In the developed world, telemedicine has been criticised as a cost-cutting device that leads to a depersonalised approach to healthcare. It has also been criticised in the developing world as an expensive, high-bandwidth overkill approach that focuses attention away from real problems and sucks up scarce resources. But at a hospital in South Africa telemedicine has proved to be more of a hands-on approach to patient care.
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CASE STUDY SERIES ON ICT-ENABLED DEVELOPMENT
An initiative of IICD and bridges.org
series is to help ground level initiatives imagine the possibilities of
what can happen if they use ICT successfully to overcome development
obstacles, and to contribute to the existing body of knowledge on the
digital divide.>
I. OVERVIEW: THE TYGERBERG CHILDREN'S HOSPITAL AND ROTARY TELEMEDICINE PROJECT
Project in South Africa links specialists from Tygerberg Hospital to
doctors at regional community or "district" hospitals to improve healthcare
in rural areas. The initiative has assembled its own telemedicine system
using off-the-shelf computer equipment and software that is more affordable
than commercial telemedicine systems.
Children's Hospital, Cape Town, South Africa.
the local Rotary Club (Signal Hill, Durbanville, Helderberg Basin,
Stellenbosch).
South Africa during 1994, one of its biggest challenges was to address
unequal access to healthcare. Under the previous Apartheid regime, public
funds for healthcare had been biased toward city hospitals that primarily
served privileged minorities. As a result, the new Government inherited
several well-serviced city hospitals, along with many healthcare facilities
in towns and rural areas -- which tended to serve more disadvantaged people
-- that had been largely neglected for a number of years. To help make
healthcare more accessible to the majority of people, the South African
Department of Health cut the budgets of many city hospitals and redirected
funds to the district health system, which is comprised of "district"
hospitals responsible for primary care in towns and rural areas. Although
many of the country's specialised doctors still practice at the city
hospitals, these hospitals now accept fewer patients due to budget cuts.
Consequently, many patients who require specialised treatment are served by
district hospitals where medical practitioners often have only general
training and experience.
at district hospitals to treat patients that require special attention or
diagnosis that is beyond their training. Tygerberg Hospital specialists
must support these doctors but usually do not have the time to visit them
on site.
Robert Gie of Tygerberg Children's Hospital set up a telemedicine system
that meets the immediate needs of the district hospitals. The system uses a
Pentium 3 computer with a 42 cm screen, printer, scanner, software, digital
camera, and light-shelf for viewing x-rays. The system is connected to the
Provincial Healthcare Department's network infrastructure, which connects
Tygerberg with the district hospitals and gives doctors unlimited access to
e-mail. The total cost of the unit based at Tygerberg Hospital was less
than R50,000 while the units at the district hospitals cost R35,000 each.
Doctors at district hospitals scan X-rays and electrocardiographs, and
e-mail them together with blood test results, digital photographs, and
clinical observations to the telemedicine unit at Tygerberg Children's
Hospital. At Tygerberg, one person monitors incoming e-mail and directs
queries to relevant specialists. The Tygerberg specialists review the
information received, send an e-mail reply, and consult remotely with the
district doctors about diagnosis and treatment. If a district doctor needs
an urgent reply, he sends an SMS message to a specialist's cell phone,
alerting the doctor to check e-mail immediately.
in Somerset West, Stellenbosch, Hermanus and Windhoek, Namibia.
three district hospital are linked to the system: Eben Dönges Hospital in
Worcester, Clanwilliam Hospital, and Paarl Hospital, which are 100km, 250km
and 100km from Cape Town, respectively.
Contact person: Dr. Etienne Nel
Email: [email protected]
URL:
http://www.sun.ac.za/healthsciences/schools/medicine/paediatrics/dept/pe...
Mailing Address:
Dr. Etienne Nel
Department of Paediatrics and Child Health
Faculty of Health Sciences
PO Box 19063
Tygerberg, 7505
South Africa
Tel: +27 21 938 9570
Fax: +27 21 938 9138
II. GAUGING REAL IMPACT
practice guidelines for successful initiatives. The bridges.org 7 Habits of
Highly Effective ICT-Enabled Development Initiatives are used here as a
framework to highlight what the specialists at Tygerberg Children's
Hospital have done well.>
The 7 Habits of Highly Effective ICT-for-Development Initiatives
1. Implement and disseminate best practice
Dr. Nel learned about telemedicine options at the Telemedicine Conference
2000 held in Gauteng, South Africa. He also read up about telemedicine
systems on the Internet and in medical journals to find out about best
practice in the field. Tygerberg's system has been designed by doctors in a
developing country and is much more affordable than more sophisticated
models used elsewhere. Doctors in Namibia, Malawi, and Zimbabwe are keen to
replicate the system in their countries. The Tygerberg team is actively
contributing towards best practice in healthcare that is relevant in an
African context.
2. Ensure ownership, get local buy-in, find a champion
Professor Gie has promoted the telemedicine system in interviews with local
newspapers and magazines. Lack of training -- especially for older doctors
who are less familiar with computer technology -- has been an obstacle. By
taking it upon himself to visit district hospitals and train doctors to use
the system, Dr. Nel has become an on-the-ground champion for the system.
3. Do a needs assessment.
The project emerged from a clear need in the healthcare environment in the
region, where district doctors need support from Tygerberg Hospital to help
them deliver more specialised care.
4. Set concrete goals and take small achievable steps.
A two-year pilot project involving only one hospital was conducted before
the project was expanded. The pilot had three clear goals: (1) to test
whether the equipment could convey clear images of X-rays,
electrocardiographs, etc; (2) to test whether the Provincial Health
Department's computer network would cope with the transfer of a vast amount
of digital information; and (3) to evaluate whether doctors would use the
system. Once the system was tested and proven, it was expanded.
5. Critically evaluate efforts, report back to clients and supporters, and
adapt as needed.
Throughout the pilot, the specialists evaluated the system to see whether
it was cost-effective and whether it would indeed improve district
healthcare. They also adapted it as needed as they went along. For example,
when it was difficult to repair the scanner because parts were not readily
available in South Africa, the scanner was replaced with a local brand to
ensure future availability of parts.
6. Address key external challenges.
A key external challenge faced is the installation of the connection points
at hospitals not yet connected to the Provincial Health Department's
computer network infrastructure. For example, Clanwilliam Hospital uses a
dial-up connection to access the telemedicine system. Continued support of
staff after initial training is also crucial, especially where the central
"receiving unit" (based at Tygerberg Hospital) is far from the "send units"
(in Worcester, Paarl and Clanwilliam). To address this problem Rotary Club
members from local communities and paramedical staff are providing support
when doctors experience difficulties in operating the system.
7. Make it sustainable.
Although Tygerberg telemedicine system is much cheaper than commercial
telemedicine models and uses the Provincial Health Department's network
infrastructure to send e-mail, the system's future is reliant on continued
donor funding from the Rotary Club. Hospitals situated in far-flung
communities such as Clanwilliam have to pay for a dial-up connection
because they are not connected to the Provincial network. Tygerberg
Telemedicine System is reliant upon future funding from the Rotary Club.
The South African Government has started implementing (much more expensive)
telemedicine systems elsewhere, but whether it will support Tygerberg's
model is not certain.
III. LESSONS LEARNED
greatest success, the challenges they have faced, key constraints and
dependencies that affect the initiative, opportunities for future
improvement of what they do, and other lessons they have learned. This is
what he had to say.>
"A number of important lessons were learnt during the implementation of the
pilot site.
Prior consultation with all stakeholders is essential. Most are
enthusiastic and eager to make use of the new facility. Some, however, felt
threatened by what was perceived as an intrusion by 'outside specialists'
into their domain. While these fears were unfounded, they had to be
addressed. There is a perception that this technology is inappropriately
costly for a country with limited health resources. Although the project is
funded by donations and the cost per unit is low in comparison to any other
medical hardware, this perception has been strong enough to delay
implementation in certain areas.
A major technical difficulty has been in the area of network access and
support. Frequent 'down time' on the network discourages use. In addition
problems accessing the network with poor technical support further dampen
enthusiasm.
Apparently minor problems emerged as significant issues limiting the use of
the system. Limited typing skills, lack of easy access to the system, time
constraints during the workday were found to be problems by staff. The
equipment needs to be kept in a secure environment while still being easily
accessible. This is a problem particularly after normal working hours if
the equipment is locked in an office.
A number of technical problems still need to be solved. These include:
1. The user interface has to be simplified. Users are still required to go
through a number of steps before they can send an enquiry. Automating these
procedures would encourage correct use of the system.
2. Image files are large. Transmission of large images is either not
permitted by the network that is being used or is slow.
3. Ensuring the security of information sent needs to be addressed.
Despite these problems medical and paramedical staff have been enthusiastic
and are learning to use the telemedicine system. It will however be some
time before the true benefits of this telemedicine application can be
quantified."
IV. THE STORY
development is particularly interesting.>
In the developed world, telemedicine has been criticised as a cost-cutting
device that leads to a depersonalised approach to healthcare. It has also
been criticised in the developing world as an expensive, high-bandwidth
overkill approach that focuses attention away from real problems and sucks
up scarce resources. But at a hospital in South Africa telemedicine has
proved to be more of a hands-on approach to patient care.
Ironically the telemedicine system at Tygerberg Children's Hospital in Cape
Town was established as a direct result of stringent budget cuts. In the
past decade the South African Government has shifted the majority of health
funding towards primary healthcare.
The budgets of academic hospitals such as Tygerberg were slashed severely
and redirected to district level. Over a period of about five years, 25% of
Tygerberg Hospital's budget was cut and redirected to district hospitals
and clinics in towns and rural areas. The Tygerberg Children's Hospital was
also adversely affected. Many physician and specialist posts were frozen
and bed space was reduced. As a consequence, doctors at district hospitals
had to make tougher decisions about which patients should occupy the
limited bed space at Tygerberg Hospital where they could get specialised
treatment. Those patients who could not be accommodated at Tygerberg had to
be treated at district hospitals -- and cared for by district doctors who
often do not have the specialised training needed for all cases.
To support district doctors with the referral process and provide more
specialised care, Professor Robert Gie and Dr. Etienne Nel, who are based
at Tygerberg Children's Hospital and had attended conferences in
telemedicine, investigated the possibility of introducing a telemedicine
system at their hospital. Their initial excitement was dampened when they
realised that the cost of such systems starts at R200,000 -- way beyond the
hospital's budget. Fortunately, the two doctors proved to be fairly
resilient. Dr. Nel started reading up about telemedicine systems on the
Internet and in medical journals, while Professor Gie contacted the Rotary
Club. They bought off-the-shelf equipment, assembled their own system, and
connected it to the Provincial Health Department's computer network to send
and receive e-mails. The main unit at Tygerberg Hospital costs R55,000 and
those at the satellite hospitals cost R35,000 each.
The system enables doctors at district hospitals to e-mail X-rays,
electrocardiographs, digital photographs of diseases, blood test results,
and their clinical observations to specialists at Tygerberg Hospital for an
opinion about a patient's condition. The system at Tygerberg is regularly
monitored for incoming e-mail and relayed to the relevant specialist whose
expertise is required. The specialist then sends an e-mail reply back to
the doctor at district level. According to Dr. Frikkie Strauss,
superintendent at Clanwilliam Hospital, the system that has been installed
at their hospital about six months ago is already making a big difference.
Thanks to his online access to specialists' advice, he can treat patients
sooner without having to refer them to Tygerberg Hospital first -- a
process that costs the Provincial Health Department a lot of money. The
system also helps him to stay in touch with specialists' opinions and keeps
him abreast of the latest treatment protocols. In addition, the
radiographer responsible for taking X-rays now receives regular feedback
about the quality of his X-rays.
Thanks to the system patients no longer have to travel unnecessarily to
Tygerberg Hospital just to have the local doctor's diagnosis confirmed.
Patients of Clanwilliam have to board an ambulance at 4 am in the morning
to beat the long queues at Tygerberg Hospital and be home by nightfall. In
addition, they have to pay R100 for the ambulance transportation fee. For
many, especially farm workers who earn a meagre weekly wage, R100 is a lot
of money. One woman, who was referred to Tygerberg Hospital because of a
bad break in her arm, did not board the ambulance because she could not
afford the fee. Today she walks around with a crooked arm.
A four-month-old baby girl who has been suffering from congenital heart
valve scars has been luckier. The girl who is from Clanwilliam, a small
town situated 250 km from Cape Town, had to be hospitalised for almost
three months and was supposed to go to Tygerberg Children's Hospital in the
city. However, her mother would not have been able to stay by her bedside
because she had to work and could not afford accommodation costs in Cape
Town. Dr. Strauss used the telemedicine system to consult specialists at
Tygerberg Children's Hospital on a regular basis and, thanks to them, was
able to treat the girl locally. "When she was brought to the hospital she
was very ill and I contacted the specialists about three to four times a
week. She has recovered to such an extent that I eventually only contacted
them about once a week".
Professor Gie and Dr. Nel are now hoping to expand the system to four more
hospitals. All that stands in their way is the small matter of funding --
and convincing the Provincial Health Department administration to expand
its network infrastructure to more district hospitals.
_______________________
Author: bridges.org
Date: 30 April 2003
The International Institute for Communication and Development (IICD) is an
independent non-profit foundation, established by the Netherlands Minister
for Development Cooperation. IICD assists developing countries to realise
locally owned sustainable development by harnessing the potential of
information and communication technologies (ICT). IICD works with its
partner organisations in selected countries, helping local stakeholders to
assess the potential uses of ICT in development. For more information on
IICD: http://www.iicd.org/about/.
Bridges.org is an international non-profit based in South Africa with a
mission to help people in developing countries use ICT to improve their
lives. Its main focus is to enable informed policy decisions, which affect
people's access to and use of ICT. Bridges.org also gets involved in ground
level projects to study the effects of policy decisions and relay lessons
learned to the international development community. It brings an
entrepreneurial attitude to its social mission, and is committed to working
with, instead of against, government agencies and the business community.
For more information on bridges.org: www.bridges.org.
This initiative is supported by the Building Digital Opportunities
Programme (www.iconnect-online.org) which is funded by the UK Department
for International Development (DFID), the Directorate General International
Cooperation (DGIS), and the Swiss Agency for Development and Cooperation (SDC).
To view this case study online, go to:
http://www.bridges.org/iicd_casestudies/case_studies.html
Author
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