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Participatory Telemedicine
Jamais Cascio, 22 Feb 05

While most of us would prefer to interact face-to-face with our doctors, that's not always an option: patients may be too remote for a doctor to reach, or a necessary specialist may not be available nearby. In the past, that meant that the patient would need to travel to receive care, or wait until a doctor or other health provider could visit. The advent of telemedicine, the examination and diagnosis of medical conditions via networked cameras and monitors, changed that. Telemedicine is increasingly used in rural areas of Western countries as a means of providing quality health care remotely, and more generally as a way for specialists to apply their knowledge globally without getting on a plane; it's also proven useful for researchers in Antarctica, where the cold and the dark of winter make travel in or out impossible, echoing the fields origins in the space programs of the 1960s.

Telemedicine isn't widely used outside of the West, despite its evident utility for the developing world. This is due, in large part, to its technological requirements: telemedicine has come to rely upon high-bandwidth network links for the transmission of medical data and high-resolution images. As a result, the developing world telemedicine focus is often on bringing in high-end hardware. But that may soon change.

Research at the University Hospital of Geneva, Switzerland, published in the current issue of Archives of Dermatology, tested the usability of camera phones as an approach for visualizing leg ulcerations. The researchers compared face-to-face evaluations of leg wounds to evaluations made via mobile phone pictures, under normal lighting, and sent via email.

The three physicians separately evaluated the 61 leg ulcers for nine variables. "The image quality was judged to be good in 36 cases (59 percent) and very good in 12 (20 percent). The participants felt comfortable making a diagnosis based on the pictures in 50 cases (82 percent)," the authors state. To compare the results, the researchers used a statistical analysis which measures agreement between two raters when both rate the same object. The value range is one to zero, where one is perfect agreement and zero is no agreement between the two raters. "Overall, the agreement between the remote and face-to-face evaluations was very good, with … values of up to 0.94," the authors state.

While this was a narrow test, it is suggestive. A wide array of telemedical applications relying on visual examination and diagnosis may be able to take advantage of the mobility and connectivity of cameraphones. Cameras in mobile phones are rapidly improving in quality, and cameras with the ability to record video are now on the market. While 3G networks aren't yet widely available, they should (in principle) also allow real-time video over the phone connection, making interactive telemedicine calls possible.

Using digital images and email for telemedicine is not new. The Australia-based Swinfen Charitable Trust provides free telemedicine services around the world using little more than digital cameras and email. While they technically don't provide emergency services, they are sometimes called upon to provide rapid assistance to remote health care workers. This brief 2002 article (PDF) by the project's founders, Roger and Pat Swinfen, gives an overview of the Swinfen project.

The SCT is run from home, by the two authors. New referrals are allocated to a panel of medical consultants, who give their advice free of charge. We have consultants in 23 specialties, who are located in Europe, Australia and the USA. Referrals are coordinated, and records kept of each referral and reply. Email messages are checked three to four times daily, seven days a week. Should a referral not receive a reply, we are able to intervene and seek another specialist’s advice.

The Internet infrastructure in remote parts of the developing world is often non-existent, while mobile phone networks cover more than 80% of the planet's population. Cameraphone photographs and phone network email have the potential to improve both the scope and reliability of the Swinfen and related low-cost telemedicine projects.

The Markle Foundation, as part of its telemedicine clinic project in Ratanakiri Province, Camobia, provides an example (PDF) of another pathway to telemedicine in areas without network access: "Motomen."

motomen.jpgWithin Ratanakiri Province, poor roads and distance isolate villages. Many of these villages have no phones, TV, electricity, water, transportation system, or much contact with the rest of the province or country. Fourteen of them do have AAfC [American Assistance for Cambodia]-built schools, each with a solar-panel fueled computer. While it would be prohibitively costly to dedicate satellite dishes to individual villages in this area, or to create a wirebased network among them, they are now being linked to each other and to the Internet wirelessly via a mobile send-and-receive system. Twice a day one of a small fleet of motorcycles is driven past each of 14 computer equipped schools and the satellite hub, the Markle Telemedicine Clinic.

Each motorcycle is outfitted with a wireless antenna and a data storage box (see photo, above). As it drives past a school, the motorcycle can transmit e-mails and information from web sites. This mechanism allows people to send e-mail and effectively surf the web in a time-delayed fashion. The schools, in addition to the clinic, are becoming community hubs from which villagers can send and receive questions and information about their personal health, regardless of whether they are able to travel to the Markle clinic, as well as communication on other topics. This so called “Motoman” initiative was designed by the Cambridge, Massachusetts-based firm First Mile Solutions in association with AAfC.

Telemedicine can be of great value in the developing world, bringing global medical expertise to regions suffering from limited resources and "brain drain." It just needs the components to be in place. Fortunately, the convergence of efforts to bring Internet access to remote areas, the growth of low-cost mobile phones, and the increased medical utility of images sent by digital camera could soon lead to a telemedicine revolution.

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Comments

Telemedicine is a very exciting development in the practice of healthcare and particularly in my field, dermatology. It is one of the areas that is rapidly being expanded. The new camera phone systems may really help with this, as in the quoted article from Geneva. In many of the existing systems the process is 'store and forward', but work is also being done on interactive audio and visual systems too. All of this will improve healthcare, delivery, diagnosis, treatment and education but may involve increased costs. There are always privacy issues with this type of medium, and these may limit some applications.

If you go to the National Library of Medicine's PubMed website at www.ncbi.nlm.nih.gov/entrez/query.fcgi you can search telemedicine. There are 6,905 references! The most up-to-date one is by Burg G. Hasse U, et al. Teledermatology: just cool or a real tool? 2005; 210(2): 169-73. this is an excellent review on the subject from a dermatological point of view.

This is already being done for radiology, and there are clinics in my town (Manchester, NH, USA) that transmit their radiologic images over the Internet to Australia, where they are read at night by a group of doctors there and the information is sent back within one hour.

As you know, there already has been surgery done over the Internet with the operator in the US operating using a robotic device in an operating room in another country!

I would anticipate this technology will revolutionize medicine. It is most needed in the developing world but it is just beginning to happen in the western world as we know it. A truly world changing subject!


Posted by: Lynne J. Margesson, MD on 24 Feb 05



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