Health IT

Generally speaking,I would expect clinicians working in such areaas to be open to the idea and possibly embrace such technology with open arms.It is important however,to initiate the process with clinicians as the key persons rather than non professionals.Direct telemedicine for the community is likely to fail.
The clinicians are going to look forward to case based help.There is no point teaching how to manage a disease in general.When confronted with an actual patient,they will be happy to learn how to do it better.
One option can be to create a web based community where doctors from such areas from all countries come on a common platform with international experts in different specialities.The community members should be able to posst cases easily and a healthy discussion generated which translates into meaningful clinical suggestions.The moderator would play a key role in ensuring that discussion proceeds in the right direction and should preferably himself be an experienced clinician who has also first hand experience of work in such areas.



Legal aspects of course,would need to be studied and it needs to be ensured that community members are not leagally liable for the ...

Generally speaking,I would expect clinicians working in such areaas to be open to the idea and possibly embrace such technology with open arms.It is important however,to initiate the process with clinicians as the key persons rather than non professionals.Direct telemedicine for the community is likely to fail.
The clinicians are going to look forward to case based help.There is no point teaching how to manage a disease in general.When confronted with an actual patient,they will be happy to learn how to do it better.
One option can be to create a web based community where doctors from such areas from all countries come on a common platform with international experts in different specialities.The community members should be able to posst cases easily and a healthy discussion generated which translates into meaningful clinical suggestions.The moderator would play a key role in ensuring that discussion proceeds in the right direction and should preferably himself be an experienced clinician who has also first hand experience of work in such areas.



Legal aspects of course,would need to be studied and it needs to be ensured that community members are not leagally liable for the advice. After all,it is all expected to be well intentioned only.

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As a prominent Tanzanian Telemedicine implementer with over 50 hospitals in our network, I'd recommend iPath network.

It may not be the slickiest out there but based on your said needs, it has proven its usefulness in a neighboring country from yours (Tanzania).
It is web based,
it has a light user interface,
the learning curve is minimal,
it loads even on older computers and browsers,
It allows personalized specialties,
It is from University hospital (Basel)
It is open sources,
You may use an online version for free,
It has a backing from specialists in most specialties,
It is made with resource minimalization in mind,
Mobile modems are just good for its use remotely,
It allows text, images, videos, Dicom seq's, XRay captures, remote microscopy and e-learning

The list may be endless and tiring so I won't put its every detail down here. You can check it online on ipath-network.com and if you need to see our own version it is on www.ipath-network.com/tanzania and I can arrange for you to have a test account and see the functioning it has. Should you also be interested in learning from us, we as a charitable ...

As a prominent Tanzanian Telemedicine implementer with over 50 hospitals in our network, I'd recommend iPath network.

It may not be the slickiest out there but based on your said needs, it has proven its usefulness in a neighboring country from yours (Tanzania).
It is web based,
it has a light user interface,
the learning curve is minimal,
it loads even on older computers and browsers,
It allows personalized specialties,
It is from University hospital (Basel)
It is open sources,
You may use an online version for free,
It has a backing from specialists in most specialties,
It is made with resource minimalization in mind,
Mobile modems are just good for its use remotely,
It allows text, images, videos, Dicom seq's, XRay captures, remote microscopy and e-learning

The list may be endless and tiring so I won't put its every detail down here. You can check it online on ipath-network.com and if you need to see our own version it is on www.ipath-network.com/tanzania and I can arrange for you to have a test account and see the functioning it has. Should you also be interested in learning from us, we as a charitable PPP organization will be more than ready to support you in your endeavors. Kurt Brauchli (UniBasel) who is one of the founders is always more than ready to support societies in getting things done while constantly participating in Telemedicine workshops a'la ones in ITM in Antwerp.

You can also contact me privately should you need further clarification. Thanks!

Sent from my BlackBerry® smartphone from Vodacom Tanzania

I also concur what Sandeep has said fully as we have seen all that over a period of time. In the six years we have been doing this, we found out that it is best if you have a bunch of specialists in various areas who will act as overseers of what clinicians in remote areas are doing by offering second opinion to them. The moderators act to control the use and making sure that those who are specialists are truly that and the clinicians are authentic and empowered to use the platform.
Sent from my BlackBerry® smartphone from Vodacom Tanzania

Telemedicine software is not an issue; it can be custom made or picked off the shelf. However, for a low income geography, the interface would need to be simple and reliable. The key issue is broadband access. If fast and reliable enough, commercial sevice providers can be used, but I would recommend VSAT connectivity between stations. Let me know if you need help in construction the software.

Thank you so much to all the 5 replies; I'm very gratefully indeed to my Prof. Ron for ground knowledge. Actually i'm completing my graduate studies in Msc. e-Health or health Informatics at KHI/Rwanda Biomedical Center. And, I was much more interested to get inputs on how to advise to an NGO setting for the use of web based, store and forward telemedicine in a low-income though moving first to reach a middle income country i.e Rwanda.

I Read and got some good information there but still i need to know where exactly do you start and where does it end as if you are tasked to do so....as a trusted leader in tele-health:?!?

Thank you all for you great inputs.

Enock
Msc. Health Informatics
KHI

Dear Enoch, I am glad you have joined E-Health expert it is in such forum
where theory learned in class could be turn into real life project by
initiating new project and activities.

Joseph

KHI

E-Health Center of Excellence

Rwanda

I agree with others' feelings that the solution should be driven by frequent meetings between clinicians and local beneficiaries, and NOT by technology or a donor.

Regarding technology, for anything web-based to work, it needs a device that supports it. Only computers and the latest "smart phone" mobile phones fall into that category. Computers are expensive, power hungry, delicate, unreliable and difficult to service in any rural area. Mobiles, even smart phones, have small screens and are difficult to enter large amounts of text on. They are also eminently desirable and stealable.

Also, if by "web based" you really mean HTML, then you clearly have not tried to use any web service on a mobile/GPRS connection in rural Africa. The "web" is normally an always-on, not a store-and-forward technology, and even if you use it to implement a store-and-forward service such as email, it requires a live, working connection at the time of entry and exit of messages from the system - in this case, users posting and retrieving their data to/from a remote clinic.

The exception, and the only new technology that would meet these requirements while still being "web", is HTML5 offline applications, possibly with PhoneGap to ...

I agree with others' feelings that the solution should be driven by frequent meetings between clinicians and local beneficiaries, and NOT by technology or a donor.

Regarding technology, for anything web-based to work, it needs a device that supports it. Only computers and the latest "smart phone" mobile phones fall into that category. Computers are expensive, power hungry, delicate, unreliable and difficult to service in any rural area. Mobiles, even smart phones, have small screens and are difficult to enter large amounts of text on. They are also eminently desirable and stealable.

Also, if by "web based" you really mean HTML, then you clearly have not tried to use any web service on a mobile/GPRS connection in rural Africa. The "web" is normally an always-on, not a store-and-forward technology, and even if you use it to implement a store-and-forward service such as email, it requires a live, working connection at the time of entry and exit of messages from the system - in this case, users posting and retrieving their data to/from a remote clinic.

The exception, and the only new technology that would meet these requirements while still being "web", is HTML5 offline applications, possibly with PhoneGap to enable using the device's camera and audio features. A platform-specific app (e.g. Android app) or the device's built-in email app might also meet those needs, with more or less features and cross-device compatibility.

Possible technical solutions to the technical challenges such a project might face:

* Smart phone
* HTML5 offline application/website, OR a platform-specific app, OR the phone's built-in email app
* Solar charger
* External, fixed, high-mounted wifi/wimax/3G access point creating a local hotspot

If you need any further assistance, feel free to contact us at .

Cheers, Chris.

Thanks Kizito for the clarification of your telemed in Tanzania

Thank you so much all of you for the personal contacts, links and insights give to me.
Let me put my question very clear and more specific.

'You have been asked by an NGO to advise them on setting up an international, web based, store and forward telemedicine service".

Question: outline the approach that will be taken and the issues that need to be addressed to provide meaningful advice:?!?

Keywords: International, web based, store and forward , telemedicine.

The most crucial aspect is to tailor solutions to the needs.It is not
enough to say that we ideally need X+Y+Z.X can not be afforded & Y is not
available,hence do Z.The correct answer may be neither X nor Y nor Z but
something totally different say,W.

Dr.Sandeep Saluja

Perhaps a step back & a quick read-up on the Systems Development Life-Cycle (SDLC) would be helpful: http://en.wikipedia.org/wiki/Systems_development_life-cycle. This, or something like it, should form the basis of your approach. The content & details of each step--the questions you would ask, the designs you would create, the metrics you would use to evaluate, etc.--would then be specific & targeted to your example of telemedicine.

I agree with James,go through the system implementation cycle to get details for each step of implementation. From this point, tailor the details to your telemedicine project.

This discussion has been very informative. I would like to add three documents that document and summarise many of the issues addressed in this discussion. I hope they help.

Great job good people; Prof. Terry, James, Ester and Saluja. Thank you.

Actually the particularities of the NGO setting that is to implement International, Web based, Store and Forward Telemedicine is not known and so, simply make this as a generic guidance of how i should go about the subject and key points or issues to be addressed in such a generic format i.e as an advisory service role only.

I promise to share with you all "the final paperwork of this short research topic.

Very much encouraged to stay in touch with GHDonline, "Health IT".
Enock

In a way there are the same health issues in every country. In industrialised countries you will find well equipped and well trained doctors in the cities and less trained doctors in the rural area. A telemedicine service makes sense for the rural area physicians and hospitals. When we look at developing countries it is the same but at a lower level. That means in developing countries it makes sense to add international expert doctors to the web-based telemedicine service.
Today it is not so much a question of "how should a telemedicine software look like" because the web-based telemedicine platforms already exist. The more important question is, how to organise a telemedicine platform. A telemedicine expert group should be organised in the country. This group should define the needs, the timetable and the budget for a telemedicine system. Next step will be to find money to make sure that all the plans can be realised.

Organisation of the telemedicine core team and the experts in the rural countries have to be defined and have to be made familiar with the project idea.

The group should also look for a web-based telemedicine platform which suits their needs. Will they only ...

In a way there are the same health issues in every country. In industrialised countries you will find well equipped and well trained doctors in the cities and less trained doctors in the rural area. A telemedicine service makes sense for the rural area physicians and hospitals. When we look at developing countries it is the same but at a lower level. That means in developing countries it makes sense to add international expert doctors to the web-based telemedicine service.
Today it is not so much a question of "how should a telemedicine software look like" because the web-based telemedicine platforms already exist. The more important question is, how to organise a telemedicine platform. A telemedicine expert group should be organised in the country. This group should define the needs, the timetable and the budget for a telemedicine system. Next step will be to find money to make sure that all the plans can be realised.

Organisation of the telemedicine core team and the experts in the rural countries have to be defined and have to be made familiar with the project idea.

The group should also look for a web-based telemedicine platform which suits their needs. Will they only need a store-and-forward platform, or should it be possible to organise a video conference (e.g. tumor conference) with several doctors at different places within a patient case and discuss it? Will they need online forms for epidemiology? Do they want to use patient cases for teaching their doctors and nurses? Should smart phones be integrated into the system? Think about sending SMS through Google Mail for situations where only simple mobile phone will be available.

Will you need a simple Hospital Information System which will allow exchanging data and images with the telemedicine system?

All the mentioned points have to be worked out in a detailed project description by the national telemedicine group.

I add a picture which I received from an African physician. That is how you should start.

I would like to show that the telemedicine software is not the most important. A high degree of own initiative and enthusiasm is essential for the implementation of a national and international telemedicine system.

If you need more support, let me know.

Anna

Thanks Anna, i suspect your are putting forward great getting started points this discussion needed. I'm sorry i might have lost the rule of the community:-)! Please Community moderators i.e Prof. Terry, Hamish Fraser and Joaquin, help us to moderator this informative discussion so as to have a composed conclusion at the end of it:-?

I did not stop the discussion please..we still need great ideas from experienced personnel in the field and generic conclusion on this topic.

Looking forward to have the moderators on board. we need their smart guidance.

Let me remind some of us our discussion circle..

"You have been asked by an NGO to advise them on setting up an international, web based, store and forward telemedicine service".

Question: outline the approach that will be taken and the issues that need to be addressed to provide meaningful advice:?!?

Keywords: International, web based, store and forward , telemedicine.

Enock, your request on this interesting subject deserves a comment. I
would like to make the following brief suggestions.
1. There was an intense and fruitful discussion on our Implementers
panel earlier this year with significant inputs from Hamish Fraser and
others. I believe those discussions have significant relevance to your
requests.
2. Joaquin is (within his busy schedule) is preparing a Discussion Brief
from that panel.
3. In early September Andy Kanter and Mourice Barasa are doing
sequential Member Spotlights that relate to their experiences with the
Millennium Villages Project. Personally I am anticipating these two
people will provide invaluable knowledge to the issues you raised
(unless I am missing the points).
4. Personally I reiterate that you must involve end users as the primary
and continuing forces for success and this is the more significant that
the technology that is available (and will evolve). The publications by
Bill Tierney, Paul Biondich, Burke Mamlin and other that I posted
earlier address many of these issues.
5. I look forward to feedback.
Terry

-----Original Message-----
From: GHDonline (enock rukundo) [mailto:]
Sent: Wednesday, 22 August 2012 6:45 PM
To: Hannan, Terry J
Subject: Re: [Health IT] You ...

Enock, your request on this interesting subject deserves a comment. I
would like to make the following brief suggestions.
1. There was an intense and fruitful discussion on our Implementers
panel earlier this year with significant inputs from Hamish Fraser and
others. I believe those discussions have significant relevance to your
requests.
2. Joaquin is (within his busy schedule) is preparing a Discussion Brief
from that panel.
3. In early September Andy Kanter and Mourice Barasa are doing
sequential Member Spotlights that relate to their experiences with the
Millennium Villages Project. Personally I am anticipating these two
people will provide invaluable knowledge to the issues you raised
(unless I am missing the points).
4. Personally I reiterate that you must involve end users as the primary
and continuing forces for success and this is the more significant that
the technology that is available (and will evolve). The publications by
Bill Tierney, Paul Biondich, Burke Mamlin and other that I posted
earlier address many of these issues.
5. I look forward to feedback.
Terry

-----Original Message-----
From: GHDonline (enock rukundo) [mailto:]
Sent: Wednesday, 22 August 2012 6:45 PM
To: Hannan, Terry J
Subject: Re: [Health IT] You have been asked by an NGO to advise them on
setting up an international, web based, store and forward telemedicine
service.

enock rukundo replied to the discussion "You have been asked by an NGO
to advise them on setting up an international, web based, store and
forward telemedicine service." in the Health IT community.

Reply contents:
"Thanks Anna, i suspect your are putting forward great getting started
points this discussion needed. I'm sorry i might have lost the rule of
the community:-)! Please Community moderators i.e Prof. Terry, Hamish
Fraser and Joaquin, help us to moderator this informative discussion so
as to have a composed conclusion at the end of it:-?

I did not stop the discussion please..we still need great ideas from
experienced personnel in the field and generic conclusion on this topic.

Looking forward to have the moderators on board. we need their smart
guidance."

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and Enock, most of the people who have commented on this discussion seem to
have more experience in this specific area than Terry and I.

We moderators are just facilitators for specific events, but that this
discussion arose from your questions and that there has been this much
feedback is wonderful.

We would love if more discussions this helpful would spawn all the time.



Joaquín

What wonderful discussion! This is a very multi-dimensional topic given the stakeholders involved (completely agree that Doctors should drive these initiatives), various IT landscapes and challenges regionally, the recent rapid growth of cell phone coverage and the decrease in costs of smart phone devices.

The Swinfen Charitable Trust has been the global pioneer in store and forward telemedicine services for developing countries and already has an enormous community of referrers and specialists around the world. This seems to be the type of community that the original discussion post author is looking for.

However, in our experience in Botswana, a more sustainable approach to store-and-forward telemedicine is to create systems the broaden the reach of local specialists, then also give those local specialists the ability to forward cases to international specialists on Swinfen or otherwise. We have been able to successfully pilot a system developed by a local IT group that uses Open Data Kit (http://opendatakit.org/). Given Rwanda's investment in local IT capacity building, I believe that such a system would not be terribly difficult to develop. It is VERY important to include local doctors in the early stages of the customization of the system.

There is also ...

What wonderful discussion! This is a very multi-dimensional topic given the stakeholders involved (completely agree that Doctors should drive these initiatives), various IT landscapes and challenges regionally, the recent rapid growth of cell phone coverage and the decrease in costs of smart phone devices.

The Swinfen Charitable Trust has been the global pioneer in store and forward telemedicine services for developing countries and already has an enormous community of referrers and specialists around the world. This seems to be the type of community that the original discussion post author is looking for.

However, in our experience in Botswana, a more sustainable approach to store-and-forward telemedicine is to create systems the broaden the reach of local specialists, then also give those local specialists the ability to forward cases to international specialists on Swinfen or otherwise. We have been able to successfully pilot a system developed by a local IT group that uses Open Data Kit (http://opendatakit.org/). Given Rwanda's investment in local IT capacity building, I believe that such a system would not be terribly difficult to develop. It is VERY important to include local doctors in the early stages of the customization of the system.

There is also open source telemedicine software called SANA that integrates with OpenMRS, which may be a more appropriate option for Rwanda given their donors' investment in OpenMRS. However, I believe SANA is still in the midst of upgrading their software to be as scalable and easy to use as ODK and others that are based on Javarosa.

Given the mobile technology trends globally, I would recommend pursuing a web-based system that utilizes inexpensive Android smart phones and open source software as the hardware for collecting the case data in the field and retrieving the responses from the specialists.

Looking forward to more interesting discussions related to store-and-forward telemedicine in this community.