A change in thinking: how do you make telemedicine work?

The use of telemedicine in Tanzania is relatively new. It’s only in the past few years that telemedicine programmes have started appearing in different parts of the country. There now exists a solid base of institutions and organisations who are working with this technology, which has prompted those involved to come together and start digging out the lessons that may have been picked up so far. So what are these lessons? How does telemedicine improve health care? Who is practicing telemedicine and what are the barriers? How can telemedicine be practiced throughout the whole country? To learn from each others’ experiences and to provide input for the development of a national policy, telemedicine practitioners and other stakeholders gathered for their second telemedicine platform meeting in Dar es Salaam on July 1st.

Starting down the (i) path

IICD and Cordaid have been supporting a project run by the Evangelical Lutheran Church in Tanzania (ELCT), which operates in the northern zone. They came to the meeting to share their own personal experiences with telemedicine, which began with a training of doctors from 14 hospitals. They were trained in the use of iPath, an Open Source online medical consultation tool, developed by the University of Basel. iPath is an international online community of doctors, who upload medical cases in the hope of receiving a consultation by return. Usually receiving a response within 24 hours, consultations can come from Tanzanian doctors, but also from foreign doctors who are part of the community. Aside from learning to use iPath, doctors were also trained in using digital cameras, so they can include pictures when submitting a case to the iPath community.

Practising telemedicine

Since the start of the project, the ELCT doctors have uploaded 43 cases to iPath; receiving 66 return consultations within the first three months. Most cases were in the field of dermatology, radiology, internal medicine and pediatrics. Having begun to use the technology doctors have started to incorporate it into their everyday working routine. So far, the signs of success are strong. In this case at least, it is safe to say that the consultations received have helped them to better treat their patients; saving time, costs, and most importantly lives. It has become clear though that though clearly making a difference, there are still many challenges to be tackled. From the 14 hospitals trained, only 5 are using the tool, and these are mainly young doctors (rather than old doctors who are less computer literate), doctors in remote hospitals, who cannot send patients to referral hospitals, and doctors in hospitals run by foreign missionaries, who tend to promote the use of telemedicine.

One particularly interesting example of telemedicine use was shared by Peramiho Hospital, located in the south-west of Tanzania. For the past year, the hospital has been using iPath specifically for tele-pathology, due to the hospital not having a local pathologist. By connecting a digital camera to a microscope, the doctors are able to then send the images for diagnosis to pathologists based in Germany, who can screen them for cancer. So far, more than 600 images of specimens have been taken and sent for consultation.

Human barriers and solutions

The discussions that took place during the one day meeting highlighted that there are still a number of difficulties, hindering the uptake and spread of this telemedicine. Apart from technical issues such as a lack of bandwidth to upload high-resolution pictures, most of the obstacles turned out to be human. One important factor is a simple lack of computer knowledge. “Computers in hospitals are mostly used as typewriters…older doctors [especially] need to get familiar with them”, said one participant. Some doctors also feel that the tool is being imposed or forced on them.

They also highlighted that a prevailing attitude towards knowledge sharing can be a barrier: doctors are not used to seeking a second opinion. One participating doctor, who is not using the tool yet, explained why she hesitates in taking up the new technology: “For me this would be an extra work load. I need a person to help me with this. Can someone be hired in each hospital to assist with telemedicine?” Sunday Morabu, the telemedicine project manager, replied that an extra person for telemedicine is unfortunately not the solution. “It is a matter of perception; doctors need to change their attitudes. This is the easiest way to help doctors and to save patients.”

One expectation when a new technology is rolled out is that the knowledge acquired from the training sessions will naturally trickle down to other colleagues in the hospital. However, doctors were (and are still) generally too busy to train their colleagues. A solution offered was to organise onsite training in each hospital, so a bigger group can be exposed and doctors do not need to leave their hospital. Morabu has learned from these challenges: “In the roll-out to other zones, we plan several changes, like offering onsite trainings and change management sessions to advocate the use of the tool. We also want to increase supportive supervision, by paying regular visits and contacting doctors by phone and email.”

The participants also came up with suggestions to improve the iPath tool. Doctors should get an SMS-alert when a new case has been uploaded, so they can provide consultations faster. Also, it would be helpful if iPath users could see who else is online.

Telemedicine in Tanzania in 2012

At the end of the session, participants were asked to share their vision on how they envisioned telemedicine use in Tanzania by 2012. The technology is definitely taking hold. Most said they would like to see a development which involved 80% of faith based hospitals and 40% of public hospitals practicing telemedicine. Steps to get there include the development of ICT and telemedicine training modules; integration in the curriculum of health care training institutions; and dissemination of this knowledge among hospitals. “Elearning is not yet integrated in the curriculum; we are late and we need to lobby”, one participant claimed. During future training sessions, change management should receive particular attention, to bring about the necessary attitude and behaviour change. Other recommendations included the compatibility of iPath with other software, and the development of a cost recovery model. Finally, participants recommended that there be an integration of all existing telemedicine networks within Tanzania (AMREF, Bugando, Aga Khan, Mikocheni, Regional Dermatological Training Centre, Peramiho, ELCT, and Ocean Road). They would like to make use of an online discussion group (Dgroup) and a wiki to collect all data, lessons, challenges and best practices.

Until the next meeting…

The 3rd telemedicine platform meeting is planned for late 2008. AfyaMtandao, the ICT for Health network who facilitated this meeting will continue to support awareness raising and knowledge sharing for the rest of the year. Before the ELCT project rolls out to the Lake Zone in September, AfyaMtandao will organise an awareness-raising session on telemedicine for health workers in that zone. In October, a knowledge sharing workshop is planned, in which the active and less active users of iPath will get together to exchange experiences, hopefully resulting in a more active use of telemedicine, for the benefit of both doctors and patients.