Health diagnosis improvement in remote community health centers through telemedicine

Abstract

Introduction:

Information and communication technologies (ICTs) applied to the healthcare offer multiple advantages for diagnostic services and remote consultations. However, evidence on the diagnosis improvement in rural communities is limited. The usability of telemedicine to improve the coverage of diagnostic services in Paraguay was investigated.

Methods:

The goal of this descriptive study was to evaluate whether a telemedicine system implemented in remote public regional and district hospitals in Paraguay over a period of 3 years from 2014 to 2016 could facilitate the universal coverage of diagnostic services in rural communities.

Results:

In the study period, 182,406 remote diagnoses from 54 hospitals through a telemedicine system were performed. Of the total, 37.31% (68,085) corresponded to tomography, 62.00% (113,059) to electrocardiogram (ECG), 0.68% (1243) to electroencephalogram (EEG), and 0.01% (19) to ultrasound (US). Tomography was performed in 12 hospitals: 54.4% corresponded to head injuries, 13.8% to chest, and the rest to other anatomical regions. ECG was carried out in 52 hospitals; and in 62.1% of the cases, the results were normal; 12.5% unspecified arrhythmias; and 10.4% sinus bradycardia among the most frequent pathologies. EEG diagnosis showed history of seizure (54.3%), evolutionary control (14.0%), and headache (11.5%) among the most frequent diagnoses. All 19 US studies corresponded to prenatal control.

Conclusion:

These results showed that telemedicine may enhance the diagnostic services in rural communities, thus reducing the number of referrals and optimizing human and financial resources.

Introduction

Technological innovations based on information and communication technologies (ICTs) applied to the healthcare of dispersed and remote populations offer multiple advantages for diagnostic services and remote consultations. ¹ The main strength of telemedicine is the remote diagnosis and consultation with specialists; whenever it is planned properly, this system is advantageous for patients, health personnel, and the community. ²

The aim of technological innovations in health is to enhance universal coverage and equity in the provision of specialized medical services (Alma Ata Declaration) ³ without neglecting the effectiveness and usefulness of the technologies involved. With these premises, telediagnosis is a valid tool to improve healthcare of remote populations with no access to specialists. In this sense, innovations through ICTs offer important possibilities for improving the coverage of services and for a more effective information exchange of clinical, administrative, and training for staff. ⁴

In order to establish the feasibility of the systematic implementation of technological innovations in public health in Paraguay, the Telemedicine Unit of the Ministry of Public Health and Social Welfare (MSPBS) together with the Department of Biomedical and Imaging Engineering of the Research Institute for Health Sciences of the National University of Asunción (IICS-UNA) and the University of the Basque Country (UPV/EHU) evaluated a telediagnostic system implemented in 2014. The results of this evaluation will serve as an independent source of information of the technical feasibility to implement and sustain the execution of technological innovation projects for diagnosis and remote consultation with specialists in the Paraguayan healthcare centers.

Methodology

Population

A descriptive study was conducted in all regional, general, and main district hospitals of Paraguay’s 18 health regions during 3 years (2014–2016). Clinical data, tomographic images, electrocardiograms (ECGs), electroencephalograms (EEGs), and sonography of patients who needed a diagnosis by a specialized physician were entered into the system. This information was sent to specialists in diagnostic imaging, cardiology, and neurology via Internet to a telemedicine platform for remote diagnosis, and the report was then forwarded to the 54 countryside hospitals connected to the system. In this sense, trained technicians in countryside hospitals (nurses, obstetricians, and health workers) performed the specialized medical tests which were requested by a clinician or family physician following a test protocol for each type of diagnosis. Then, a staff of six radiologists, six cardiologists, and three neurologists downloaded the clinical data and images to perform the diagnosis. After this, they sent the results back to the countryside hospitals to be printed or viewed by the clinician or treating physician. A coordination department that included a radiologist, cardiologist, and neurologist was responsible for reviewing the diagnosis results (productivity and quality control) of the 54 connected countryside hospitals. This observational and descriptive study included 182,406 patients who received medical requests for diagnostic imaging studies (tomography and ultrasound (US)) and biological electrical signals (ECG and EEG) from January 2014 to November 2016 in the 54 regional, district, and specialized hospitals and health centers of MSPBS’s health regions. The digital technology used for the transmission of images in this study is called “store & forward.” Once the images were obtained, the patient electronic card module (standalone or Web application) was executed. The “remote specialist” (medical professional who specialized in imaging, US, cardiology, and neurology) visualized the clinical data of the patients and the attached images for the diagnosis after entering the diagnostic system (telemedicine platform). Immediately after the specialist made the diagnosis, the report was available for printing and delivery to the patient and/or for referral by mail to the treating physician.

Results

This study had 182,406 requests from 54 regional or district health centers. They were analyzed through the telemedicine system of the MSPBS Telemedicine Department; 55.0% of the requests were women (mean age: 39.0 years). The distribution of the type and number of studies performed are shown in Figure 1.

Figure 1.

Type and number of remote studies performed from January 2014 to November 2016.

The 113,059 ECGs analyzed corresponded to routine medical check-ups. The ECG diagnoses performed in the 52 hospitals were distributed as follows: normal (62.1%), sinus bradycardia (10.4%), unspecified arrhythmias (deviated axes), conduction disorders (12.5%), left ventricular hypertrophy (4.1%), sinus tachycardia (4.4%), right bundle branch block (3.5%), ischemia (1.4%), atrial fibrillation (1.0%), and left bundle branch block (0.6%).

Regarding tomographic studies, 68,085 remote diagnoses were performed in 12 hospitals in the interior of the country equipped with this service. The largest number of studies (54.4%) corresponded to head accidents (mainly involving motorcycles) and cerebrovascular diseases, 13.8% chest, 6.2% dorsal spine, 5.4% abdomen, and the rest to other anatomical parts. The distribution of the type and percentage of tomographic studies performed are shown in Figure 2.

Figure 2.

Type and percentage of tomographic studies performed from January 2014 to November 2016.

The 1243 electroencephalographic studies corresponded to different causalities with the most common reasons being history of seizure (54.3%), follow-ups (14.0%), headache (11.5%), epileptic seizure, cognitive impairment (2.0%), attention deficit in children (learning; 2.0%), brain death (1.0%), abnormal movements (0.8%), and sleep disturbances (obnubilation; 0.3%). The distribution of the type and number of electroencephalographic studies performed are shown in Figure 3.

Figure 3.

Type and number of electroencephalographic studies performed from December 2015 to November 2016.

All 19 USs corresponded to prenatal care from the gynecological–obstetric area.

Discussion

This study shows how technological innovation in the diagnostic services of public hospitals using telemedicine may improve the health diagnosis in remote community health centers at relatively low cost. Economic sustainability of a public telediagnosis system and the development of resilient systems in rural and isolated communities of the country, where specialized studies are not available, have been shown in other countries. ⁵

The analysis of the usefulness of telediagnosis in four areas of diagnostic services and its benefit and usefulness in monetary terms have been widely demonstrated ⁶ which is important especially for developing countries ⁷ such as Paraguay. The implementation of telediagnosis in diagnostic services brings benefits related to the reduction of the costs of medical care, patient transfers and specialized personnel, and equity in the access to healthcare technologies in remote populations where few equipment and professionals are available. Also, the telediagnosis system could be used as a contingency plan for medical assistance in cases of catastrophes, epidemics, pandemics, or any event with a large influx of patients.^5,6 The incorporation of this technological innovation in the diagnostic services of the healthcare centers implies a review and analysis of the classic routine procedures of the medical service due to the change in the form of registration, capture, transmission, and treatment of the information (images and data) from the scientific, legal, and ethical points of view.^7,8 It should also be mentioned that there are no international regulations, which cover all the aspects of telediagnosis, although there are already some algorithms for representation and information transfer using communication standards such as Digital Imaging and Communications in Medicine (DICOM). ⁹

Telemedicine technology in less developed countries is very promising.^6,10 Studies that support the suitability and capacity of such technology to solve specific problems in certain regions or countries in safe, effective, useful, efficient, and sustainable ways are still scarce. ¹¹ In this sense, and according to a systematic review of the literature, it has been determined that the evidence found is still insufficient to ensure that this tool is more cost-effective than the face-to-face diagnosis.^12–14 Technological innovation in the MSPBS telediagnostic services shows advantages such as reduced patient care times, faster diagnosis, improved quality of service with standardized procedures, continued care for remote diagnosis, and referral of the online diagnosis to the attending physician.

Finally, these results show that technological innovation in diagnostic services of public hospitals through telemedicine could facilitate the universal coverage of these same diagnostic services in rural communities. It will also help to improve substantially the local resolving capacity of the regional and district hospitals in the country. However, before recommending its massive use, its implementation and technical–economic sustainability should be contextualized according to the epidemiological profile of each region.

Conclusion

Despite the potential benefits of the implementation of remote diagnosis technology in public health, such as increased universal coverage, reduced number of referrals, and optimization of human and financial resources in low-income countries, other important aspects such as the acceptance of this technology by physicians and health workers, patient satisfaction, and a widespread use-assessment should be analyzed before a large investment into these tools in the healthcare system is adopted.