Experience with low-cost telemedicine in three different settings. Recommendations based on a proposed framework for network performance evaluation

Figures & data

Table 1. Telemedicine networks for low- and middle-income countries (second opinion teleconsultation networks providing services in the developing world with more than 7 years of experience)

Network	Countries	Model
Swinfen Charitable Trust	Various	Targeted
Ukraine	Mainly Ukraine	Targeted
Institute of Tropical Medicine	Mainly Africa	Targeted
iPath	Various	Open
Partners Healthcare, Boston, USA	Cambodia	Targeted
Tripler Army Medical Center, Honolulu, USA	Mainly Pacific region	Targeted

Fig. 1.  A telemedicine network viewed as a black box.

Fig. 2.  Overview of a telemedicine system. Telemedicine networks are not isolated but located within larger health organisations that in turn are part of the general environment.

Table 2. Three second opinion networks that have operated for periods of 7–10 years

1. Swinfen Charitable Trust network
This service is provided by a UK charity and started operations in 1999. It provides advice to doctors in developing countries using web-based store-and-forward messaging. In 2009, there were approximately 300 referrers from 45 developing countries. The advice is provided by a panel of about 400 consultants who donate their expertise to the charity. In the first 10 years of operation, the network handled approximately 2,000 telemedicine cases.
2. Ukrainian Teleconsultation network
This service started in 2000. This network is based in an expert trauma centre in Donetsk and provides treatment advice to seven community hospitals in the Donetsk region and four regional centres in the Ukraine using web-based store-and-forward and low-cost videoconferencing (Skype) methods. In the first 10 years, more than 700 teleconsultations were conducted in trauma and orthopaedics.
3. Institute of Tropical Medicine HIV/AIDS Telemedicine network
This service is based at the Institute of Tropical Medicine in Antwerp and started in 2003. It provides second opinion advice about the use of antiretroviral therapy and AIDS care delivery using email and web-based store-and-forward methods. Expert advice from a network of 20 specialists in HIV/AIDS is offered to health care workers in resource-limited settings. In the first 7 years, the telemedicine service provided over 1,000 teleconsultations to health workers in more than 40 countries, most located in sub-Saharan Africa.

Table 3. Performance of three telemedicine networks

Performance measure	SCT		Ukraine		ITM
	Comment	Value	Comment	Value	Comment	Value
	Statistics for the year 2009		Statistics for the year 2007–2009		Statistics from April 2003–March 2009
Requester's perspective
1. Rate of query arrival (new cases)		19.4/month		5.8/month		15.5/month
2. Proportion of failed queries		0		0		0
3. Time to first reply from an expert	Median	17 hours		30 hours		24 hours
4. Quality of replies	Some evidence from a research project (10). Referring clinicians reported that in 100% of cases followed up (n=22), the advice was useful	Not measured routinely	Some evidence from a research project (11). The quality of replies was measured according to a specially developed scale 20. Ninety-two per cent of replies (n=132) were judged to be highly relevant	Not measured routinely	Some evidence from a research project (12)
					User satisfaction (38 respondents) measured on a scale 1–10. Utility of advice was rated 8–9 by 70% of the respondents	Not measured routinely
5. Ease of system usage		Not measured		Not measured		Not measured
Coordinator's perspective
1. Rate of query arrival	New queries, plus those requiring additional responses	37.7/month	New queries	5.8/month	New queries.	15.5/month
2. Time required		Not measured		15–30 min		Not measured
3. Resources available		406 experts available		Five experts available		16 experts available
4. Feedback from experts/feedback on patient outcomes		Not measured	Some evidence from a research project (11). Feedback was available on the relevance of the teleconsultation for 63% of the cases (n=132)
			Feedback was available on patient outcomes for 33% of the patients (n=132)	Not measured routinely		Not measured
5. Ease of system usage		Not measured		Not measured		Not measured
Expert's perspective
1. Rate of requests received (for those experts who received queries)		2.8/year per expert		5.4/year per expert		9.9/year per expert
2. Time required to answer	Median time from allocation to response	11.0 hours		30 min		Not measured
3. Relevance to own expertise		Not measured		Not measured		Not measured
4. Feedback on patient outcomes	Some evidence from a research project (10)	Not measured routinely	Some evidence from a research project (11)	Not measured routinely		Not measured
5. Ease of system usage		Not measured		Not measured		Not measured
Societal perspective
1. Clinical-effectiveness	Some evidence from a research project (10). Referring clinicians reported that the telemedicine advice was useful in 21 of 22 cases followed up, and the outcome for the patient was good in 15 cases	Not measured routinely	Some evidence from a research project (11). Referring clinicians reported that telemedicine produced satisfactory outcomes in 22% of cases (n=132) and good or excellent outcomes in a further 76%	Not measured routinely	Some evidence from a research project (13). Referring clinicians reported that telemedicine was useful in influencing the management of their patients in 100% of cases (n=37)	Not measured routinely
2. Cost-effectiveness		Not measured		Not measured		Not measured
3. Integration into the health care system, for example, involvement of local people		Not measured		Not measured		Not measured

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