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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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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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slide1
TelemedicineinDeveloping CountriesK. Brauchli Telemedicine Unit, University of Transkei Department of Pathology, University of Basel
content
Content
  • IntroductionCase study: Pathology in Solomon Islands
  • How to do Telemedicine
  • iPath – Open Source Telemedicine Server
  • Experiences worldwide
solomon islands5
Solomon Islands

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

solomon islands6
Solomon Islands

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

National Referral Hospital

solomon islands7
Solomon Islands

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

National Referral Hospital

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

limitations in developing countries
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)
limitations in developing countries9
Limitations in Developing Countries
  • Limited Transportation- no roads or very bad roads
limitations in developing countries10
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
implications
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)
solomon islands pathology
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
suggested solution
Suggested solution

Telemedicine:

  • Access to advice and diagnosis from remote specialists with the help of telecommunication technologies.
solomon islands14
Solomon Islands

Telepathology:

Phase 1: Histology Lab- September 2001

Phase 2: Establishing remote diagnostics- 2001-2003

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

phase 1 histology lab
Phase 1: Histology Lab

Needs for Histology Lab:

  • Operational under local conditions:- frequent power cuts- high temperature and humidity
  • Sustainable- locally available spare parts
phase 1 histology lab16
Phase 1: Histology Lab

Tissue Processing

phase 1 histology lab17
Phase 1: Histology Lab

Tissue Processing

Preparing blocks

phase 1 histology lab18
Phase 1: Histology Lab

Tissue Processing

Preparing blocks

Cutting

phase 1 histology lab19
Phase 1: Histology Lab

Tissue Processing

Preparing blocks

Cutting

Staining

phase 1 histology lab20
Phase 1: Histology Lab

Tissue Processing

Preparing blocks

Cutting

Staining

Histology slides

phase 2 remote consultations
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)

phase 2 remote consultations22
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)

how to do telemedicine
How to do Telemedicine

Two basic ways for telemedicine:

  • Active telemedicine(or real-time telemedicine)
  • Passive telemedicine(store-and-forward)
active telemedicine
Active Telemedicine

Active telemedicine:

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

Example: Video-conferencing

active telemedicine25
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

active telemedicine26
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)
active telemedicine example
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 ...

slide30

Tsilitwa Clinic

Wireless link

Sulenkama(hospital)

Tsilitwa(clinic)

Mountain

Sulenkama Hospital

Repeater Site

slide31

Tsilitwa Clinic

Wireless link

Sulenkama(hospital)

Tsilitwa(clinic)

Mountain

Sulenkama Hospital

Repeater Site

slide32

Tsilitwa Clinic

Wireless link

Sulenkama(hospital)

Tsilitwa(clinic)

Mountain

Sulenkama Hospital

Repeater Site

slide33

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
pass ive telemedicine
Passive Telemedicine

Passive telemedicine:

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

Example: consultation by email

passive telemedicine
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.

passive telemedicine example
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)
ipath telemed icine server
iPath - Telemedicine Server
  • Concept of Technology mediated communication
  • A central Server
  • Access via WWW or Email
  • Discussions and collaboration in defined user groups
ipath telemed icine server38
iPath - Telemedicine Server
  • Why do we need anything special for passive telemedicine?won\'t email be enough?
how to collaborate43
How to collaborate

iPath = technology mediated communication

slide44

Web Application Server:

(iPath-Server Software)

Case Database- images- comments/diagnoses

WWW interface

Email interface

slide47

Sending cases:

email

www

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

slide48

Reviewing cases:

email (alerts)

slide49

Reviewing cases:

email (alerts)

web interface

slide50

Reviewing cases:

email (alerts)

web interface

special remote control (e.g. JAVA applet)

user interface

Personal start page

List of the groups

New cases and comments at a glance

User Interface
user interface52
User Interface

Group Display

case list

user interface53
User Interface

Case Display

Description & Images

user interface55
User Interface

Case Display

Description & Images

Comments

user interface56
User Interface

Case Display

Description & Images

Comments

New comments: automatic email alert

user interface57
User Interface

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

slide58

Experiences

  • Examples of Telemedicine using iPath
slide59

Telemedicine using iPath

Users - Non-Experts and Experts

Servers running iPath

slide61

Ukraine: Neonatology

Case from Ukraine

Coordinated by:Swiss Centre for International Health

slide63

Cambodia: orthopaedic surgery

Plastic Surg

Plastic Surg

slide64

Jimma University: Teleradiology

Radiology case

  • University Collaboration:
  • Jimma University, Jimma, Ethiopia
  • Ludwig Maximilan University (LMU), Munich, Germany
slide65

Addis Abeba: Telepathology

Radiology case

Pathology

slide67

Transkei:Teledermatology

Case on iPath

Clinic

slide68

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

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

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

Resources

slide70

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)

slide71

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)

applications
Applications
  • Discussion groups (second opinion consultations)
  • Primary Diagnosis
  • Teaching & CME (continuing medical education)
slide73

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
slide75

Applications:Primary Diagnosis

  • Sender and Experts
  • Discussion among the Experts
  • Conclusion of the Experts delivered to the Sender
slide76

Sender

Experts

slide80

Request (Image & Text)

Comment of the Experts

slide81

Teaching & CME

  • Teacher and Student
slide84

iPath

  • One Technology
  • Different Organisation
  • Many Applications
slide85

Further Applications

  • Studies & Reviews
  • Clinical Conferences (CPC)
  • Tumour board meetings
  • ...
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