Telemedicine Proposal [PDF]

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INTRODUCTION 1.0 Background of the study Health care, as we know, is primarily about people-to-people interactions. It is about understanding, diagnosis, physical contact, communication and ultimately, providing care. All of this is facilitated by the technical processes of imaging, pathological testing, information gathering, research and so forth. The task for every health care system is how to maximize the personal contact at the same time as maximizing the technical input, while all the time operating within a sustainable financial framework. People working in developing countries have had to think about this task with even more urgency than those working in richer countries. They have had to think about how to obtain an expert opinion in remote places, how to support local clinicians who may not have all the skills they need, how to make sure technical information is interpreted wisely in very difficult circumstances and how best to use very scarce resources. Telemedicine offers help in meeting these conflicting needs by improving access to data and to individuals, while driving down the costs of doing so (Richard Wootton et al). Telemedicine tool enables the communication and sharing of medical information in electronic form and thus facilitates access to remote expertise and knowledge. A physician located far from a reference centre can consult his colleagues remotely in order to solve a difficult case, follow a continuing education course over the internet to improve his knowledge, or access medical information from digital libraries. Telemedicine is defined as the use of information technologies to exchange health information and provide health care services across geographical, time, social, and cultural barriers (Reid, 1996). In general; telemedicine technology includes both store-and-forwards (asynchronous) as well as live videoconferences (synchronous) transmissions via satellite networks. In the last decade, pilot studies in SSA countries have shown the potential benefits of telemedicine for patients and healthcare providers (Kifle et al., 2006). The results demonstrated the socio-economic impacts of telemedicine, and its potential in the area of improving accessibility, containing costs, and providing quality care (Brauchli et al., 2004; Craig et al., 2005; Kifle et al., 2006).



Statement of Research Problem In most developing countries, many villages still lack basic ICT infrastructure, such as telephone lines and power supplies that influence telemedicine technology transfer (Avgerou, 2002; Messo et al., 2005). That is why the transfer of information systems in developing countries is usually described as a problem (Heeks, 2002a, 2002b; Madon and Sahay, 2000; Montealegre, 1999; Moore and Benbasat, 1991). Specifically, when it comes to the health sector, the digital divides between developed and developing countries are wider than the gap observed in other productive and social sectors (Ratzan, 2000; Strecher, 2000; Street et al., 1997). Furthermore, productive sectors such as banking have accepted ICT faster, and allocate 5-10 percent budget for IT, while the healthcare sector is 10-15 years behind the productive sector, with only 2-3 percent of its budget allocated to IT (Gravitz, 2000; Lu and Farrell, 1990; Raghupathi and Tan, 2002). Previous Information and Communication Technology Transfer (ICTT) attempts from partners in developed countries to developing countries have failed because of neglecting infrastructural, socioeconomic and cultural factors that impact such transfers (Avgerou & Walsham, 2000; Bada, 2002; Loch et al., 2003; Mbarika et al., 2001; Meso et al., 2005, Straub et al., 2001). Accordingly, understanding barriers due to infrastructural and cultural factors for telemedicine transfers motivates this work. The following rationale underscores the research significance: •



Recent ICTs (and telemedicine) developments in Africa and Ghana as such are encouraging, including wireless ICT diffusion, Internet use, electronic information exchanges, and remote consultations.



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Healthcare is essential for Ghanaians with multiple medical problems. Many have reported growing medical problems in Sub-Saharan Africa (SSA). These problems stimulated new approaches like telemedicine for better access and reduced costs as iterated by Dr. Osei Darkwa, President Ghana Telecom University College on Monday May 7, 2007.



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There is dire shortage of medical personnel and facilities in SSA including Ghana.



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The “brain drain” phenomenon is apparent throughout SSA. WHO (2006) statistics revealed that SSA-trained physicians currently practicing in OECD countries represent 23% of existing doctor workforce in countries of origin.



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Healthcare providers in developing countries and international organizations are promoting telemedicine transfer. Additionally, influence of ICTs due to governmental policies, economic, sociopolitical, cultural and infrastructure factors have attracted international collaborations (Avgerou, 1998).



Objectives 1.2.1 General Objective •



To assess the infrastructure readiness of telemedicine in rural communities in the country



1.2.2 Specific Objective •



To increase the rural segment access to quality health care



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To investigate the use of the mobile phone to access health care in rural communities



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To save time cut cost of delivering health services for person living in remote villages



1.3 Justification The following rational underscores the research significance; •



There are disparities in the provision of health care within developing countries, where the health facilities in the urban areas are relatively well off in terms of manpower. Other medical facilities and resource as compared to those in rural areas. Such disparities mean that rural areas are often at a disadvantage with health workers facing daunting challenges.



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In order to provide basic health care for all population, health workers need communication facilities to obtain advice and information from more affluent urban health centres, as well as to transmit pertinent data such as epidemiological information hence, the need for extensive research into telemedicine



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Health care providers in developing countries and international organization are promoting telemedicine transfer. (Avgerou,1998)



1.4 Significance of the Study • Telemedicine is significant particularly, in countries where specialists are few and where distance and the quality of the infrastructure hinders the movement of physicians or patients from rural to the urban centres. It will guide policy makers to consider telemedicine by stimulating infrastructure development, funding specific telemedicine programs, or reducing policy barriers. •



Ghanaians have experienced many inequalities and these have extended to the health care setting. One of the major challenges that needs to be addressed is the accessibility and availability of health care and specialized medical services in rural areas in Ghana hence the need for an extensive research into telemedicine as a tool in arresting the problem.



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The study document could serve as a secondary source data for further study of economic importance in future



1.5 Anticipated Problems • Financial constraint or cost involved in conducting research over a wide area or scope •



Limited time of conduct and present the project



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Scarcity of data on telemedicine as it is a developing application of clinical medicine



LITERATURE REVIEW 2.0 Introduction Telemedicine is defined in the Webster’s New world Medical Dictionary as the use of medical information for the health and education of the patient or health care provider and for the purpose of improving patient care. According to the European Commission’s Health care Telematics Programme, telemedicine was define as “rapid access to share and remote medical expertise by means of telecommunication and information technologies, no matter where the patient or relevant information is located”. From these definitions it is clear that Telemedicine is the application of telecommunication technology within the health industry. In essence, it eliminates distance as a barrier in the delivery of healthcare. Telemedicine is the delivery of health care and the exchange of health care information across distances using telecommunication technology.



It can include the transfer of basic patients



information’s over computer networks (medical Informatics), the transfer of images such as radiographs, CT scans, MRIs, Ultrasound Study pathology images, Video images of endoscopic or other procedures. Patient’s interviews and examinations, consultation with medical specialist and healthcare educational services (Ferguson et al.1995). Telemedicine covers a growing number of medical specialties such as; Cardiology, Home Care, Radiology, Emergency Care, Surgery, Dermatology, Psychiatry, Oncology, Pathology, Ophthalmology, Hematology, ENT, Nephrology, Pre-hospital Care etc.



2.1 History The term ‘telemedicine’ derives from the Greek word ‘tele’ meaning’ and the present word ‘medicine’ which itself derives from the Latin word ‘mederi’ meaning ‘healing’. It is a phrase first coined in the 1970’s by Thomas Bird, referring to health care delivery where physicians examine



distant patients through the use of telecommunication technologies as simple as complex as telephones and fax machines or as complex as computers and interactive multimedia application. --- (W.A. Mbarika is Telemedicine the Panacea for sub-Saharan Africa’s medical Nightmare). The idea of performing medical examinations and evaluations through the telecommunication network is not new. Shortly after the invention of the telephone, attempts were made to transmit heart and lung sounds to a trained expert who could assess the state of the organs. However, poor transmission systems made the attempts a failure. The table below gives a retrospective account of telemedicine Table 1; Telemedicine in Retrospect Year 1906



Field ECG Transmission



Details Einthoven, the father of electrocardiography, first investigated on ECG transmission over telephone lines in 1906! He wrote an article, Le telecardiogramme at the Archives Internationales Physiologie; 4:132, 1906 1920s Help for ships Telemedicine dates back to the 1920s. During this time, radios were used to link physicians standing watch at shore stations to assist ships at sea that had medical emergencies 1924 The first Perhaps it was the cover showed below of "Radio News" magazine from exposition of April 1924. The article even includes a spoof electronic circuit diagram Telecare which combined all the gadgets of the day into this latest marvel! (Information and photo by courtesy of Dennis J. Streveler Ph.D. Healthcare IT Consultant). 1955: Telepsychiatry The Nebraska Psychiatric Institute was one of the first facilities in the country to have closed-circuit television in 1955. In 1971 the Nebraska Medical Center was linked with the Omaha Veterans Administration Hospital and VA facilities in two other towns. 1967 Massachusetts This station was established in 1967 to provide occupational health General services to airport employees and to deliver emergency care and medical Hospital attention to travelers 1970s Satellite Via ATS-6 satellites. In these projects, paramedics in remote Alaskan and telemedicine Canadian villages were linked with hospitals in distant towns or cities. Source: Telemedicine; Technology for medical diagnosis and patient care; http://users.forthnet.gr/ath/giovas/telemed/ (Accessed 1st September 2011 at 11am)



2.2 Types of Telemedicine - (Wikipedia, the free encyclopaedia) Basically telemedicine is divided into three main types namely: •



Store-and-forward



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Interactive services



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Remote monitoring



2.2.1 Store and forward With the help of store and forward Telemedicine type all details related to medical data, images, video, audios reports and everything is collected and transmitted to the medical expert, doctor, for diagnosis or assessment offline. It requires the clinician to rely on a history report and audio information in place of physical examination.



2.2.2 Interactive Service This is a real time communication in between patient and doctor. This includes telephonic conversation, home visit as well as online interactions. Lots of activities like review of history, physical examination, assessment and check-ups are carried out in such type of telemedicine. This clinician interaction telemedicine procedure is affordable as compared to the treatment and diagnosis carried out at face to face interview.



2.2.3 Remote monitoring Also known as self-monitoring or testing enables medical professionals to monitor a patient remotely using various technological devices. Lots of chronic disease, specific conditions like heart disease, asthma, or even diabetes can be managed and monitored by this means. These are definitely comparable and cost effective as compared to those traditional; face to face interactions between the doctor and patient. 2.3 Growing Demand for Telemedicine - (Sandy Taylor; 2010) Telemedicine can be depended on in times of emergency when there is no medical doctor. Learning and using telemedicine techniques during emergency is simple today with the help of



online source. Care at a distance, telemedicine is a handy tool for people trying to reach some medicines, treatment consultancy during illness. Today telemedicine has developed rapidly as a means of receiving and interacting all about medical information, examination, and consultation.



All thanks to the latest technology,



telemedicine is supporting diagnosis and treatment with no personal face to face communication. Surly telemedicine is fast, effective, simple, cost saving as well as the best way to receive some medical guidance when no doctor is around. Due to the high demand of medical care needs especially for those who do not have access to medical centres and are most often concentrated within the rural areas. The aim is to find answers to the following; •



Will telemedicine improve the quality of health care?



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Will it improve the delivery of health care in remote areas?



2.4 Concept of Telemedicine From the various definitions, a telemedicine system creates a ‘visual’ medical consultation where the local medical attendant becomes the eyes, ears and hands of the remote medical expert. He/she collects the necessary information for decision making and serves to implement the necessary actions and treatment. Telemedicine provides tertiary healthcare to people at remote areas through a visual reduction in distance. Text, sound, pictures and videos are being merged and interconnected in completely new way for diagnoses and treatment thereafter. 2.4.1 Potentials of telemedicine – (Richard Wootton, 2001) •



Building bridges between clinicians and patients to overcome the barriers of distance and time.



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Developing visual communities that interacts and shares knowledge



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Enhancing continuity of care



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Improving access to healthcare in remote or isolated areas.



2.4.2 Generic application of Telemedicine – (S.R Joshi, 2000) •



Clinical applications - include handling urgent consultations, scheduled consultations, remote visits of patients and the video reviews of certain studies done in advance.



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Administrative applications- covers telemedicine system for promoting and accelerating the replication, update and transfer of clinical information including medical records, examination data and financial information



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Educational application: this includes applications that facilitate the process of sharing the material available for teaching and examination purposes in the medical field.



2.4.3 Benefits of Telemedicine – (Samuel K Moore, 2002) Telemedicine has a number of benefits namely: •



Reducing the cost of service delivery



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Easy and quick access to the specialist



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Cost effective post treatment consultation



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Travel time reduction



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Enhanced quality and efficiency of medical care



2.5 Technology Telemedicine technology is based on a speciality centre and a consultation centre linked to each other. A speciality centre is a well-equipped room where a specialist can communicate with a patient in a remote area the equipment required are a high- resolution video camera (polycam) web camera, document camera, microscope, computer, microphone, speaker, telephone and a modem. A consultation centre is a centre from whence the local Registered Medical Practitioner (RMP) or patient can consult the specialist in the speciality centre. The consultation centre and the speciality centre are linked to each other through on Integrated Services Digital Network (ISDN).



One of the essential devices used for consultation is a polycam. A polycam is a video conferencing tool accompanied by a voice transmission enabler. The polycam is connected to the ISDN lines and to the TV both at the speciality and consultation centre as shown in fig 1. From the consultation centre x-rays, CT-scan, colour Doppler, Ultrasound etc. are transferred over the ISDN line with the help of an interface. In the speciality centre the medical records are received on the system and can be alternatively viewed on the TV through the polycam using an interface. A web camera can be used in the absence of a polycam. A high resolution/luminosity subsystem is used for better transmission of x-rays and echocardiograms. High-end scanners are used in the speciality centre to capture negative and positive images. For the transfer of ECG, special trans-telephonic equipment is used which is connected to the ECG machine on one side be seen and heard on the system at the speciality centre. An electronic or digital stethoscope can be used to hear the heartbeat. The equipment is placed on the patient and connected to the telephone line and the doctor at the speciality centre can hear the heart beat on the system or the telephone directly.



Figure 1; Telemedicine Network



2.6 Telemedicine Consultation Case Study A live case handle by Dr Alok Ranjan (consultant Neurosurgeon, Apollo Hospitals-Hyderabad): A patient named shanker Chandra was undergoing treatment in Calcutta under Dr Tamal Bhaltacharya at the consultation centre in Calcutta. In the cause of the treatment a specialist opinion was required and Dr Tamal Bhaltacharya referred the case to Dr Alok Ranjan at the speciality centre in Hyderabad. Calcutta is a full fledge Telemedicine consultation centre and is connected to the Hyderabad Apollo Hospital. The patient records were sent in advance and the appointment was fixed according to Dr Alok Ranjan’s schedule. Before the consultation begins both the centres have to enter each other’s internet protocol (IP) address for a wed camera meeting in the absence of a polycam. The meeting took place for ten minutes in the course of which Dr Alok advised the patient on his future treatment plan (www.appollohospitalgroup.com). 2.7 Process Of Telemedicine - (Aaragonda project- India) In a telemedicine project, the usage of software can be divided into three stages namely •



Data is transferred from consultation centre



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Accepting the patient record and fixing up a teleconsultation



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Viewing post consultation details.



The three phases of telemedicine process is schematically shown in figure 2 below.



Figure 2; Three phases of telemedicine process



METHODOLOGY 3.1 Study Area Sunyani is located in the mid-western part of Ghana in the Brong Ahafo Region. The Brong Ahafo Region is one of 10 administrative regions in Ghana. The region itself has 17 administrative districts and 2 municipalities of which Sunyani is one. Sunyani is the largest settlement in the Brong Ahafo Region in terms of population and area. It also doubles as the regional capital. According to the 2000 population census the Region has a population of 179,267. Of this total Sunyani Town has 61,992 representing 34.5% of the total population with a growth rate of 3.4% per annum.



Figure 3; Map of Sunyani showing the two hospitals



3.2 Type of Study A non-intervention exploratory study will be used for the research, since little is known about the problem. Exploratory study will be used to address the following; •



Who is affected?



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What is the magnitude of the problem?



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How do the affected people behave?



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What do they know, believe, and think about the problem



3.3 Data Collection Technique The survey will be conducted by administering questionnaires which will be based on the objectives of the study to professionals and staff in Ghana Health Service (GHS) and residence Secondary research will be relied on such as reviewing available literature/or data or qualitative approaches such as informal discussions with patients, staff and a more formal approach through in-depth interviews with stakeholder. 3.4 Plan for Data Collection The research plans to use both primary and secondary source for data collection. Primary sources will consist of interviews documented in reports. Secondary sources will include articles, websites etc. Also Doctors, Administrators and staffs will be surveyed to access their knowledge of computers and familiarity with telecommunication and information technology products within the health services will also be examined. This will be done by sending questionnaires to two hospitals, one urban and one rural. 3.5 Plan for Data Processing and Analysis The researcher will use EPI-INFO to perform the data entry and analysis for the primary and secondary data. EPI-INFO is a public domain database and statistics program for use by public health officials (doctors, nurses, epidemiologists, etc.) managing databases for public health activities, and performing statistical applications. EPI-INFO will allow me to develop a questionnaire, customize the data entry process, enter data, and analyse the data. I will also use the



EPI-INFO to generate statistics, graphs, and tables. Pearson Chi-Square test will be used to test the hypothesis. 3.6 Ethical Consideration Since majority of the data will be gathered using self-administered questionnaires; stakeholders will be informed of the research intention by means of an introductory letter that briefly states the study purpose and its significance. They will be made aware that the research is solely for academic purpose and that their identities will not be disclose in anyway. Also questionnaires will be designing a way not to tackle sensitive areas head-on. 3.7 Pre-Test or Pilot Study The questionnaire and all other techniques for data collection will be pre-tested on fellow students and colleagues to help discern, alter or delete questions that are being misinterpreted or are too sensitive to be asked without offending respondents. 3.8 Discussions of Findings This part will discuss the result of the study in relations to the objective, literature review and key variables of the research. 3.9 Conclusions and Recommendation Conclusions drawn from the study will be put across in this part. Also the researcher will give out his recommendations to the various stakeholders concerned with the study as to how the situation can be improve upon for the betterment and the good of all people.