Telemedicine: An alternative to costly patient transport in developing countries

By Maria J. Treurnicht

Quality healthcare is considered a fundamental human right to all citizens, in most countries. However providing quality care to all is a daunting challenge, especially in developing countries. The Primary Health Care (PHC) model aims to provide access for all patients to quality care, while limiting healthcare expenditure. In PHC, patients visit low-level of care facilities and are only referred to higher-level hospitals when necessary. Nevertheless, patient referrals have many drawbacks, mostly related to patient transportation.

Telemedicine could be invaluable in cases where the facilities to treat a patient are available at the lower-level of care hospital, but a patient is referred for a specialist’s diagnosis. In these cases the specialists could diagnose over a distance, using information and communication technologies. Therefore the need to transport patients between hospitals is reduced by transmitting information of the patients to the specialist rather than physically transporting the patients.

In theory, it makes sense to support the PHC referral system with telemedicine. Hence, the South African Department of Health has started investing in telemedicine implementation throughout the country since 1997. Unfortunately, rather few telemedicine projects have been successful. Also, among those successful, there is a severe lack of proof that telemedicine is saving costs on a meaningful level.

Subsequently, we have to ask what we are doing wrong. Is the infrastructure in the developing world adequate to allow for reliable telemedicine? Is there really a need for telemedicine? How can we support decision makers to implement telemedicine in response to a need, as opposed to merely pushing the technology onto physicians, telling them to use it as they please?

Many critics in South Africa are of the opinion that the infrastructure is not adequate for successful telemedicine. Some hospitals do not have reliable power supply and no internet connectivity. However, many hospitals in South Africa do have reliable internet, but are constrained by very low bandwidth. These challenges are limiting our ability to embrace the various possibilities of telemedicine. Therefore, we have to start small, by first implementing technologies that do not require high bandwidth or rely on live streaming.

I am of the opinion that if we apply a few industrial engineering principles to telemedicine, we would see much better results. Some of these principles are:

• Needs assessments using the Push-Pull and Pareto principles
• Systems thinking & Total quality management
• Change management

Implementing technologies without first performing a proper needs assessment could do more harm than good. It is likely that if technology is pushed into hospitals without first considering the requirements, such as the desired utilization, required telemedicine devices and necessary bandwidth, the equipment will be dormant. A needs assessment that considers the potential of telemedicine for a network of hospitals should be done prior to implementing telemedicine workstations.

In South Africa, various telemedicine workstations were implemented without providing sufficient structure to physicians as to how and where to use the equipment. Due to a lack of time, physicians are likely to save time in the short term, by transporting patients rather than spending time on technical issues. It is therefore critical to include proper training, support and change management when implementing telemedicine workstations.

Because telemedicine referrals necessitate effective collaboration between hospitals, a network of hospitals should be considered as a system. In this system, total quality management principles have to be applied to ensure quality results for the entire network of hospitals. Through continuously improving the utilization of telemedicine and adding new technologies, telemedicine could become an integral part of delivering quality healthcare to all, and at the same time adding lifechanging value.