The Use of Mobile (Cellular) Oral Telemedicine in Botswana

Sankalpo GHOSE, BS, Medical Student,1,2 Ryan LITTMAN-QUINN, BA,2 Neo MOHUTSIWA-DIBE, BDS,3 Tsholo 3 3 2,4 MOLEFI, BDS, Motsholathebe PHUTHEGO, BS, DDS, MS(OMFS), Carrie L. KOVARIK, MD,
1

Medical College of Wisconsin, Milwaukee, WI, USA; 2Botswana-UPenn Partnership, Gaborone, Botswana; 3Princess Marina Hospital, Department of Oral Medicine, Gaborone, Botswana; 4 University of Pennsylvania Medical Center, Department of Dermatology, Philadelphia, PA, USA, email: carrie.kovarik@uphs.upenn.edu

BACKGROUND
Telemedicine is becoming a more relevant and realistic means of providing for the delivery of health information and services to resource-poor populations. In Botswana, there is at present only one oral and maxillofacial surgeon in public service. As a result, all complex oral medicine and oral surgery cases in the country - numbering about 300 per year - are referred to his practice in the capital city of Gaborone, in a process limited by cost, time, transportation, and lack of reliable means for follow-up. We present preliminary results of a pilot study evaluating the use of mobile telemedicine for diagnosis and triage of oral medicine and oral surgery in Botswana.

OBJECTIVES
1. To demonstrate that mobile telemedical technology can connect resource-poor areas with remote oral medicine and oral surgery specialists. 2. To demonstrate that mobile telemedical technology is a reliable method for diagnosing, triaging, and treating complex cases in oral medicine and oral surgery.

RESEARCH DESIGN & METHODOLOGY
Clinicians in district hospitals use a Sony Ericsson C905 mobile phone, equipped with customized software from ClickDiagnostics and a built-in 8.1 megapixel camera, to prepare and send digital referrals to the country’s sole specialist in Gaborone. The cases – each consisting of at least 30 unique medical data fields and one to multiple photographs – are sent from the phones over a data-enabled mobile phone network and are stored on a secure website on the internet. The website and referral request are accessed by the specialist for review and remote consultation. Information at every stage of the process – including, for example, time between referral request and response – is collected in a centralized database.

ORIGINAL DATA AND RESULTS
MAUN GENERAL HOSPITAL, MAUN
Cases: 9 Average response times (hrs) Before protocol: 68 After protocol: n/a

Categories by which data model can be filtered and analyzed:
• Age • Occupation • Marital status • Smoking history • Gender • Past medical history • Prescriptions • Allergies • Duration of condition • Previous symptoms • Family history • First lesion • Number of lesions • Size of lesions • Consistency of lesions • Lesion visual descriptors • Locations intra-oral • Locations extra-oral • Facial pain • White patch presence • Medications used • Effect of medication • Differential diagnosis • Comments

A total of 69 remote consultations – 43 actual, 26 test – concerning complex cases from one central and four satellite hospitals were successfully conducted between March and October of 2010, building upon institutional and preparatory work ongoing since September, 2009.
NYANGABGWE REFERRAL HOSPITAL, FRANCISTOWN
Cases: 13 Average response times (hrs) Before protocol: 64.8 After protocol: 9.2

The data we collected is of two sorts: 1. A detailed demographic of the patient population in complex oral medicine and oral surgery cases 2. A record of the telemedical system’s use itself, particularly in terms of time taken at each step The organization of this data into a cross-referenceable and updateable model is a further result of this pilot, which has analytic and management functionality. One particular example of our use of this relates to the introduction of a written protocol: The introduction and distribution of an institutional and documented standard was shown to result in drastic – and measurable – improvement, especially in response time.

SEKGOMA MEMORIAL HOSPITAL, SEROWE
Cases: 8 Average response times (hrs) Before protocol: 38 After protocol: .4

IMPLICATIONS
PRINCESS MARINA HOSPITAL, GABORONE
Cases: 8 Average response times (hrs) Before protocol: 171.2 After protocol: 1.2

TSHABONG PRIMARY HOSPITAL, TSHABONG
Cases: 5 Average response times (hrs) Before protocol: 76.3 After protocol: 11.6

Mobile telemedical technology can: • Connect patients and populations in resource-poor areas with remote specialists • Provide a reliable method for diagnosing, triaging, and treating complex cases in oral medicine and oral surgery • Approach real-time operation • Collect vast amounts of data that are readily filtered and analyzed for use In our experience, this requires: • Solid and sustained partners at every level of the healthcare system, from patients, to health workers, practitioners, and specialists, to government ministers and corporate officers. The technology aims to improve, not replace, the existing structure, even if its improvements have the potential to effect large systematic “leapfrogs” • Active monitoring, support, and management of software, hardware, protocols, and practitioners

RELEVANCE AND IMPACT
It is our contention that we have demonstrated the practical application of a mobile telemedicine approach that provides patients and practitioners with a more rapid, cost-effective, and informed means of care in complex cases. While this approach has been first piloted with oral medicine and oral surgery in the country of Botswana, the general framework should have utility as a model for other fields of medicine and other locations. Lastly, as our approach operates by virtue of its continual data collection, the what, why, when, and where of just how exactly it does work could potentially be analyzed – in real-time – to best manage, and most rapidly improve, delivery of care. However, in order to have such an impact, the field of mobile telemedicine will need more than just a technological focus on the real-time; it will need a systematic vision for the long-term.

ACKNOWLEDGEMENTS
Software development, technical support, and program consultation provided by ClickDiagnostics (Boston, USA). SIM card and data plans donated by the Orange Foundation of Botswana. Institutional and grant support provided by the Center for International Health (Milwaukee, USA) and the BotswanaUPenn partnership (Gaborone, Botswana).

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