Telemedicine in Developing Countries K. Brauchli Telemedicine Unit, University of Transkei Department of Pathology, University of Basel - PowerPoint PPT Presentation

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Telemedicine in Developing Countries K. Brauchli Telemedicine Unit, University of Transkei Department of Pathology, University of Basel. Content. Introduction Case study: Pathology in Solomon Islands How to do Telemedicine iPath – Open Source Telemedicine Server Experiences worldwide.

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Telemedicine in Developing Countries K. Brauchli Telemedicine Unit, University of Transkei Department of Pathology, University of Basel

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TelemedicineinDeveloping CountriesK. Brauchli Telemedicine Unit, University of Transkei Department of Pathology, University of Basel


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Content

  • IntroductionCase study: Pathology in Solomon Islands

  • How to do Telemedicine

  • iPath – Open Source Telemedicine Server

  • Experiences worldwide


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Solomon Islands


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Solomon Islands


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Solomon Islands

Solomon IslandsCapital: HoniaraPopulation: 450‘000Islands: ~1000Independence: 1978


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Solomon Islands

Solomon IslandsCapital: HoniaraPopulation: 450‘000Islands: ~1000Independence: 1978

National Referral Hospital


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Solomon Islands

Solomon IslandsCapital: HoniaraPopulation: 450‘000Islands: ~1000Independence: 1978

National Referral Hospital

Doctors: 15 (30)Radiologists: 1Pathologists: 0Dermatologists: 0


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Limitations in Developing Countries

  • Shortage of general practitioners- many rural clinics are run by nurses only

  • Shortage of medical specialists - many countries have no dermatologists, pathologists, ophthalmologists, radiologists, etc.

  • No access to current information- medical libraries have no current material, no continuing medical education (CME)


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Limitations in Developing Countries

  • Limited Transportation- no roads or very bad roads


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Limitations in Developing Countries

  • Limited Communication InfrastructureExample: many islands in Solomons have no telephone – communication only my VHF radio.Existing telephones are often slow and too unreliable for stable internet access.

  • Limited financial resources


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Implications

  • Patients - cannot afford to visit hospital - visit hospital late

  • Doctors- no access to specialist knowledge- no advise for patient management- no experience with rare diseases- no communication with patient (unless at hospital)


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Solomon Islands Pathology

  • Problem for Pathology Services:–Specimen sent to Brisbane (AU) by air–Time until diagnosis: 60 days!

  • Patients do not return:–No communication infrastructure– Limited transport


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Suggested solution

Telemedicine:

  • Access to advice and diagnosis from remote specialists with the help of telecommunication technologies.


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Solomon Islands

Telepathology:

Phase 1: Histology Lab- September 2001

Phase 2: Establishing remote diagnostics- 2001-2003

Phase 3: Routine diagnostics - 2003 - ....


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Phase 1: Histology Lab

Needs for Histology Lab:

  • Operational under local conditions:- frequent power cuts- high temperature and humidity

  • Sustainable- locally available spare parts


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Phase 1: Histology Lab

Tissue Processing


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Phase 1: Histology Lab

Tissue Processing

Preparing blocks


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Phase 1: Histology Lab

Tissue Processing

Preparing blocks

Cutting


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Phase 1: Histology Lab

Tissue Processing

Preparing blocks

Cutting

Staining


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Phase 1: Histology Lab

Tissue Processing

Preparing blocks

Cutting

Staining

Histology slides


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Phase 2: Remote consultations

Step 1:Selected images captured with digital camera (Nikon CoolPix 990) and submitted to server in Basel via email

Step 2:Cases are reviewed by a group of 7 pathologists(Switzerland, Germany and South Africa)


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Phase 2: Remote consultations

Results:

  • 360 cases submitted and diagnosed

  • turn-around time 10 days(1-3 days for diagnosis)

  • Quality of diagnosis (preliminary results, n=80)*:70% identical diagnosis23% minor discrepancies7% major discrepancies**

* Full report in preparation** Includes two cases of sampling errors (false negative needle biopsies)


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How to do Telemedicine

Two basic ways for telemedicine:

  • Active telemedicine(or real-time telemedicine)

  • Passive telemedicine(store-and-forward)


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Active Telemedicine

Active telemedicine:

all partners work at the same time in a fully interactive way.

Example: Video-conferencing


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Active Telemedicine

Active telemedicine:

all partners work at the same time in a fully interactive way.

Example: Video-conferencingPro: Very interactive. Consultant at remote site can influence what and how things are presented at the other side.

Con:

- All partners must be available at the same time.

- Difficult to archive & reuse


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Active Telemedicine

Problems in developing countries:

  • High demand on bandwidthVideo-Conferencing: min. ISDN with 128kb/s

  • Consultant needs to be available in real time(problematic when in different time zones)


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Active Telemedicine - Example

Tsilitwa Clinic in rural Transkei

  • No doctor

  • No telephone lines

  • Next hospital with 1 doctor: - 30km over very bad road

... during rainy season

Tsilitwa community

Roads ...


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Tsilitwa Clinic


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Tsilitwa Clinic


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Tsilitwa Clinic

Wireless link

Sulenkama(hospital)

Tsilitwa(clinic)

Mountain

Sulenkama Hospital

Repeater Site


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Tsilitwa Clinic

Wireless link

Sulenkama(hospital)

Tsilitwa(clinic)

Mountain

Sulenkama Hospital

Repeater Site


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Tsilitwa Clinic

Wireless link

Sulenkama(hospital)

Tsilitwa(clinic)

Mountain

Sulenkama Hospital

Repeater Site


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Tsilitwa Clinic

Tsilitwa Clinic:

  • Scheduled meeting with remote doctor on Tuesday morning

  • More patients visit the clinic(transport)

  • Less unnecessary referrals to hospital

  • Continuing education and empowerment for the nurse


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Passive Telemedicine

Passive telemedicine:

Material submitted in advance. “Experts” comment at a later time.

Example: consultation by email


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Passive Telemedicine

Passive telemedicine:

Material submitted in advance. “Experts” comment at a later time.

Example: consultation by emailPro: All involved parties can work at time convenient to them – easy to schedule.Written requests and comments allow easy archiving.

Con: Experts cannot easily influence selection of presented material and cannot ask questions immediately.


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Passive Telemedicine - Example

Store-and-forward telemedicine with iPath

iPath is ....

  • ... an open source telemedicine platform

  • ... Developed at University of Basel

  • ... Originally designed for telepathology but now used in may specialities

  • ... Optimized for low bandwidth application (email)


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iPath - Telemedicine Server

  • Concept of Technology mediated communication

  • A central Server

  • Access via WWW or Email

  • Discussions and collaboration in defined user groups


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iPath - Telemedicine Server

  • Why do we need anything special for passive telemedicine?won't email be enough?


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How to collaborate


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How to collaborate


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How to collaborate


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How to collaborate


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How to collaborate

iPath = technology mediated communication


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Web Application Server:

(iPath-Server Software)

Case Database- images- comments/diagnoses

WWW interface

Email interface


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Sending cases:

email


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Sending cases:

email

www


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Sending cases:

email

www

special equipment:e.g. remote control microscope, ultrasound ...


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Reviewing cases:

email (alerts)


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Reviewing cases:

email (alerts)

web interface


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Reviewing cases:

email (alerts)

web interface

special remote control (e.g. JAVA applet)


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Personal start page

List of the groups

New cases and comments at a glance

User Interface


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User Interface

Group Display

case list


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User Interface

Case Display

Description & Images


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User Interface


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User Interface

Case Display

Description & Images

Comments


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User Interface

Case Display

Description & Images

Comments

New comments: automatic email alert


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User Interface

Comments:All members of the group can write and read comments


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Experiences

  • Examples of Telemedicine using iPath


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Telemedicine using iPath

Users - Non-Experts and Experts

Servers running iPath


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Solomon Islands: Telepathlogy


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Ukraine: Neonatology

Case from Ukraine

Coordinated by:Swiss Centre for International Health


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Cambodia: Plastic surgery consultations

Plastic Surg


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Cambodia: orthopaedic surgery

Plastic Surg

Plastic Surg


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Jimma University: Teleradiology

Radiology case

  • University Collaboration:

  • Jimma University, Jimma, Ethiopia

  • Ludwig Maximilan University (LMU), Munich, Germany


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Addis Abeba: Telepathology

Radiology case

Pathology


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Transkei:Teledermatology

Clinic


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Transkei:Teledermatology

Case on iPath

Clinic


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Telepathology at Uni Baselhttp://telepath.patho.unibas.ch

Telemedicine at UNITRA http://telemed.utr.ac.za

iPath Software: http://ipath.sourceforge.net

Resources


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Regional Telemedicine Network

Tele-radiology

Tele-radiology

Tele-pathology

Tele-pathology

Tele-oncology ?

Tele-cytology

Tele-dermatology

Tele-pathologyTele-teaching

Telemedicine Server at UNITRA(operational since June 2003)


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Regional Telemedicine Network

Tele-radiology

Tele-radiology

Tele-pathology

Tele-pathology

Tele-oncology ?

Tele-cytology

Tele-dermatology

Tele-pathologyTele-teaching

Telemedicine Server at UNITRA(operational since June 2003)


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Applications

  • Discussion groups (second opinion consultations)

  • Primary Diagnosis

  • Teaching & CME (continuing medical education)


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Applications:Discussion Groups

  • Common Cases (Images & Text)

  • Common user profile for everybody:- Create and read cases- Read and write comments

  • Ideal for second opinion consultation


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Applications:Primary Diagnosis

  • Sender and Experts

  • Discussion among the Experts

  • Conclusion of the Experts delivered to the Sender


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Sender

Experts


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Request (Images & Text)


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Request (Image & Text)


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Request (Image & Text)

Comments


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Request (Image & Text)

Comment of the Experts


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Teaching & CME

  • Teacher and Student


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Teaching:case presentation

Teacher

Students


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Teaching:student feedback


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iPath

  • One Technology

  • Different Organisation

  • Many Applications


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Further Applications

  • Studies & Reviews

  • Clinical Conferences (CPC)

  • Tumour board meetings

  • ...


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Example – Tsilitwa Clinic

Tsilitwa:


  • Login