The cost-effectiveness of technology transfer using telemedicine

Telediagnosis of dental caries: Possible or impossible? A pilot cross-sectional study

OBJECTIVES

The aims of this study were to evaluate the effectiveness of teledentistry (based on a home intraoral imaging protocol) in detecting dental caries and to assess the accuracy of this method compared to clinical examination.

METHODS

Forty-three patients were recruited for the study. Using a protocol for taking intraoral photographs at home with a smartphone proposed by the Dental School of Verona, a remote diagnosis of dental caries (TD) was performed by an experienced dentist. The same caries sites were also assessed by clinical diagnosis (CD) by a second experienced dentist. Ten photos were taken at home in five different perspectives, with and without flash, and emailed to one of the authors. The best five photos were selected for telediagnosis. The International Caries Detection and Assessment System (ICDAS II) score was used for caries diagnosis. Statistical tests were performed: Sensitivity and specificity of TD, the positive and negative predictive value of TD (PPV-NPV), and Spearman correlation to evaluate the relationship between the scores of TD and CD.

RESULTS

A total of 430 photographs were submitted; TD was performed on 215 photographs and 43 patients were visited. A total of 1201 teeth were analyzed. The sensitivity of TD was 74.0, the specificity was 99.1, the PPV of TD was 91.7, and the NPV was 96.4. The Spearman correlation was 0.816, showing a very strong correlation between the values obtained with TD and CD.

CONCLUSIONS

The study showed good potential for TD, which proved to be a feasible method to combine with routine caries diagnosis in daily preventive dentistry practice.

Efficacy of Telemedicine Utilization for Cardiac Outpatients’ Care during the Pandemic of COVID-19: A Large Center Experience in the Wave of the Pandemic

Introduction

Synchronous telemedicine using teleconferencing may play a role in clinical care. In a tertiary care center, video conferencing-enhanced virtual clinics were established via a new application platform. They were introduced during COVID-19 pandemic to connect patients to trained health-care providers via a secured line. While maintaining patients' privacy, they were theorized to offer effective communications and continuous clinical care. In this cross-sectional cohort study, we ought to examine the impact of service and the assistance they may offer to cardiac patients in the outpatient setup.

Methods

A prospective cohort study looking at all video-conferencing virtual clinics' visits during the pandemic with primary focus on cardiac outpatient clinic, addressing primary endpoints of need for admission or emergency visits from cardiac demises during the pandemic and secondary endpoint of patient satisfaction based on patients' experiences.

Results

A total of 6000 live care video-based chats were made over 10 months period from March 10^th, 2020, to January 30^th, 2021, among which 277 patients were evaluated in the virtual cardiac clinic, of these 193 (69.7%) were males, with mean age of 48 ± 15.60 (22.3%), patients were requested to present to clinic for further evaluation and testing, 20 (7.2%) patients were asked to visit the emergency room, of whom 8 (2.8%) patients were hospitalized. All 8 were admitted for high-risk findings that require immediate medical attention, 4/8 underwent cardiac catheterization, mean duration of admission was 2 ± 1 days. When compared to regular walk-in care, there was a statistical difference in admission rate and emergency visits p = 0.001 and p = 0.0001, respectively, both were statistically higher in the virtual clinic. The satisfaction rate in a 5-scale grading system was 97% of 4 and above recommending the continuation of the service beyond pandemic time.

Conclusions

Video-enhanced virtual cardiology clinic works safely and efficiently during COVID-19 pandemic with a difference in admission rate and ER visits when compared to walk-in clinic. It can be used during nonpandemic time to reduce load on hospital and clinic crowdedness. It also decreases the chances of COVID-19 transmission indirectly by reenforcing physical distance.

Digital Approaches for a Reliable Early Diagnosis of Psoriatic Arthritis

Psoriatic arthritis (PsA) is a chronic inflammatory disease that develops in up to 30% of patients with psoriasis. In the vast majority of cases, cutaneous symptoms precede musculoskeletal complaints. Progression from psoriasis to PsA is characterized by subclinical synovio-entheseal inflammation and often non-specific musculoskeletal symptoms that are frequently unreported or overlooked. With the development of increasingly effective therapies and a broad drug armamentarium, prevention of arthritis development through careful clinical monitoring has become priority. Identifying high-risk psoriasis patients before PsA onset would ensure early diagnosis, increased treatment efficacy, and ultimately better outcomes; ideally, PsA development could even be averted. However, the current model of care for PsA offers only limited possibilities of early intervention. This is attributable to the large pool of patients to be monitored and the limited resources of the health care system in comparison. The use of digital technologies for health (eHealth) could help close this gap in care by enabling faster, more targeted and more streamlined access to rheumatological care for patients with psoriasis. eHealth solutions particularly include telemedicine, mobile technologies, and symptom checkers. Telemedicine enables rheumatological visits and consultations at a distance while mobile technologies can improve monitoring by allowing patients to self-report symptoms and disease-related parameters continuously. Symptom checkers have the potential to direct patients to medical attention at an earlier point of their disease and therefore minimizing diagnostic delay. Overall, these interventions could lead to earlier diagnoses of arthritis, improved monitoring, and better disease control while simultaneously increasing the capacity of referral centers.

Addressing the Third Epidemic of Retinopathy of Prematurity Through Telemedicine and Technology: A Systematic Review

The rising prevalence of retinopathy of prematurity (ROP) in low- and middle-income countries has increased the need for screening at-risk infants. The purpose of this article was to review the impact of tele-medicine and technology on ROP screening programs. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review was performed using PubMed, Pro-Quest, and Google Scholar bibliographic search engine. Terms searched included retinopathy of prematurity, telemedicine, and tele-ophthalmology. Data regarding internet access and gross domestic product per capita were obtained from the World Bank. Information was also obtained about internet access, speeds, and costs in low-income countries. There has been increasing integration of telemedicine and technology for ROP screening and management. Low-income countries are using available internet options and information and communications technology for ROP screening, which can aid in addressing the unique challenges faced by low-income countries. This provides a promising solution to the third epidemic of ROP by expanding and improving screening and management. Although telemedicine systems may serve as a cost-effective approach to facilitate delivery of health care, programs (especially in lowand middle-income countries) require national support to maintain its infrastructure. [J Pediatr Ophthalmol Strabismus. 2021;58(4):261-269.].

Critical Success Factors for Leveraging Technology Transfer from Higher Education Institutions to Industry: Indian Context

This study aims to identify and empirically evaluates the critical factors of successful technology transfer (TT) from higher education institutions (HEI) to industry and to develop a TT model in the Indian context. With the help of questionnaire survey, the perception profile of 318 respondents was collected from PAN-India. Utilizing the survey data, factor analysis identified six constructs representing five critical factors of TT and an outcome factor. The results of multiple regression analysis indicate significant effect of all five critical factors on an outcome factor. The findings of the study validate the TT Model and identify supportive and promotive TT environment factor, market and finance factor and HEI factor to be the most important factors of successful TT. This study may help the policymakers in strategizing future initiatives to improve the rate of successful TT.

Healthcare Technology Transfer in Sub-Saharan Africa: An Inductive Approach

The research addressed within this paper sets out to develop a framework towards facilitating health-related technology transfer (TT) to and within sub-Saharan African countries. In turn, this framework will attempt to alleviate healthcare burdens in developing nations through a combination of acquisitions and collaborative technology development. Systematic conceptual and comparative literature reviews have been conducted to identify the major characteristics of TT. The conceptual review has outlined the universal characteristics of TT such as TT methods, prominent stakeholders and the importance of knowledge transfer while the systematic comparative review exclusively evaluated sub-Saharan African healthcare TT characteristics such as infrastructure barriers and the marketability of the transfer object. The outcomes of the literature reviews have been clustered into five phases, forming the basis of the conceptual framework. This framework aims to guide a user through the phases of technology development, technology analysis, technology transfer method application, change management and commercialization by providing managerial best practices at each phase. The conceptual framework has been evaluated by incorporating the outcomes of 16 semi-structured interviews conducted with healthcare and TT industry experts. The final framework aims to provide guidelines for any stakeholder involved in healthcare technology transfer regardless of the healthcare implementation by highlighting best practices surrounding stakeholder co-creation, transfer method application and constructing a sustainable healthcare technology transfer venture.

Teleophthalmology through handheld mobile devices: a pilot study in rural Nepal

Background

To compare screening referral recommendations made by remotely located ophthalmic technicians with those of an ophthalmologist examining digital photos obtained by a portable ophthalmic camera system powered by an iOS handheld mobile device (iPod Touch).

Methods

Dilated screening eye exams were performed by ophthalmic technicians in four remote districts of Nepal. Anterior and posterior segment photographs captured with a Paxos Scope ophthalmic camera system attached to an iPod Touch 6^th generation device were uploaded to a secure cloud database for review by an ophthalmologist in Kathmandu. The ophthalmic technicians' referral decisions based on slit-lamp exam were compared to the ophthalmologist's recommendation based on the transmitted images.

Results

Using the transmitted images, the ophthalmologist recommended referral for an additional 20% of the 346 total subjects screened who would not have been referred by the ophthalmic technician. Of those subjects, 34% were referred to the retina clinic. Conversely, among the 101 patients referred by the technician, the ophthalmologist concurred with the appropriateness of referral in more than 97% of cases but thought eight (2.8%) of those patients had variants of normal eye pathology.

Conclusion

An ophthalmologist who reviewed data and photos gathered with the mobile device teleophthalmology system identified a significant number of patients whose need for referral was not identified by the screening technician. Posterior segment pathology was most frequently found by the remote reader and not by the technician performing dilated slit lamp examinations. These results are promising for further clinical implementation of handheld mobile devices as tools for teleophthalmic screening in resource-limited settings.

Review of economic evaluations of teleophthalmology as a screening strategy for chronic eye disease in adults

BACKGROUND/AIMS

Teleophthalmology is well positioned to play a key role in screening of major chronic eye diseases. Economic evaluation of cost-effectiveness of teleophthalmology, however, is lacking. This study provides a systematic review of economic studies of teleophthalmology screening for diabetic retinopathy (DR), glaucoma and macular degeneration.

METHODS

Structured search of electronic databases and full article review yielded 20 cost-related articles. Sixteen articles fulfilled the inclusion criteria and were retained for a narrative review: 12 on DR, 2 on glaucoma and 2 on chronic eye disease.

RESULTS

Teleophthalmology for DR yielded the most cost savings when compared with traditional clinic examination. The study settings varied among urban, rural and remote settings, community, hospital and health mobile units. The most important determinant of cost-effectiveness of teleophthalmology was the prevalence of DR among patients screened, indicating an increase of cost savings with the increase of screening rates. The required patient pool size to be screened varied from 110 to 3500 patients. Other factors potentially influencing cost-effectiveness of teleophthalmology were older patient age, regular screening and full utilisation of the equipment. Teleophthalmology for glaucoma was more cost-effective compared with in-person examination. Similarly, increasing number of glaucoma patients targeted for screening yielded more cost savings.

CONCLUSIONS

This economic review provides supportive evidence of cost-effectiveness of teleophthalmology for DR and glaucoma screening potentially increasing screening accessibility especially for rural and remote populations. Special selection of the targeted screening population will optimise the cost-effectiveness of teleophthalmology.

Telemedicine: A systematic review of economic evaluations

Background: Telemedicine is an expanded term in health information technology that comprises procedures for transmitting medical information electronically to improve patients’ health status. The objective of this research is to evaluate the cost-effectiveness of telemedicine interventions in various specialty areas.

Methods: The Cochrane Library and Centre for Review and Dissemination were searched up to February 2013 using Mesh. Studies that compared any kind of telemedicine with any other routine care technique and used cost per health utility unit’s outcomes were included.

Results: Twenty-one articles were included. According to the included studies, it seems that using telemedicine in cardiology can be effective and cost-effective enough but pre-hospital telemedicine diagnostics program are likely to have little impact on acute myocardial infarction fatality. In pulmonary, telemedicine can be a cost-effective strategy for delivering outpatient pulmonary care to rural populations which have limited access to specialized services, but telemedicine is not cost- effective in asthma and airways cancer. In ophthalmology, especially in the diagnosis of diabetic retinopathy, the use of telemedicine is a cost-effective tool. In dermatology, telemedicine is not cost-effective enough in comparison of conventional cares. In other fields such as physical activity and diet, eating disorder, tele-ICU, psychotherapy for depression and telemedicine on ships, telemedicine can be used as a cost-effective tool for treatments or cares.

Conclusion: Most of the included studies confirmed that telemedicine is cost-effective for applying in major medical fields such as cardiology; but in dermatology, papers could not confirm the positive capability of telemedicine.

Real-time teleophthalmology versus face-to-face consultation: A systematic review

Introduction Advances in imaging capabilities and the evolution of real-time teleophthalmology have the potential to provide increased coverage to areas with limited ophthalmology services. However, there is limited research assessing the diagnostic accuracy of face-to-face teleophthalmology consultation. This systematic review aims to determine if real-time teleophthalmology provides comparable accuracy to face-to-face consultation for the diagnosis of common eye health conditions. Methods A search of PubMed, Embase, Medline and Cochrane databases and manual citation review was conducted on 6 February and 7 April 2016. Included studies involved real-time telemedicine in the field of ophthalmology or optometry, and assessed diagnostic accuracy against gold-standard face-to-face consultation. The revised quality assessment of diagnostic accuracy studies (QUADAS-2) tool assessed risk of bias. Results Twelve studies were included, with participants ranging from four to 89 years old. A broad number of conditions were assessed and include corneal and retinal pathologies, strabismus, oculoplastics and post-operative review. Quality assessment identified a high or unclear risk of bias in patient selection (75%) due to an undisclosed recruitment processes. The index test showed high risk of bias in the included studies, due to the varied interpretation and conduct of real-time teleophthalmology methods. Reference standard risk was overall low (75%), as was the risk due to flow and timing (75%). Conclusion In terms of diagnostic accuracy, real-time teleophthalmology was considered superior to face-to-face consultation in one study and comparable in six studies. Store-and-forward image transmission coupled with real-time videoconferencing is a suitable alternative to overcome poor internet transmission speeds.

Cost-utility and cost-effectiveness studies of telemedicine, electronic, and mobile health systems in the literature: a systematic review

OBJECTIVE

A systematic review of cost-utility and cost-effectiveness research works of telemedicine, electronic health (e-health), and mobile health (m-health) systems in the literature is presented.

MATERIALS AND METHODS

Academic databases and systems such as PubMed, Scopus, ISI Web of Science, and IEEE Xplore were searched, using different combinations of terms such as "cost-utility" OR "cost utility" AND "telemedicine," "cost-effectiveness" OR "cost effectiveness" AND "mobile health," etc. In the articles searched, there were no limitations in the publication date.

RESULTS

The search identified 35 relevant works. Many of the articles were reviews of different studies. Seventy-nine percent concerned the cost-effectiveness of telemedicine systems in different specialties such as teleophthalmology, telecardiology, teledermatology, etc. More articles were found between 2000 and 2013. Cost-utility studies were done only for telemedicine systems.

CONCLUSIONS

There are few cost-utility and cost-effectiveness studies for e-health and m-health systems in the literature. Some cost-effectiveness studies demonstrate that telemedicine can reduce the costs, but not all. Among the main limitations of the economic evaluations of telemedicine systems are the lack of randomized control trials, small sample sizes, and the absence of quality data and appropriate measures.

Mobile phone-based mHealth approaches for public health surveillance in sub-Saharan Africa: a systematic review

Whereas mobile phone-based surveillance has the potential to provide real-time validated data for disease clustering and prompt respond and investigation, little evidence is available on current practice in sub-Sahara Africa. The objective of this review was to examine mobile phone-based mHealth interventions for Public Health surveillance in the region. We conducted electronic search in MEDLINE, EMBASE, IEE Xplore, African Index Medicus (AIM), BioMed Central, PubMed Central (PMC), the Public Library of Science (PLoS) and IRIS for publications used in the review. In all, a total of nine studies were included which focused on infectious disease surveillance of malaria (n = 3), tuberculosis (n = 1) and influenza-like illnesses (n = 1) as well as on non-infectious disease surveillance of child malnutrition (n = 2), maternal health (n = 1) and routine surveillance of various diseases and symptoms (n = 1). Our review revealed that mobile phone-based surveillance projects in the sub-Saharan African countries are on small scale, fragmented and not well documented. We conclude by advocating for a strong drive for more research in the applied field as well as a better reporting of lessons learned in order to create an epistemic community to help build a more evidence-based field of practice in mHealth surveillance in the region.

The Muranga Teleophthalmology Study: Comparison of Virtual (Teleglaucoma) with in-Person Clinical Assessment to Diagnose Glaucoma

PURPOSE

While the effectiveness of teleophthalmology is generally accepted, its ability to diagnose glaucomatous eye disease remains relatively unknown. This study aimed to compare a web-based teleophthalmology assessment with clinical slit lamp examination to screen for glaucoma among diabetics in a rural African district.

MATERIALS AND METHODS

Three hundred and nine diabetic patients underwent both the clinical slit lamp examination by a comprehensive ophthalmologist and teleglaucoma (TG) assessment by a glaucoma subspecialist. Both assessments were compared for any focal glaucoma damage; for TG, the quality of photographs was assessed, and vertical cup-to-disk ratio (VCDR) was calculated in a semi-automated manner. In patients with VCDR > 0.7, the diagnostic precision of the Frequency Doubling Technology (FDT) C-20 screening program was assessed.

RESULTS

Of 309 TG assessment photos, 74 (24%) were deemed unreadable due to media opacities, patient cooperation, and unsatisfactory photographic technique. While the identification of individual optic nerve factors showed either fair or moderate agreement, the ability to diagnose glaucoma based on the overall assessment showed moderate agreement (Kappa [κ] statistic 0.55% and 95% confidence interval [CI]: 0.48-0.62). The use of FDT to detect glaucoma in the presence of disc damage (VCDR > 0.7) showed substantial agreement (κ statistic of 0.84 and 95% CI 0.79-0.90). A positive TG diagnosis of glaucoma carried a 77.5% positive predictive value, and a negative TG diagnosis carried an 82.2% negative predicative value relative to the clinical slit lamp examination.

CONCLUSION

There was moderate agreement between the ability to diagnose glaucoma using TG relative to clinical slit lamp examination. Poor quality photographs can severely limit the ability of TG assessment to diagnose optic nerve damage and glaucoma. Although further work and validation is needed, the TG approach provides a novel, and promising method to diagnose glaucoma, a major cause of ocular morbidity throughout the world.

Improving diabetic retinopathy screening in Africa: patient satisfaction with teleophthalmology versus ophthalmologist-based screening

Purpose:

To assess patient preference for diabetic retinopathy (DR) screening with teleophthalmology or face-to-face ophthalmologist evaluation in Nairobi, Kenya.

Materials and Methods:

Fifty seven diabetic patients from a one-stop multidisciplinary diabetic clinic (consisting of a diabetologist, nurse educator, foot specialist, nutritionist, ophthalmologist, and neurologist) in Nairobi, Kenya were included if they had undergone both a teleophthalmology (stereoscopic digital retinal photographs graded by an ophthalmologist remotely) and a traditional clinical screening exam (face to face examination). A structured questionnaire with a 5-point Likert scale was developed in both English and Swahili. The questionnaire was administered over the telephone. Ten questions were used to compare patient experience and preferences between teleophthalmology and a traditional clinical examination for DR. A mean score >3.25 on the Likert scale was considered favourable.

Results:

Successfully telephone contact was possible for 26 (58% male, 42% females) of the 57 patients. The mean ages of the male and female patients were 52.4 and 46.5 years respectively. Patients were satisfied with their teleophthalmology examination (mean 4.15 ± 0.97). Patients preferred the teleophthalmology option for future screenings (mean 3.42 ± 1.52). This preference was driven primarily by convenience, reduced examination time, and being able to visualize their own retina.

Conclusion:

In this study, diabetic patients preferred a teleophthalmology based screening over a traditional ophthalmologist-based screening. The use of teleophthalmology in Africa warrants further study and has the potential to become the screening model of choice. Cost effectiveness in comparison to an ophthalmologist-based screening also requires evaluation.

The state of health economic research in South Africa: a systematic review

BACKGROUND

Economic factors are a limiting factor toward the implementation of many health programmes and interventions. Economic evaluation has a great potential to contribute toward cost-effective healthcare delivery in South Africa. Little is known about the characteristics and quality of health economic (including pharmacoeconomic) research in South Africa.

OBJECTIVE AND METHODS

This study assessed the state of health economic (including pharmacoeconomic) research in South Africa. PUBMED, MEDLINE, HealthSTAR, EconLit and PsycINFO databases were searched to identify health economic articles pertaining to South Africa published between 1 January 1977 and 30 April 2010. The searches used the following Medical Subject Headings (MeSH) terms and text words alone and in combination: 'costs', 'health' and 'South Africa'. Our study included only original economic studies/analyses that pertained to South Africa, addressed a health-related topic, and had a statement or word in the title, abstract or keywords that indicated that an economic (including cost) analysis had been conducted. The study only included complete peer-reviewed publications (e.g. abstracts were excluded) that were reported in the English language. Two reviewers independently scored each article in the final sample using the data collection form designed for the study.

RESULTS

In total, 108 studies investigating a wide variety of diseases were included in the study. These articles were published in 39 different journals mostly based outside of South Africa between 1977 and 2010. On average, each article was written by three authors. Most first authors had medical/clinical training and resided in South Africa at the time of publication of their study. Based on a 1-10 scale, with 10 indicating the highest quality, the mean quality score for all studies was 7.59 (SD 1.42) and half of the articles were of good quality (score 8-10) The quality of studies was related to the country in which the journal publishing the article was based (outside South Africa = higher); current residence of the primary author (outside South Africa = higher); method of economic analysis (economic evaluations higher than cost studies); type of data used (secondary higher than primary); primary training of the first author (health economics/pharmacoeconomics = higher); type of medical function (diagnosis = higher); study perspective (societal = higher); primary health intervention (pharmaceuticals = higher); study design (modelling = higher); number of authors (more = higher); and year of publication (more recent = higher) [p ≤ 0.05].

CONCLUSION

Half of the articles were of poor or fair quality. Measures are needed to promote the commissioning of more and better quality health economic and pharmacoeconomic studies in South Africa.

Telemedicine across borders: a systematic review of factors that hinder or support implementation

PURPOSE

Innovative technologies to deliver health care across borders have attracted both evangelists and sceptics. Our aim was to systematically identify factors that hinder or support implementation of cross-border telemedicine services worldwide in the last two decades.

METHODS

Two reviewers independently searched ten databases including MEDLINE and EMBASE, in June 2011 including citations from 1990 onwards when at least an abstract was available in English. We also searched ELDIS and INTUTE databases and Internet search engines to identify grey literature. We included studies which (a) described the use of telemedicine to deliver cross-border healthcare and, or (b) described the factors that hinder or support implementation of cross-border telemedicine services. All study designs were included. Two reviewers independently assessed titles and abstracts of articles identified. Papers were allocated to one of four reviewers who extracted relevant data and validated it. We took a qualitative approach to the analysis, conducting a narrative synthesis of the evidence.

RESULTS

6026 records were identified of which 5806 were excluded following screening of titles and abstracts. We assessed 227 full text articles, excluding 133 because they were fatally flawed or did not meet the inclusion criteria, producing a final sample of 94. They involved 76 countries worldwide, most involving collaborations between high and low or middle income countries. Most described services delivering a combination of types of telemedicine but specialties most represented were telepathology, telesurgery, Emergency and trauma telemedicine and teleradiology. Most link health professionals, with only a few linking professionals directly to patients. A main driver for the development of cross-border telemedicine is the need to improve access to specialist services in low and middle income countries and in underserved rural areas in high income countries. Factors that hinder or support implementation clustered into four main themes: (1) legal factors; (2) sustainability factors; (3) cultural factors; and (4) contextual factors.

CONCLUSIONS

National telemedicine programmes may build infrastructure and change mindsets, laying the foundations for successful engagement in cross-border services. Regional networks can also help with sharing of expertise and innovative ways of overcoming barriers to the implementation of services. Strong team leadership, training, flexible and locally responsive services delivered at low cost, using simple technologies, and within a clear legal and regulatory framework, are all important factors for the successful implementation of cross-border telemedicine services.

Developed-developing country partnerships: benefits to developed countries?

Developing countries can generate effective solutions for today's global health challenges. This paper reviews relevant literature to construct the case for international cooperation, and in particular, developed-developing country partnerships. Standard database and web-based searches were conducted for publications in English between 1990 and 2010. Studies containing full or partial data relating to international cooperation between developed and developing countries were retained for further analysis. Of 227 articles retained through initial screening, 65 were included in the final analysis. The results were two-fold: some articles pointed to intangible benefits accrued by developed country partners, but the majority of information pointed to developing country innovations that can potentially inform health systems in developed countries. This information spanned all six WHO health system components. Ten key health areas where developed countries have the most to learn from the developing world were identified and include, rural health service delivery; skills substitution; decentralisation of management; creative problem-solving; education in communicable disease control; innovation in mobile phone use; low technology simulation training; local product manufacture; health financing; and social entrepreneurship. While there are no guarantees that innovations from developing country experiences can effectively transfer to developed countries, combined developed-developing country learning processes can potentially generate effective solutions for global health systems. However, the global pool of knowledge in this area is virgin and further work needs to be undertaken to advance understanding of health innovation diffusion. Even more urgently, a standardized method for reporting partnership benefits is needed--this is perhaps the single most immediate need in planning for, and realizing, the full potential of international cooperation between developed and developing countries.

Experience with low-cost telemedicine in three different settings. Recommendations based on a proposed framework for network performance evaluation

Background

Telemedicine has been used for many years to support doctors in the developing world. Several networks provide services in different settings and in different ways. However, to draw conclusions about which telemedicine networks are successful requires a method of evaluating them. No general consensus or validated framework exists for this purpose.

Objective

To define a basic method of performance measurement that can be used to improve and compare teleconsultation networks; to employ the proposed framework in an evaluation of three existing networks; to make recommendations about the future implementation and follow-up of such networks.

Methods

Analysis based on the experience of three telemedicine networks (in operation for 7–10 years) that provide services to doctors in low-resource settings and which employ the same basic design.

Findings

Although there are many possible indicators and metrics that might be relevant, five measures for each of the three user groups appear to be sufficient for the proposed framework. In addition, from the societal perspective, information about clinical- and cost-effectiveness is also required. The proposed performance measurement framework was applied to three mature telemedicine networks. Despite their differences in terms of activity, size and objectives, their performance in certain respects is very similar. For example, the time to first reply from an expert is about 24 hours for each network. Although all three networks had systems in place to collect data from the user perspective, none of them collected information about the coordinator's time required or about ease of system usage. They had only limited information about quality and cost.

Conclusion

Measuring the performance of a telemedicine network is essential in understanding whether the network is working as intended and what effect it is having. Based on long-term field experience, the suggested framework is a practical tool that will permit organisations to assess the performance of their own networks and to improve them by comparison with others. All telemedicine systems should provide information about setup and running costs because cost-effectiveness is crucial for sustainability.

Evaluation of a tele-education programme in Brazil

We evaluated a tele-education programme for primary care staff in Pernambuco State, Brazil. During 2008 and 2009, tele-education sessions occurred four times each week for one hour per day. The topics included public health, child and adolescent health, mental health and nursing. After each session, participants completed an evaluation questionnaire. A total of 73 municipalities and 141 health centres participated in the programme. There were 254 tele-education sessions scheduled during the 20-month study period; of these, 224 sessions were successfully performed and 30 were cancelled. We collected 3504 responses from the satisfaction survey. There was high acceptance of the programme: 97% rated it as excellent or good.

In what circumstances is telemedicine appropriate in the developing world?

Objectives

To review papers reporting actual experience with telemedicine in developing countries and to summarize their findings, including the strength of the evidence.

Design

A retrospective review was conducted. Study quality was assessed.

Setting

Four commonly-used electronic databases.

Main outcome measures

Study quality scores.

Results

From a total of 202 potential articles, 38 relevant papers were identified. Thirty-four articles (89%) reported clinical experience and 14 articles (37%) reported the use of telemedicine for educational purposes. The quality of the reports was rather weak (median quality-score 3, on a scale 0–9); only one study, rated at 7, fell into the high quality score band. The fact that almost all studies reported positively in favour of telemedicine suggests a publication bias. Of the 38 articles, 15 (39%) reported the use of real-time telemedicine and 25 (66%) reported the use of asynchronous, or store-and-forward, telemedicine. Email was the most commonly reported modality (half of all studies).

Conclusion

Some of the longer established telemedicine operations have developed into substantial networks. The review suggests that great potential exists for telemedicine in the developing world. However, some caution is required in future telemedicine work if telemedicine exemplars are to be produced which can be widely copied.

Can economic evaluation in telemedicine be trusted? A systematic review of the literature

BACKGROUND

Telemedicine has been advocated as an effective means to provide health care services over a distance. Systematic information on costs and consequences has been called for to support decision-making in this field. This paper provides a review of the quality, validity and generalisability of economic evaluations in telemedicine.

METHODS

A systematic literature search in all relevant databases was conducted and forms the basis for addressing these issues. Only articles published in peer-reviewed journals and written in English in the period from 1990 to 2007 were analysed. The literature search identified 33 economic evaluations where both costs (resource use) and outcomes (non-resource consequences) were measured.

RESULTS

This review shows that economic evaluations in telemedicine are highly diverse in terms of both the study context and the methods applied. The articles covered several medical specialities ranging from cardiology and dermatology to psychiatry. The studies analysed telemedicine in home care, and in primary and secondary care settings using a variety of different technologies including videoconferencing, still-images and monitoring (store-and-forward telemedicine). Most studies used multiple outcome measures and analysed the effects using disaggregated cost-consequence frameworks. Objectives, study design, and choice of comparators were mostly well reported. The majority of the studies lacked information on perspective and costing method, few used general statistics and sensitivity analysis to assess validity, and even fewer used marginal analysis.

CONCLUSION

As this paper demonstrates, the majority of the economic evaluations reviewed were not in accordance with standard evaluation techniques. Further research is needed to explore the reasons for this and to address how economic evaluation in telemedicine best can take advantage of local constraints and at the same time produce valid and generalisable results.

Case report: an example of international telemedicine success

An 8-month old girl presented to the Angkor Hospital for Children in Siem Riep, Cambodia with fevers, bilateral eye discharge and an extensive body rash. The rash consisted of large, fluid-filled bullae and significant desquamation. The patient was admitted to the hospital and given intravenous cloxacillin for presumed bullous impetigo. Despite treatment with antibiotics, the skin lesions did not improve and the fevers continued. Telemedicine consultations were initiated by email between Angkor Hospital for Children and paediatric specialists in the USA. Several diagnoses were entertained throughout the subsequent collaborative dialogue. Ultimately, teleconsultation led to a diagnosis of chronic bullous dermatosis of childhood (CBDC), a rare sub-epidermal blistering disease. The child was started on appropriate medications. Within 24 hours, the lesions showed significant improvement and fevers resolved. By enabling advice from distant providers on diagnosis and treatment of paediatric patients, telemedicine may improve health care in developing countries.

Information and communications technology for future health systems in developing countries

There has been much discussion of the role that recent advances in information and communication technologies (ICTs) could play in improving health systems in developing countries, but limited independent analysis of existing applications. Combining a case study approach with a general discussion of the issues, this paper attempts to assess the potential benefits of a diverse range of ICT innovations and some of the constraints they will need to overcome. Four broad areas are considered: improvements in traditional health information systems; computer-aided diagnosis and treatment monitoring; a range of applications generically labelled 'telemedicine'; and the use of ICT to inform general populations on health and healthcare. The final section speculates on the possible medium-term impacts of ICT in terms of improving the performance of existing systems, allowing scope for radical innovations, or even changing basic assumptions about the provider-patient relationship.

HIV Online Provider Education (HOPE): the internet as a tool for training in HIV medicine

Human immunodeficiency virus (HIV) treatment programs in resource-limited areas are expanding rapidly. Providing training and education to health care providers in these programs is a major challenge. We have employed Internet-based conferencing technology to conduct interactive case-based training conferences with health care professionals in Africa, Asia, and the Caribbean. This online program may be a model for other efforts to provide education to health care providers treating HIV-infected patients in the developing world.

The prospect of pandemic influenza: why should the optometrist be concerned about a public health problem?

BACKGROUND

Optometrists are uniquely placed in the health care field because they provide both services as well as goods to patients. In the event of an influenza pandemic, optometrists may be challenged with a host of issues, including impediments to clinical patient care, manufacture and delivery of ophthalmic devices, and maintaining business continuity and infection control.

OVERVIEW

This report reviews pandemic influenza, the effect of a pandemic event on business survival, and response measures for the primary eye care provider. The ethical and legal issues surrounding control of a pandemic influenza and the prospect of telemedicine as a form of social distancing are also discussed.

CONCLUSIONS

Knowledge of the pharmacologic and nonpharmacologic measures to control a pandemic influenza will help prepare the eye care provider for addressing challenges to patient care and business continuity in the face of a highly contagious disease. Understanding the legal and ethical issues that arise during a pandemic event will help optometrists make informed choices as health care professionals and as citizens.

Software for reading and grading diabetic retinopathy: Aravind Diabetic Retinopathy Screening 3.0

OBJECTIVE

To evaluate the validity and reproducibility of software for reading digital images and grading diabetic retinopathy.

RESEARCH DESIGN AND METHODS

A prospective, comparative observational study was conducted on a series of patients with type 2 diabetes who presented at the retina clinic of a tertiary care center in India. A total of 210 eyes of 105 patients were allocated to one of three ophthalmologists, who performed dilated indirect and direct ophthalmoscopy and subsequently assessed the digital images of the same group of patients who were masked to the patient's identity. The interobserver and intertest agreement between clinical assessments and grading of diabetic retinopathy using the software was estimated.

RESULTS

Moderate nonproliferative diabetic retinopathy (NPDR) was most frequently diagnosed, both clinically and on evaluating digital images. The overall agreement between the clinical grading of diabetic retinopathy and the grading of images was 81.3% (kappa = 0.69, SE 0.04, P < 0.0001); there was good agreement (81.3%) for NPDR (kappa = 0.61, SE 0.05, P < 0.0001), but agreement was not as good (54.6%) for proliferative diabetic retinopathy (kappa = 0.29, SE 0.11, P = 0.005). Clinically significant macular edema was diagnosed in 33.3% (70 of 210) of eyes clinically and in 40.2% (84 of 209) of eyes by grading images, and there was good agreement (89.5%) between the two (kappa = 0.77, SE 0.07, P < 0.0001).

CONCLUSIONS

Aravind Diabetic Retinopathy Screening 3.0 is a simple and valid tool to assist in the detection of sight-threatening retinopathy and could supplement dilated fundus examinations by ophthalmologists on patients to detect diabetic retinopathy.

Patient satisfaction levels during teleophthalmology consultation in rural South India

The application of new technologies for analysis of retinal images, neural networks for automated retinopathy grading, and teleophthalmology have been shown to have great value in ophthalmology. India has only one ophthalmic surgeon for every 107,000 population. Given this situation, teleophthalmology can play a vital role in addressing to the eye care needs of the country. The objective of this study was to assess patient satisfaction levels and factors influencing it during teleophthalmology consultation in India. A patient satisfaction questionnaire was prepared to assess the prominent aspects of patient satisfaction, including teleophthalmology screening, confidence in the technology used to transfer the fundus images, comprehensiveness of information available to the doctor in the central hub, and graded the opinion regarding the teleophthalmology. A cross-sectional survey among patients who attended a teleophthalmology screening conducted across eight villages in rural Tamilnadu. Responses were then subjected to qualitative analysis and conclusions made. The number of respondents was 348. Of this, 56.4% were males. The mean age of was 50 +/- 17 years. Age ranged from 2 years to 83 years. 44.4% of the respondents were satisfied with teleophthalmology screening. (95% confidence interval [CI]: 38.58%-49.42%) No association was found between age, gender, education, and occupation, respectively, with satisfaction levels. We found that patients who asked questions during the screening were 2.18 times more likely to be satisfied with teleophthalmology than those who did not (odds ratio [OR] = 2.19, 95% CI 1.37-3.5). This study highlights sentiments of the rural subjects when they underwent teleophthalmology consultations. This study provides valuable insights about patient's preferences and satisfaction levels with this newer technology.

Telemedicine for eye care

Tele-ophthalmology has been employed mainly for patients in under-served rural areas in need of specialty care, but other applications such as telementoring have also been used. In certain populations, cost containment is a significant issue and telemedicine is a solution. Tele-ophthalmology can be performed in realtime, by store-and-forward mode, or by hybrid techniques. After appropriate modification, a range of peripherals may be used for tele-ophthalmology, including the direct ophthalmoscope, indirect ophthalmoscope, slit lamp or retinal camera. Tele-ophthalmology applications include: detecting, screening and diagnosing diabetic retinopathy; anterior segment imaging; glaucoma screening; low vision consultation; telementoring. Tele-ophthalmology shows great promise for improving patient care and increasing access to specialty care not available in under-served areas. In developing countries tele-ophthalmology may be a cost-effective method by which richer countries can assist them.

Remote consultations and HIV/AIDS continuing education in low-resource settings

BACKGROUND

Telemedicine is a way to support physicians working in resource-poor settings, providing remote consultations and continuing medical education on HIV/AIDS care.

METHODS

A hybrid E-mail/web support telemedicine service was created in 2003 at the Institute of Tropical Medicine, Antwerp, Belgium, with a discussion forum hosting more than 170 healthcare professionals from 40 different countries, generally resource constrained. Interesting posts and recurring questions from this discussion forum have been elaborated as case studies or frequently asked questions, available on the website for consultation. Education and support are also provided through interactive quizzes, user-friendly guidelines, and policy documents with a particular focus on HIV/AIDS care in developing countries.

RESULTS

From April 2003 to March 2005, 342 questions were sent from over 17 countries in Africa, Asia, and South America. The vast majority of these questions (93%) were patient-oriented, with only 7% being general questions. Of the patient-oriented questions, 49% were related to antiretroviral therapy, and 44% were related to the diagnosis and treatment of opportunistic infections.

CONCLUSIONS

Telemedicine is a cheap and effective method of providing clinical support and continuing education to healthcare workers treating HIV-positive patients in resource-poor settings.

Retinal image analysis: concepts, applications and potential

As digital imaging and computing power increasingly develop, so too does the potential to use these technologies in ophthalmology. Image processing, analysis and computer vision techniques are increasing in prominence in all fields of medical science, and are especially pertinent to modern ophthalmology, as it is heavily dependent on visually oriented signs. The retinal microvasculature is unique in that it is the only part of the human circulation that can be directly visualised non-invasively in vivo, readily photographed and subject to digital image analysis. Exciting developments in image processing relevant to ophthalmology over the past 15 years includes the progress being made towards developing automated diagnostic systems for conditions, such as diabetic retinopathy, age-related macular degeneration and retinopathy of prematurity. These diagnostic systems offer the potential to be used in large-scale screening programs, with the potential for significant resource savings, as well as being free from observer bias and fatigue. In addition, quantitative measurements of retinal vascular topography using digital image analysis from retinal photography have been used as research tools to better understand the relationship between the retinal microvasculature and cardiovascular disease. Furthermore, advances in electronic media transmission increase the relevance of using image processing in 'teleophthalmology' as an aid in clinical decision-making, with particular relevance to large rural-based communities. In this review, we outline the principles upon which retinal digital image analysis is based. We discuss current techniques used to automatically detect landmark features of the fundus, such as the optic disc, fovea and blood vessels. We review the use of image analysis in the automated diagnosis of pathology (with particular reference to diabetic retinopathy). We also review its role in defining and performing quantitative measurements of vascular topography, how these entities are based on 'optimisation' principles and how they have helped to describe the relationship between systemic cardiovascular disease and retinal vascular changes. We also review the potential future use of fundal image analysis in telemedicine.

Telemedicine for access to quality care on medical practice and continuing medical education in a global arena

Health care practices continue to evolve with technological advances integrating computer applications and patient information management into telemedicine systems. Telemedicine can be broadly defined as the use of information technology to provide patient care and share clinical information from one geographic location to another. Telemedicine can lower costs and increase access to health care, especially for those who live in remote or underserved areas. The mechanism of telemedicine raises some difficult legal and regulatory issues as well since technology provides remote diagnosis and treatment across state lines resulting in unclear definitions for liability coverage. Physician licensing becomes an issue because telemedicine facilitates consultations without respect to state or national borders. With the increased access to current information and resources, continuing medical education becomes more feasible with synchronous or asynchronous access to educational content. The challenge in implementation of these unique educational tools is the inclusion for standards of practice and appropriate regulatory mechanisms to cover the audiences.