Telemedicine for improving access to health care in resource-constrained areas : from individual diagnosis to strengthening health systems

In many developing countries there is an acute shortage of trained medical specialists. This
does not only hamper individual patients’ access to medical diagnostics but furthermore limits
the development of health systems because a major role of the specialists is the provision of
continuous medical education of health care personnel.
The rapid development of information and communication technologies has enabled radically
new forms of virtual collaboration at a distance. So-called telemedicine enables us today to
transmit knowledge to the patient rather than to only transport patients to the centres where the
knowledge is available; this has promising implications in particular for remote and under-served
areas.
Initiated by a request from a Swiss surgeon from Solomon Islands, a project for supporting the
hospital in Honiara, capital of Solomon Islands, with pathology diagnoses was started between
Honiara and the Department of Pathology in Basel in 2001. After a successful start this pilot
project found broad interest, and the Internet platform that had been developed was soon utilised
by projects from other countries and medical disciplines. Thus, questions arose about the diagnostic
accuracy of such remote diagnoses as well as about their acceptance and impact on the
local health care system. The work presented here was initiated on this background. It analyses
the applicability of telemedicine in the context of resource-constrained areas and in particular
the possibilities to extend its impact from improving individual diagnosis towards strengthening
health care systems.
A central part of this project was the development of iPath, an Internet- and email-based telemedicine
platform, which facilitates medical consultations, knowledge exchange and continuous
education on a global scale. A particular emphasis was put on the applicability and accessibility
for users from developing countries with limited infrastructure and network connectivity. The
complete software was released under an open-source licence in order to allow unrestricted reuse
for other institutions.
The diagnostic accuracy of this form of telemedicine was studied in two projects from the field of
pathology. A retrospective review of over 200 glass slides from each project revealed complete
diagnostic concordance between the telemedical diagnosis and review diagnosis in 69% and 85%
respectively. Clinically relevant discrepancies were found in 8% and 3.3% of all examinations.
Selection of images by the non-expert and communication were found to have the greatest impact
on diagnostic accuracy. Both factors can be addressed by training and organisation of workflow.
In comparison to submitting material for pathological examination by courier, the turn-around
time could be reduced from weeks to days or hours. Besides the more rapid availability of
diagnosis, telemedicine enabled a direct dialogue between the surgeon and the pathologist and
thus facilitated an implicit permanent medical education.
The educational aspects of telemedicine were studied within the scope of a tele-dermatology
project in South Africa. Distance collaboration with a dermatologist empowered a general practitioner
based in a rural area to diagnose and treat a majority of patients with dermatological
problems. Besides the direct benefit of saving the patients the cost of transportation to visit the
dermatologist, the general practitioner could strengthen his own diagnostic skills under direct
guidance and quality control of a specialist. As a consequence he will be able to treat more patients
locally, close to their homes and families. The whole project was implemented within the
local health system in order to facilitate a future inclusion of other primary care facilities.
Regional telemedicine networks play a major role to ensure relevance and acceptability of consultative
and educational telemedicine. Within the scope of the Ukrainian Swiss Perinatal Health
Program a telemedicine component was included, and it was found that the use of regional
language as well as inclusion of the regional specialists are important for the acceptance of
telemedicine and should not be neglected in a era of globalisation.
The presented results demonstrate that save and reliable telemedicine can be implemented with
limited resources. Telemedicine is suitable in particular to strengthen existing international collaborations
and to support professionally isolated medical specialists.
Regional collaboration and inclusion of regional specialists are desirable if telemedicine shall
help to strengthen health care systems. The application of telemedicine should not only focus
on providing care to individual patients, but should explicitly incorporate skills development and
capacity building of primary care staff.
Organisation of work flow and communication have been found to be the most challenging task
for the implementation of telemedicine networks. Resources must be invested not only in technology
but more importantly in training and organisation. Utilisation of existing technological
infrastructure is advisable wherever possible and greatly reduces the complexity of providing
support and maintenance.
The presented telemedicine platform provides an efficient tool for the organisation of interdisciplinary,
regional and international telemedicine networks. We hope that the unrestricted availability
of the software developed during this project will enable other institutions to utilise it for
their own purpose and that they will thus be able to allocate resources on the organisation of
workflow rather than technology.