoine in the RAFT project has some "measures" and I think Richard has some measures from his Australian work. I stand to be corrected if I am writing out of ignorance. Terry Hannan

Sent from my iPad

Antoine Geissbuhler
Replied at 3:30 PM, 21 Feb 2012

Joseph, the question of measuring the impact of telemedicine and teleeducation is an important one. We know that this field suffers from too little evidence of its impact on meaningful outcomes, thus probably limiting its relevance to address key health issues. One of the challenges is to establish causal relationships between telemedicine/teleeducation activities and eventual changes in outcomes. Most of the impact evaluations deal with easier measures such as activity indicators, from which outcome changes are expected to be inferred. For example, in the RAFT project we are trying to measure changes in patient referral rates, or in rotation rates of care professionals, expecting these to be proxies to better decision-making capabilities and job satisfaction, respectively. An additional problem is that most projects that have evaluation components tend to evaluate different indicators, so that it is difficult to compare the respective impacts of these projects. As part of the call for action (Consensus Statement of the WHO Global eHealth Evaluation Meeting, attached), we recommended to "identify appropriate, high quality eHealth indicators (direct and proxy) that allow measurement of input, process and effect to facilitate consistent outcome measurements and comparability of studies. These could be made available in an eHealth Indicators Databank."

Attached resources:

Neil Pakenham-Walsh
Replied at 3:57 PM, 21 Feb 2012

Terry Hannan asked: "Are you able to formulate specific questions to the three panelists and maybe address Prof. Richard Wootton for more detailed external assessment of the Swinfen project?"
1. Yes, I would like to ask the three panellists and indeed all participants in this discussion if they can provide descriptions of initiatives where health professionals are provided expert advisory support for emergencies. When I was a hospital doctor in the NHS (UK) back in the 80s, there were many times when I sought essential, urgent life-saving advice from seniors by phone - especially overnight. Often these patients were unknown to the seniors - they may have just arrived in the emergency room. Occasionally I was unable to contact my senior, for example if their bleep was not working (I suspect this may be a common problem for junior hospital doctors and other health professionals in hospitals in low-income countries)? Equally valuable, life-saving advice might have been obtained from anyone of equivalent expertise, anywhere in the world. It would be wonderful if any doctor (or indeed any professional) could, if faced with a critically ill patient, count on a global support system.
2. Which brings us to the Swinfen Trust, which with I am familiar (I was honoured to be invited by Lord and Lady Swinfen to a reception at Westminster Abbey recently). The Swinfen Trust is a miscrocosm of what _could_ be achieved on a larger scale (for non-urgent support and, to a lesser extent, urgent support - the latter would ideally require availability of volunteers 24/7). I would certainly be interested to learn about Richard Wootton's observations.
With thanks,
Neil Pakenham-Walsh, www.hifa2015.org

Neil Pakenham-Walsh
Replied at 4:19 PM, 21 Feb 2012

Antoine, good comments but I would like to comment on your statement: "We know that this field suffers from too little evidence of its impact on meaningful outcomes, thus probably limiting its relevance to address key health issues." I think the lack of evidence of impact is due mainly to the difficulty of measuring impact (as is the case with health information and knowledge initiatives in general). The lack of evidence does not limit the relevance of telemedicine and tele-education to address key health issues - it just limits our ability to demonstrate the relevance/impact, which in turn limits our ability to attract increased investment in the field. This may seem a fine point, but I think it's significant. As Deming said, "The most important things cannot be measured." There are arguably few things more important than the availability and use of relevant, reliable healthcare knowledge, and yet their impact on health outcomes is notoriously hard to measure.
Thanks, Neil Pakenham-Walsh
HIFA2015.org
Twitter #hifa2015

Antoine Geissbuhler
Replied at 5:01 PM, 21 Feb 2012

Neil, still, even if WE are convinced of the relevance of such tools, it is out job to carefully document and measure their impact, and, eventually, quantify the returns on investment. At some point, decision makers must choose amongst competing interventions (e.g., sanitation, immunization, telemedicine, etc.) knowing that not all of them can be pursued because of limited resources, and should base their decisions on facts, or, better, evidence. I truly believe that the current paucity of evidence of the impact on health outcomes of telemedicine, of teleeducation or of availability of quality health information diminishes their perceived relevance. I also believe that the current political goodwill (or hype) about eHealth might not sustain if actual improvements in care and health are not documented (see the ongoing discussions about meaningful use of EHR in the US). I recommend a good overview on the evaluation of the impact of eHealth by Black et. al in PLOS medicine (see link).

Attached resources:

Richard Wootton
Replied at 1:09 AM, 22 Feb 2012

I'm responding to Neil P-W's comment/question (No 14 in this sequence) in which he said "it would be valuable if there was a global service for _any_ internet-connected health professional in a low-income country to have access to urgent expert advice from a global group of medical volunteer advisers. The Swinfen Trust does this, but only for individual pre-registered institutions. Is anyone aware of existing services that provide this for any healthcare professional, without institutional pre-registration?"

My answer is that no, I'm not aware on any body which provides medical advice to health professionals without requiring some kind of pre-registration. One obvious reason why not is that it would be impossible to be sure that the person requesting the advice was in fact a bona fide health professional.

All the networks that I know (about a dozen) have systems in place to confirm that the requesting person is a doctor, nurse etc, and also have systems to ensure that the experts they use to respond to e-referrals are suitable accredited with the relevant national body.

To clarify what Neil said, the Swinfen Charitable Trust provides a free service to support doctors in developing countries. All they need to do is contact the Trust () and provide some basic information about who they are and where they work. They can then use the Trust's secure web-based messaging system to submit referrals and obtain advice from a panel of over 500 international specialists.

Richard Wootton
Replied at 1:19 AM, 22 Feb 2012

This is my response to comment/question no 22, in which Neil P-W says "The Swinfen Trust is a miscrocosm of what _could_ be achieved on a larger scale (for non-urgent support and, to a lesser extent, urgent support - the latter would ideally require availability of volunteers 24/7). I would certainly be interested to learn about Richard Wootton's observations."

My observations are that the Swinfen telemedicine network, which has been operating for about 14 years, appears to provide useful clinical support, as judged by surveys of the referrers and some limited follow-up data of patients treated via telemedicine. There are several other networks around the world which provide similar services, and we have recently been working on methods to improve collaboration between them. This is a small step towards building a larger global network of networks.

It is worth noting that the main use of these networks is to support doctors and other health staff who are working in resource-limited circumstances and require non-emergency advice about diagnosis, management and treatment. Arguably, store-and-forward telemedicine (which is what is used here) is not suitable for life-threatening emergencies -- some kind of real-time link (like Neil bleeping his senior from the Emergency Room) is needed if the problem is really urgent. However, the Swinfen charity does receive semi-urgent referrals from time to time -- usually multiple trauma cases -- and it is surprising how much useful management advice can be delivered via web-based messaging.

Neil Pakenham-Walsh
Replied at 1:51 AM, 22 Feb 2012

Antoine: "I truly believe that the current paucity of evidence of the impact on health outcomes of telemedicine, of teleeducation or of availability of quality health information diminishes their perceived relevance."
I agree with everything you say in this message. The key word here, that was missing in the previous message, is 'perceived'.
Neil Pakenham-Walsh, www.hifa2015.org @hifa2015

Neil Pakenham-Walsh
Replied at 2:01 AM, 22 Feb 2012

In response to Richard Wootton #25: "My answer is that no, I'm not aware on any body which provides medical advice to health professionals without requiring some kind of pre-registration. One obvious reason why not is that it would be impossible to be sure that the person requesting the advice was in fact a bona fide health professional."

Yes, I agree it would make sense to have a pre-registered system (or systems) where any individual health professional could join.

"To clarify what Neil said, the Swinfen Charitable Trust provides a free service to support doctors in developing countries. All they need to do is contact the Trust () and provide some basic information about who they are and where they work. They can then use the Trust's secure web-based messaging system to submit referrals and obtain advice from a panel of over 500 international specialists."

This is great. The work of the Swinfen Trust itself (or something similar) could (with more resources) potentially be more widely marketed, scaled up, and respond to the needs of far more health professionals than it does at present. The initiative might also start to look at whether and how it is possible to put volunteer expert advisers on call for emergencies?

Neil Pakenham-Walsh
Replied at 2:10 AM, 22 Feb 2012

Richard Wootton #26: "There are several other networks around the world which provide similar services, and we have recently been working on methods to improve collaboration between them. This is a small step towards building a larger global network of networks."

Fantastic. Please can you say a bit more about current efforts to build a larger global network of networks.

Richard: "Swinfen charity does receive semi-urgent referrals from time to time -- usually multiple trauma cases -- and it is surprising how much useful management advice can be delivered via web-based messaging."

This is indicative of the huge potential of distant global expert support for both non-urgent and urgent cases.

Furthermore, coming back to the discussion with Antoine on measurement of impact and perceived relevance of telemedicine by donors and others, I would be interested to learn more about the experience of the Swinfen Trust in documenting and demonstrating impact on patient outcomes.

Many thanks - interesting discussions!
Neil Pakenham-Walsh www.hifa2015.org

Richard Wootton
Replied at 11:59 PM, 22 Feb 2012

This is my response to comment/question no 29 in which Neil P-W asks about current efforts to build a global network of networks. The first step in this process is to improve collaboration between them. At present, this occurs on an informal basis, so the next stage is to develop a more formal process. The enclosed paper suggests a possible mechanism: a central clearing house for use by the network coordinators.

Attached resource:

Neil Pakenham-Walsh
Replied at 3:39 AM, 23 Feb 2012

Richard, many thanks for this paper. The second step you describe - a central clearinghouse for use by network coordinators - sounds interesting. You propose in the article that 'a coordinators’ conference should be held to discuss who would operate the clearing house and how it would be resourced'. There are potentially many other ways in which networks might be able to communicate and cooperate more effectively. Going back to your first step 'to improve collaboration', I would like to suggest that building further informal collaboration among network coordinators - and, indeed, 'ordinary' members of different networks - would be invaluable in the first instance. This would provide the basis for exploration of _all_ possible options for increased collective impact, including but not restricted to the option of a clearinghouse.
Best wishes, Neil Pakenham-Walsh www.hifa2015.org @hifa2015

Alvin Marcelo, MD
Replied at 5:49 AM, 23 Feb 2012

Interesting thread. Would Swinfen agree to accept referrals vetted by pre-registered telehealth units? Then it would be a matter of connecting hubs from each country to form an inter-network of domain experts...


Sent from my BlackBerry® wireless handheld

Joaquin Blaya, PhD
Replied at 5:32 PM, 23 Feb 2012

In another discussion about telemedicine, someone posted a video of work
Doctors Without Borders (MSF) had done in Somalia
http://www.youtube.com/watch?v=rH7617_MR98&list=UUtVkQP9AKVbgftmzNI72KHQ&inde...

Do you see this experience and system would be useful in the projects
you've seen? What do you think it would take to replicate this in other
settings?

Thanks,

Joaquín
___________________________________________________________________
Gerente de Desarrollo, eHealth Systems <http://www.ehs.cl/>
Research Fellow, Escuela de Medicina de Harvard <http://hms.harvard.edu/>
Moderador, GHDOnline.org <http://www.ghdonline.org/>

Anna E. Schmaus
Replied at 3:21 AM, 24 Feb 2012

Dear Alvin,
you can use CampusMedicus and form a network of expert doctors. CampusMedicus is a web-based platform which allows to exchange patient records, images and other files using store-and-forward as well as live videoconferences. Communities can be organised by a group of doctors. Every doctor who has a PC, laptop with internertnet connection or a smart phone can send images, write diagnoses and receive those diagnoses. This will become the world wide expert network. You can find a video on Youtube showing the basic features of CampusMedicus http://med.cx/tHSGGJ

Antoine Geissbuhler
Replied at 3:43 AM, 24 Feb 2012

Regarding Neil's comment #22 about emergencies, our experience in the RAFT is somewhat limited, as most of the tele-expertise activity is based on a secure store-and-forward mechanism. Typical response times are around 24 hours. Nevertheless, the need for faster turnaround times, compatible with medical emergencies, has been identified and we are working on two different solutions:

1. there is a junior physican on call at the CERTES in Bamako. He is notified whenever a new tele-expertise request is posted on the platform, with a task to find the appropriate expert in the appropriate delay.

2. we are currently testing a tool for synchronous communication of live video images from portable ultrasound devices, in order to assist general practitioners to make appropriate diagnoses and decisions regarding difficult, emergent cases. Lab tests have shown that we can do this (voice and video) with 40 kbps links, and real-world testing is underway in Mali.

Antoine Geissbuhler
Replied at 3:57 AM, 24 Feb 2012

Regarding Joaquin's comment #33: this presentation is an excellent illustration of the potential of tele-expertise, congratulations to MSF for measuring it. As mentioned earlier, synchronous tele-expertise consultations are a bit more difficult to organize due to logistical constraints (making sure that the expert is available when needed) and to technical constraints (high bandwidth is necessary, and still very expensive, thus limiting sustainability). Our positive experiences in such synchronous tele-expertise support include the ongoing weekly clinical case discussions with the Mirwais hospital in Kandahar (Afghanistan) in collaboration with the ICRC, and bi-monthly tele-psychiatry consultations between Yaoundé and remote hospitals in Cameroon (there are only 4 psychiatrists in Cameroon, for a population of 20 millions...). Hopefully, with more accessible bandwidth, these activities will scale-up.

A/Prof. Terry HANNAN
Replied at 5:31 AM, 26 Feb 2012

To all who have been contributing to this sequential discussion (wonderful professioanl interactions) I can see that the panelists responses have in many ways adressed their resposnes to Question 3 that was originally posed to them.
Q 3. What has been shown to be the highest benefits of telemedicine and what still needs to be shown as benefits?
I have been on conference leave when this discussion got underway. So for completeness and acknolwledgement of the the efforts put in by the 3 panelists I am posting their responses in the next three Reply Submits.

A/Prof. Terry HANNAN
Replied at 5:32 AM, 26 Feb 2012

Q3 response: Prof. A. Geissbuhler.
What has been shown so far is that telemedicine is feasible in low-resource settings, that it answers clear and important needs of care professionals by providing continuing medical education, by facilitating access to expert advice, and by enabling task-shifting and decentralization of diagnostic tools.

A/Prof. Terry HANNAN
Replied at 5:33 AM, 26 Feb 2012

Addendum A. Geissbuhler: omitted in Copy and Paste:
What hasn’t been shown convincingly yet, and must be in order to be able to justify a wider deployment of these tools, are the impacts of such tools on healthcare processes, on financial returns on investment, and on health outcomes.

A/Prof. Terry HANNAN
Replied at 5:34 AM, 26 Feb 2012

Q3. Prof.R. Wootton:The principal benefit of telemedicine is that it improves access to health care, for example, by reducing the travel required from doctor or patient. While there is some evidence that telemedicine is clinically effective in developing countries, the evidence is not strong, and there is almost no information about cost-effectiveness. This is important because if resources are to be expended on telemedicine, then they will not be available for proven measures such as vaccination or sanitation.

A/Prof. Terry HANNAN
Replied at 5:34 AM, 26 Feb 2012

Q3. A/Prof.S. Khoja: Most Telehealth initiatives have shown good volumes, demonstrating improvement in access and also improving quality of care by providing exposure to and improving knowledge of remote health providers. Telehealth programs have also demonstrated reduction in cost for clients by avoiding travel to health facilities and saving opportunity cost for the patients. Reports also show improvement in patient care by ensure quick diagnosis by experts, and improved knowledge of health providers. There are number of areas which need to be evaluated in telemedicine, such as the changing relationships among the providers, and between the providers and the patients, improvement in health outcomes that can be attributed to telehealth, and cost-effectiveness of telehealth for the providers and health systems. It is also important to evaluate the changing organizational cultures, security of information, and impact of different policies on the practice of telemedicine.

A/Prof. Terry HANNAN
Replied at 3:19 PM, 26 Feb 2012

CONCLUDING THIS DISCUSSION:
To all panellists and contributors,
This notation confirms the official closure of this panel discussion on Telemedicine.
This is an opportune time to thank GHDonline for their support and our amazing panellists Antoine, Richard and Shariq. Their willingness to commit time to this discussion and share their knowledge within is their busy schedules cannot be underestimated. Of course all those responding to the panel provide a measure of the worth of these discussions which has been robust and to you I extend my thanks.
GHDOnline encourages further discussion in this and other forums, both internal and external. Please feel free to start new related discussion threads on GHDonline, e.g., by using a new subject line if you reply by email (which would actually be preferred over extending this impressively long discussion.) Looking forward to more! Thanks again. Terry Hannan

Joaquin Blaya, PhD
Replied at 3:41 PM, 14 Mar 2012

Hi everyone,
I wanted to send the link to another follow up discussion that ocurred
http://www.ghdonline.org/tech/discussion/telemedicine-panel-follow--on/

Marie Connelly
Replied at 4:48 PM, 17 Apr 2012

Thank you all for joining us for this Expert Panel discussion on telemedicine. We've summarized the key points from the panel into a short discussion brief available at: http://bit.ly/HNT56x
(Please note, you must be logged in to GHDonline to view and download this brief.)

If you would like to share additional examples of existing telemedicine resources, or details of telemedicine projects you have implemented or used in clinical settings, please add them to our follow-on discussion at: http://www.ghdonline.org/tech/discussion/telemedicine-panel-follow--on/

Again, many thanks to our panelists and members for such a rich discussion!

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