THE IMPACT OF TELEMEDICINE AND ONLINE MEDICAL CONSULTATION ON HEALTH CARE DELIVERY IN NIGERIA (A CASE STUDY OF TREMENDOC)
CHAPTER ONE
1.3 Objectives of the Study
The main objective of this study is to examine the impact of telemedicine and online medical consultation on health care delivery in Nigeria by using Tremendoc as a case study. However, the specific objectives are:
- To assess the effectiveness of telemedicine and online medical consultation on health care delivery in Nigeria.
- To determine the various types of telemedicine available in Nigeria.
- To examine the challenges associated with the use of Telemedicine in Tremendoc.
1.4 Research Questions
This study shall seek to provide answers to the following questions:
- What is the effectiveness of telemedicine and online medical consultation on health care delivery in Nigeria?
- What are the various types of telemedicine available in Nigeria?
- What are the challenges associated with the use of Telemedicine in Tremendoc?
CHAPTER TWO
LITERATURE REVIEW
2.1 Definition of Telemedicine
Most definitions focus on improved access to healthcare services through use of telecommunications technology. Logan (1998) defined telemedicine as: “Simply a tool that permitted more equitable distribution of comprehensive specialty and sub-specialty healthcare services to remote populations.”
Other definitions include using and accessing remote medical expertise when needed to seek or give advice on patient care. It is evident therefore that telemedicine is a diverse and comprehensive concept that incorporates transfer and exchange of medical information using telecommunication technologies. Beyond the key concept of single patient/practitioner interface, Craig and Patterson (2006) outlined natural extensions that could include electronic links between multi-centre care facilities either locally, nationally or internationally, heralding the notions of “telehealth” and “telecare”.
However, such technological advances should not be interpreted as a new form of medicine, but merely as a new location (Bashshur et al, 2005) that will not in itself provide a cure or replace healthcare professionals (Craig and Patterson, 2006). Other terms used when discussing technology in healthcare include telehealth, which refers to the delivery of health-related services and information via telecommunications technologies. Telehealth delivery could be as simple as two healthcare professionals discussing a case over the telephone, or as sophisticated as using videoconferencing between providers at facilities in two countries, or even as complex as robotic technology.
Telehealth is an expansion of telemedicine, but unlike telemedicine (which more narrowly focuses on the curative aspect), it encompasses preventive, promotive and curative aspects (Maheu et al, 2001). Although originally used to describe administrative or educational functions related to telemedicine, the term is now used to describe a myriad of technology solutions. For example, doctors use email to communicate with patients, order drug prescriptions and provide other health services (Field, 1996).
E-health is a term introduced relatively recently to describe healthcare practice supported by electronic processes and communication. The term is inconsistently used: some would argue it is interchangeable with healthcare informatics and a subset of health informatics, while others use it in the narrower sense of healthcare practice using the internet (Field, 1996).
The term telecare refers to the continuous, automatic and remote monitoring of real-time emergencies and lifestyle changes over time to manage the risk associated with independent living (Telecare Aware, 2009).
In the UK the NHS set targets for implementing e-health:
- 2001 – to have up to 90% of GP practices and 25% of hospitals connected to NHSmail;
- 2002 – to have desktop connections for all NHS clinical staff linking them to basic emails, browsing and directory services;
- 2003 – to have completed migration to national standards for all email, internet browsing and office systems used in the NHS and all NHS staff to have desktop access;
- 2004 – to have access to electronic patient records (EPRs) and electronic transfer of prescriptions (ETP);
- 2005 – to have all appointments bookable electronically. There will be local telemedicine facilities and all GP practices and hospitals will be able to use EPRs and ETP (House of Commons Committee of Public Accounts, 2007).
2.2 Types of Telemedicine
Craig and Patterson (2006) said all telemedicine interventions are based on patients or professionals obtaining an opinion on treatment or care from someone who is more experienced or an expert in a particular field. Accordingly, telemedicine interventions could be classified on the basis of the type of interaction and information transmitted between patients and professionals. Telemedicine can be broken into three main categories: Store-and-forward, Remote monitoring and Interactive services.
2.2.1 Store-and-forward
Telemedicine involves acquiring medical data (like medical images, biosignals etc) and then transmitting this data to a doctor or medical specialist at a convenient time for assessment offline. It does not require the presence of both parties at the same time. Dermatology, radiology and pathology are common specialties that are conducive to asynchronous telemedicine. A properly structured Medical Record preferably in electronic form should be a component of this transfer. A key difference between traditional in- person patient meetings and telemedicine encounters is the omission of an actual physical examination and history. The store-and-forward process requires the clinician to rely on history report and audio/video information in lieu of a physical examination.
2.2.1.1 Telecardiology
ECG or electrocardiograph can be transmitted using telephone and wireless. Einthoven, the inventor of the ECG, actually did tests with transmission of ECG through telephone lines. This was because the hospital did not allow him to move patients outside the hospital to his laboratory for testing of his new device. Teletransmission of ECG using indigenous methods. One of the oldest known telecardiology system (teletransmission of ECG) was established in Gwalior, India in 1975 at GR Medical college by Dr. Ajai Shanker, Dr. S. Makhija, P.K. Mantri using indegenous technique for the first time in India. This system was also used to monitor patients with pacemakers in remote areas. The central control unit at the ICU was able to correctly interpret arrhythmia. This technique helped medical aid reach in remote areas.
2.2.1.2 Teleradiology
Teleradiology is the ability to send radiographic images (x-rays, CT, MR, PET/CT, SPECT/CT, MG, US…) from one location to another. For this process to be implemented, three essential components are required, an image sending station, a transmission network, and a receiving / image review station. The most typical implementation are two computers connected via Internet. The computer at the receiving end will need to have a high-quality display screen that has been tested and cleared for clinical purposes. Sometimes the receiving computer will have a printer so that images can be printed for convenience. The teleradiology process begins at the image sending station. The radiographic image and a modem or other connections are required for this first step. The image is scanned and then sent via the network connection to the receiving computer (Kontaxakis, et al, 2006).
2.2.1.3 Telepsychiatry
Telepsychiatry, another aspect of telemedicine, also utilizes video conferencing for patients residing in underserved areas to access psychiatric services. It offers wide range of services to the patients and providers, such as consultation between the psychiatrists, educational clinical program, diagnosis and assessment, medication therapy management, etc.
2.2.1.4 Telepharmacy
Telepharmacy is another growing trend for providing pharmaceutical care to the patients at remote locations where they may not have physical contact with pharmacists. It encompasses drug therapy monitoring, patient counseling, prior authorization, and refill authorization, monitoring formulary compliance with the aid of teleconferencing or videoconferencing. In addition, video-conferencing is vastly utilized in pharmacy for other purposes, such as providing education, training, and performing several management functions (Angaran DM. 1999).
A notable telepharmacy program in the United States conducted at a federally qualified community health center, Community Health Association of Spokane (CHAS) in 2001, which allowed the low cost medication dispensing under federal government’s program. This program utilized video telephony for dispensing medication and patient counseling at six urban and rural clinics. There were one base pharmacy and five remote clinics in several areas of Spokane, Washington under the telepharmacy program at CHAS. “The base pharmacy provided traditional pharmacy study to the clients at Valley clinic and served as the hub pharmacy for the other remote clinics.”
The remote site dispensing and patient education process was described as follows: once the prescription is sent from the remote clinics to the base pharmacy, the pharmacist verifies the hard copy and enters the order. The label is also generated simultaneously, and the label queue is transmitted to the remote site. When the label queue appears on the medication dispensing cabinet known as ADDS, the authorized person can access the medicine from ADDS followed by medication barcode scanning, and the printing and scanning of labels. Once those steps are done, the remote site personnel are connected to the pharmacist at base pharmacy via videoconferencing for medication verification and patient counseling (Dennis Clifton G, et al, 2003).
In recent time, the U.S. Navy Bureau of Medicine took a significant step in advancing telepharmacy worldwide. The telepharmacy program was piloted in 2006 “in the regions served by Naval Hospital Pensacola, Florida, and Naval Hospital Bremerton, Washington.” Starting from March 2010, the Navy expanded its telepharmacy system to more sites throughout the world. According to Navy Lieutenant Justin Eubanks at Navy Hospital Pensacola, Florida, telepharmacy would be initiated at more than 100 Navy sites covering four continents by the end of 2010.
2.2.2 Remote monitoring
Remote monitoring, also known as self-monitoring or testing, enables medical professionals to monitor a patient remotely using various technological devices. This method is primarily used for managing chronic diseases or specific conditions, such as heart disease, diabetes mellitus, or asthma. These services can provide comparable health outcomes to traditional in-person patient encounters, supply greater satisfaction to patients, and may be cost- effective.
2.2.3 Interactive services
Interactive telemedicine services provide real-time interactions between patient and provider, to include phone conversations, online communication and home visits. Many activities such as history review, physical examination, psychiatric evaluations and ophthalmology assessments can be conducted comparably to those done in traditional face-to-face visits. In addition, “clinician-interactive” telemedicine services may be less costly than in- person clinical visits.
2.3 Telemedicine Usage Models
2.3.1 Real-Time
This is the most common use in Telemedicine. Like the example above, live video allows the provider, patient and specialist to all communicate together to achieve the best outcome for the patient.
- In or outpatient specialty consultation
- Physician supervision of non-MD clinician
- Generally require higher bandwidths (minimum 256kb)
2.3.2 Home Health Telemedicine
When a patient is in the hospital and he is placed under general observation after a surgery or other medical procedure, the hospital is usually losing a valuable bed and the patient would rather not be there as well. Home health allows the remote observation and care of a patient. Home health equipment consists of vital signs capture, video conferencing capabilities, and patient stats can be reviewed and alarms can be set from the hospital nurse’s station, depending on the specific home health device.
- Usually low bandwidth analog Plain Old Telephone System (POTS). Some newer systems do support higher bandwidth
- Disease management, post-hospital care, assisted living,
2.4 The Role of Telemedicine
Telemedicine can be used when healthcare professionals and patients are unable to meet face to face due to geographical distances, convenience or practicality. Eng and Gustafson (1999) identified a number of functions that telemedicine can provide for healthcare systems:
- Providing individualised health information;
- Enhancing decision making in clinical management;
- Facilitating communication between healthcare professionals;
- Health promotion/changing health behaviours and lifestyle to adopt and maintain good health;
- Offering support;
- Educating patients, careers and relatives on managing health problems by facilitating remote monitoring and information delivery.
There is scope for telemedicine to improve healthcare outcomes, in terms of reducing secondary complications, enhancing communication, and centralising data sources to allow information sharing. Craig and Patterson (2006) also argued that telemedicine can contribute to improving equity in accessing care by enhancing communication between healthcare professionals.
2.5 Benefits of Telemedicine
Telemedicine can be used to monitor patients’ health from a distance, offer advice and manage healthcare needs effectively.
Hui et al (2001) conducted a pilot study on the feasibility of telemedicine in providing geriatric services and whether this method of care delivery might increase productivity and cost savings. Two hundred residents were recruited from a local nursing home. Teleconferencing was used to replace face-to-face outreach services over one year. The feasibility of telemedicine was evaluated by participating specialists (medical staff, nurses, psychologists, physiotherapists and occupational therapists), who tested productivity gains, use of hospital services and user satisfaction.
The findings suggested telemedicine was an adequate means of service delivery in up to 99% of cases, in that follow-up intervals were reduced, follow-up care via teleconferencing was cheaper than face-to-face outreach or clinic activities and, importantly, patients accepted telemedicine as a valid form of continuity with healthcare professionals. A 9% reduction in A&E visits and 11% fewer admissions to acute hospital wards demonstrates more tangible economic savings.
Hui et al (2001) concluded that telemedicine is a feasible means of delivering multidisciplinary care to frail nursing home residents and may result in increased productivity and significant savings.
Pain et al (2007) conducted a randomised controlled trial in three centres over two years to evaluate the effectiveness of using internet-based video link technology. The study was for patients in the first six months post-discharge from spinal rehabilitation centres. Standardised assessments took place before allocating participants to intervention or control groups. Both groups received standard post-discharge support, but the intervention group also had regular videoconferencing sessions. Participants also underwent assessment at two months and six months post-discharge. The results (from 77 participants) revealed significant differences between the two groups when quality of life intra-subject score differences between discharge and month six were compared (p=0.025). Other findings indicated that the video link was accepted by the intervention group.
Pain et al (2007) suggested regular expert consultation after discharge via video-link technology benefited participants’ quality of life. Participants suggested that tele-rehabilitation should be targeted at people assessed as having continuing healthcare or rehabilitation needs. This supports earlier points on the efficacy of telemedicine as a malleable tool for acute care and follow-up and preventative healthcare (Maheu et al, 2001).
Other benefits include educational opportunities for healthcare professionals. Similar considerations of ease of access, travel constraints and costs, applicable to patient care, also apply here (Hjelm, 2006).
2.5.1 Home Care
Elford et al (2000) stressed that the most important potential benefit of telemedicine is access to quality healthcare for rural communities. It means patients no longer need to travel to consult medical specialists.
Telemedicine is also playing a major role in home care collaboration and partnership working between primary and acute care professionals. The driving forces for this are patients being discharged earlier from hospital with some additional care needs at home; treating patients at home is cheaper than in hospital and many prefer to stay in their own homes rather than moving to nursing homes or hospices (Elford et al, 2000).
Advocates of telemedicine argue it offers effective advice and enhanced communication between healthcare professionals and relatives. Guest et al (2005) examined its use in helping neurologically impaired children at home. One family was recruited as a pilot study to assess the feasibility of telemedicine.
The findings suggested the family did not feel isolated from expert help and advice since the technology was simple to use and they found tele-consultations as reassuring as face to face consultations. The child was able to spend more time with family in a familiar setting instead of hospital. The family indicated significantly improved independence (Guest et al, 2005).
Soopramanien et al (2005) examined telemedicine in providing post-discharge support for patients with spinal cord injury (SCI), with a sample of 12 patients recruited from a spinal centre in the UK. Preliminary results indicated telemedicine enabled healthcare professionals to gain better understanding of family interactions, facilitating more effective care. The study concluded that telemedicine offers an additional means of support for outpatients with SCI.
2.5.2 Referral
Telemedicine also provides the opportunity to refer patients directly to specialist consultants for advice on managing their conditions. Magjarevic et al (2003) considered the acceptability and usability of information technology as a means of psychosocial rehabilitation for patients with SCI in Croatia.
Findings indicated that most participants accepted telemedicine support in psychosocial.
So far the literature indicates that telemedicine can reduce healthcare costs by providing appropriate care to patients at home, reducing the need to travel to specialist centres. In addition, unnecessary duplication of test results and other information can be reduced (Bashshur, 2001).
However, there is a need for large-scale trials to examine the cost effectiveness of telemedicine applications in healthcare services as there is little quantitative information about potential savings (Hjelm, 2006; Magjarevic et al, 2003).
2.6 Disadvantages of Telemedicine
One possible consequence of using tele-consultations or video link is a breakdown in the patient/healthcare professional relationship. Arguably, communication breakdown could result from poor interpersonal skills as well poor mastery of telemedicine technology.
Nonetheless, “depersonalisation” due to physical and mental factors, new and different processes of consultation, inability to perform the whole consultation due to technical difficulties and patients’ reduced confidence in healthcare professionals are all potential negative aspects of using telemedicine.
Hjelm (2006) argued that relationship breakdown has not been explored to any great extent. She suggested that highly skilled healthcare professionals may perceive that their autonomy is threatened by telemedicine, and feel they become no more than information technology technicians relegated to operating computers and transforming information electronically.
Maheu et al (2001) identified several barriers for telemedicine in healthcare to be Poor infrastructure and inadequate regulation of telecommunications, Costs for services, Policies/protocols regulating the use of telemedicine, Licence regulations for practising telemedicine, Maintaining quality of care, Professional regulation activities and implementing healthcare policies, Potential medical malpractice liability due to uncertainties concerning the legal status of telemedicine within and between states and Confidentiality due to increased (unauthorised) access to patient records.
Stanberry (2006) illustrated the complexity of managing change in healthcare and pointed to key obstacles related to using telemedicine: Lack of evidence about cost effectiveness and efficiency of telemedicine applications; Potential/perceived threat to healthcare professionals’ role and status; Possibly increasing workload; Fear that telemedicine is “market driven” rather than “user driven”; Lack of knowledge and skills regarding telemedicine technology; Cultural and linguistic differences among healthcare professionals and patients; Lack of agreed standards about the use of telemedicine.
Hjelm (2006) argued that many of these points could be incorporated into clinical risk assessments as specific evaluation criteria when considering telemedicine use. To date the evolution of effective protocols and guidance has been piecemeal.
Since most professionals are not currently familiar with telemedicine, there is clearly a need for further research into how best to achieve competency and efficiency of the system and the staff within it, while maintaining safeguards for patients. Equally, there is scant evidence on the reliability of telemedicine for either diagnostic or therapeutic intervention.
2.6 Applications
Telemedicine applications to medical consultations
Telemedicine applications to patient monitoring and counseling
Telemedicine applications to radiology
Telemedicine applications to other services
CHAPTER FIVE
SUMMARY, CONCLUSION AND RECOMMENDATIONS
5.1 Summary
This study focused on the impact of telemedicine and online medical consultation on health care delivery in Nigeria (a case study of TREMENDOC). The study was set to address three objectives which include;
- To assess the effectiveness of telemedicine and online medical consultation on health care delivery in Nigeria.
- To determine the various types of telemedicine available in Nigeria.
- To examine the challenges associated with the use of Telemedicine in Tremendoc.
Based on the above stated objectives and the study carried out, the following findings were made:
- that the effectiveness of telemedicine and online medical consultation on health care delivery in Nigeria include but not limited to Rapid and efficient communication; Alleviate imbalances in geographical allocation of resources; Decreases patient anxiety; Increases access to health facilities; and Elimination of real – time interaction.
- that the various types of telemedicine available in Nigeria include but not limited to Telecardialogy; Teledermatology; Teleradiology; Telepharmacy; and Telenursing.
- that the challenges associated with the use of Telemedicine in Tremendoc include but not limited to Poor internet facilities; Poor funding; Unfavorable government policy; Difficulty in retrieving record; and Difficult remote access.
5.2 Conclusion
The main purpose of this study was to assess the impact of telemedicine and online medical consultation on health care delivery in Nigeria (a case study of TREMENDOC). All the workers of TREMENDOC) were selected for the study. Three research questions guided the study with one research hypothesis.
In this study, a survey research design was adopted, the population comprises all the staff of TREMENDOC), a simple random sampling technique was used to select 100 respondents from the population and a questionnaire was the instrument for data collection. Relevant literatures were reviewed which guided the objectives and methodology of this study. As result of the field study and analysis of results, the following findings were made:
- that the effectiveness of telemedicine and online medical consultation on health care delivery in Nigeria include but not limited to Rapid and efficient communication; Alleviate imbalances in geographical allocation of resources; Decreases patient anxiety; Increases access to health facilities; and Elimination of real – time interaction.
- that the various types of telemedicine available in Nigeria include but not limited to Telecardialogy; Teledermatology; Teleradiology; Telepharmacy; and Telenursing.
- that the challenges associated with the use of Telemedicine in Tremendoc include but not limited to Poor internet facilities; Poor funding; Unfavorable government policy; Difficulty in retrieving record; and Difficult remote access.
5.3 Recommendations
Based on the findings of this study, the following recommendations are made:
- There is need for basic training and familiarity with the computer and associated communication systems in order to facilitate the use of telemedicine and telehealth applications and systems.
- Health communication professionals should devise methods of approaching medical schools to encourage them to integrate courses into their programs that instruct the students on the most commonly used forms of telemedicine and the forms likely to be used in the future.
- Establishing a basic understanding of what this medical technology can lead to will help health communication scholars enlighten the telemedicine debate by turning unique insights into more adequate approaches that will enrich and humanize mediated channels of health communication, thereby offering remedies and clarifications for effective health care exchange and delivery.
- The surveyed Federal Medical Centers should embark on drastic development of telemedicine in line with global trend in order to promote effective utilization of telemedicine services.
