Puget Sound Partners for Global Health Request for Pilot ...



A Teledermatology Network for Underserved Areas of South Africa

Principal Investigator: Roy Colven, M.D., Associate Professor of Medicine, University of Washington School of Medicine, in collaboration with Professor Gail Todd, Head, Division of Dermatology, University of Cape Town

1) Statement of Problem

Sub-Saharan Africa has long suffered from a huge burden of disease and limited resources to deal with it. Significant health care deficiencies exist, and access to basic health care, let alone specialty care, is impaired in many areas. In the 1980’s, the AIDS pandemic brought a bewildering twist to overburdened health care providers. At the end of 2002, 25% of adults aged 15-49 in South Africa, for example, were HIV-infected. 1,2 Skin disease in this region, already a cause of significant morbidity and mortality before AIDS, has become more prevalent, complex and stigmatizing now in the HIV era. Because of the skin’s role in immunologic protection, it is no surprise that studies have shown at least 90% of HIV-infected patients will develop skin disease during the course of their infection.3 A skin condition is commonly the first sign of HIV infection. Once HIV infection is established, the kind and number of cutaneous diseases is a gauge to the stage of infection. Cutaneous conditions are often multiple in a single patient and recalcitrant to therapy. As a result, a significant proportion of primary care providers in one U.S. study were unable to recognize skin signs associated with HIV infection.4

In contrast to widely available specialty care in the U.S., medical care from specialists, including dermatologists, in Sub-Saharan Africa is scarce.5 Within the public sector of health care in South Africa, the system that serves the majority of patients in this country, there is on average one dermatologist serving 3-4 million people.6 When a basic health provider needs help with a skin-diseased patient whom he or she is seeing, referral to a dermatologist is often impossible to deliver to that patient, owing to distance and lack of funds to travel. How can consultation for dermatological care be delivered to African health care providers by an alternative means?

2) Research Proposed

This pilot project will study the feasibility of and satisfaction with a telemedicine network that aims to enhance delivery of dermatological care in relatively remote areas of South Africa using a simple telemedicine system. Telemedicine is the delivery of health care from across a distance.7,8 In the 1990’s telemedicine made great leaps forward with the rise of iInformation technology (IT), satellite communication, and higher resolution audiovisual equipment., telemedicine made great leaps forward. The application of telemedicine is especially useful in the visually -oriented specialties, particularly radiology, pathology, and dermatology. The addition of images to clinical history aids significantly to the diagnosis and management of skin diseases.9 Teledermatology utilizingsing relatively easier andconvenient and inexpensive store-and-forward (SAF) technology involves capturing patient images and electronically transmitting them asynchronously to a specialist who can render an opinion. As most dermatological consultation is not emergent, a turn -around of the consultant’s opinion within 24-48 hours iwas very acceptable for the referring provider and the patient, particularly given the savings in travel cost and time to referral.10,11

The real challenge intest of telemedicine, and particularly teledermatology will be in the developing world.12, has yet to be tested. Despite the lack of specialty health care, IT continues to grow and reach more people, including those in Sub-Saharan Africa.13 Even basic health centers have the ability to upload and transmit images, accompanied bywith clinical data, via the Internet. It is in these areas that provision of teledermatology services could have its greatest impact.

This project will establish and assess the quality of a teledermatology network linking the University of Cape Town to outlying primary-care clinics to provide critically needed consultation for underserved skin-diseased patients in South Africa. The objectives of this pilot project are to:

• Establish a collaborative and sustainable network of teledermatology consultation, based at the University of Cape Town (UCT), supporting selected underserved areas of South Africa.

• Determine whether patients and referring primary health care providers believe the system impacts patient outcomes.

• Collect quality assurance data regarding patient and provider satisfaction with the network.

• Explore the feasibility of extending this network to other parts of South Africa and other countries in Sub-Saharan Africa.

• Establish sister institution ties between UCT and the University of Washington (UW) via virtual exchange of instructive patient cases and interactive distance learning. Eventually, exchange rotations will be established to enable UCT and UW dermatology residents to learn directly from the sister institutions.

The procedure for implementing this network and assessing its quality involves setting up digital equipment at health centers or hospitals where in-person dermatological consultation is unavailable. After health care providers receive training taking and uploading digital images, they will transmit images of skin-diseased patients via a secure email system, along with medical history and the specific referring question(s). A dermatologist experienced in teledermatological interpretation will then review these images and provide a rendered opinion, with feedback and references, to the primary provider within 24 to 48 hours. Assessment of quality measures will focus on the patients’ and providers’ satisfaction with the system, and the providers’ assessment of outcome improvement and cost savings. Network sustainability will occur as a result of the P.I. training South African dermatology registrars in teledermatological consultation and system management. This study will involve human subjects. The anticipated dates for carrying out this project are September 1, 2004 to July 15, 2005.

The main questions that will be addressed in this study are:

1. Is a network to provide virtual dermatological consultation in South Africa feasible at the present time with the current state of technology and IT infrastructure?

2. Will such a system be sustainable?

3. Will outcomes according to the referring health care provider be improved?

4. Will patients and referring providers be satisfied with the system?

3) Significance of the Study

This project will enhance the delivery of dermatological care in underserved areas of South Africa using simple and inexpensive technology. Prior to this time, the cost of computers and digital cameras, as well as limited Internet access in this region, had made the prospects of initiating a sustainable teledermatology network in Sub-Saharan Africa less hopeful. The results of this study will provide to other countries with similar specialty health care deficiencies valuable information on the satisfaction with and feasibility of this IT-based solution. The results of this study will also have the following impact by demonstrating:

1. A decrease in morbidity and mortality from skin disease through delivery of dermatological care to underserved South African patients who would not have

received such care otherwise.

2. A perpetuated teledermatology network eventually managed by trained South African dermatologists.

3. Clinical education in skin disease recognition for referring health providers through consultant feedback and provision of resources for learning.

4. The potential for expanding a simple technological network to similarly underserved areas in Sub-Saharan Africa.

Cited References

1. Joint United Nations Programme on HIV/AIDS (UNAIDS), World Health Organization (WHO). AIDS epidemic update 2002. .

Nelson Mandela/HSRC Study of HIV/AIDS, South African National HIV Prevalence, Behavioural Risks and Mass Media Household Survey 2002.

Tschachler E, Bergstresser PR, Stingl G. HIV-related skin diseases. Lancet 1996; 348:659-63.

Paauw DS, Wenrich MD, Curtis JR, Carline JD, Ramsey PG. Ability of primary care physicians to recognize physical findings associated with HIV infection. JAMA. 1995 Nov 1;274(17):1380-2.

Schmid-Grendelmeier P, Masenga EJ, Haeffner A, Burg G. Teledermatology as a new tool in sub-Saharan Africa: an experience in Tanzania. J Am Acad Dermatol 2000; 42:833-5.

Todd, G. Personal communication.

Wootton R. Telemedicine: a cautious welcome. Br Med J 1996; 313: 1375-7.

Eedy DJ, Wootton R. Teledermatology: a review. Br J Dermatol 2001; 144:696-707.

Mann T, Colven R. A picture is worth more than a thousand words: enhancement of a pre-exam telephone consultation in dermatology with digital images. Acad Med. 2002 Jul;77(7):742-3.

Williams T, May C, Esmail A, et al. Patient satisfaction with store-and-forward teledermatology. J Telemed Telecare. 2001;7 (Suppl 1):45-6.

Whited JD, Hall RP, Foy ME, et al. Teledermatology's impact on time to intervention among referrals to a dermatology consult service. Telemed J E Health 2002; 8(3):313-21.

Fraser HSF, McGrath JD. Information technology and telemedicine in sub-Saharan Africa. BMJ 2000; 321:465-6.

Schmid-Grendelmeier P, Doe P, Pakenham-Walsh N. Teledermatology in Sub-Saharan Africa. In Burg G (ed): Telemedicine and Teledermatology. Curr Prob Dermatol 2003; 32:233-46.

Grant Support:

• Fulbright Scholarship, Council for International Exchange of Scholars, U.S. Department of State, 2004-05 (R. Colven, P.I.).

• Puget Sound Partners for Global Health, Seattle, WA, 2004-05 (R. Colven, P.I.).

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