Digital Pulse - Chap 3 - Sec 4 - Tygerberg Children's Hospital and Rotary Telemedicine Project

Development Issues: Children's Health, ICTs, Telemedicine

Programme Summary

The Tygerberg Children's Hospital and Rotary Telemedicine Project in South Africa uses computers and e-mail to link specialists from Tygerberg Hospital in Cape Town to doctors in more remote community or district hospitals to improve healthcare in rural areas. The system currently links Tygerberg with Eben Donges Hospital in Worcester, Clanwillaim Hospital and Paarl Hospital, which are 100km, 250km, and 100km from Cape-Town respectively.

The Telemedicine Project was initiated for two main reasons: budget cuts to Tygerberg hospital meant that more patients needed to be treated at the district level and many members of the community could not afford the costs associated with going to the hospital. There is a demand for doctors at the district level to treat patients that require special attention or diagnosis that is beyond their training. Tygerberg Hospital specialists must support these doctors but usually do not have time to visit them on site. The initiative has assembled off the shelf computer equipment and software that is more affordable than commercial telemedicine systems. The projects also involves ongoing training and close consultations with users.

Summary of ICT Initiatives

Dr. Etienne Nel and Professor Robert Gie of Tygerberg Children's Hospital set up a telemedicine system that meets the immediate needs of the district hospitals. The system uses a Pentium 4 computer with a 42 cm screen, printer, scanner, software, digital camera, and light-shelf for viewing x-rays. The system is connected to the Provincial Department's network infrastructure, which connects Tygerberg with the district hospitals and gives the doctors unlimited access to e-mail. The total cost of the unit based at Tygerberg Hospital was less than R50,000 while the units at the district hospitals cost R45,000 each.

Doctors at district hospitals scan x-rays and electrocardiographs, and e-mail them together with blood test results, digital photographs, and clinical observations to the telemedicine unit at Tygerberg Children's Hospital. At Tygerberg one person monitors incoming e-mail and directs queries to relevant specialists. The Tygerberg specialists review the information received, send an e-mail reply, and consult remotely with the district doctors about diagnosis and treatment. If a district doctor needs an urgent reply, he sends an SMS message to a specialist's cellphone, alerting the doctor to check e-mail immediately.

Observations

This section considers whether and how this telemedicine system has made a Real Impact at the ground level by looking through the lens of basic best practice guidelines for successful initiatives. The bridges.org 7 Habits of Highly Effective ICT-Enabled Development Initiatives are used here to evaluate what the specialists at Tygerberg Children's Hospital have done well.

1. Implement and disseminate best practice. - Tygerberg's system has been designed by doctors in a developing country and is much more affordable than more sophisticated models used elsewhere. Doctors in Namibia, Malawi, and Zimbabwe are keen to replicate the system in their countries. The Tygerberg team is actively contributing towards best practice in healthcare that is relevant in an African context.
2. Ensure ownership, get local buy-in, find a champion. – Organizers have promoted the telemedicine system in interviews with local newspapers and magazines. Lack of training – especially for older doctors who are less familiar with computer technology – has been an obstacle. By taking it upon himself to visit district hospitals and train doctors to use the system, Dr. Nel has become an on-the-ground champion for the system.
3. Do a needs assessment. - The project emerged from a clear need in the healthcare environment in the region, where district doctors need support from Tygerberg Hospital to help them deliver more specialized care.
4. Set concrete goals and take small achievable steps. - A two-year pilot project involving only one hospital was conducted before the project was expanded. The pilot had three clear goals: (1) to test whether the equipment could convey clear images of X-rays, electrocardiographs, etc; (2) to test whether the Provincial Health Department's computer network would cope with the transfer of a vast amount of digital information; and (3) to evaluate whether doctors would use the system. Once the system was tested and proven, it was expanded.
5. Critically evaluate efforts, report back to clients and supporters, and adapt as needed. - Throughout the pilot, the specialists evaluated the system to see whether it was cost-effective and whether it would indeed improve district healthcare. They also adapted it as needed as they went along.
6. Address key external challenges. - A key external challenge faced is the installation of the connection points at hospitals not yet connected to the Provincial Health Department's computer network infrastructure. Continued support of staff after initial training is also crucial, especially where the central "receiving unit" (based at Tygerberg Hospital) is far from the "send units" (district hospitals). To address this problem Rotary Club members from local communities and paramedical staff are providing support when doctors experience difficulties in operating the system.
7. Make it sustainable. - Although Tygerberg telemedicine system is much cheaper than commercial telemedicine models and uses the Provincial Department's network infrastructure to send e-mail, the system's future is reliant on continued donor funding from the Rotary Club. The South African Government has started implementing (much more expensive) telemedicine systems elsewhere, but whether it will support Tygerberg's model is not certain.

Dr. Nel also noted some of the challenges that became apparent during implementation. “There is a perception that this technology is inappropriately costly for a country with limited health resources ... and has been strong enough to delay implementation in certain areas. A major technical difficulty has been in the area of network access and support. Frequent 'down time' on the network discourages use. In addition problems accessing the network with poor technical support further dampen enthusiasm. Limited typing skills, lack of easy access to the system because of security needs and time constraints during the workday were found to be problems by staff. A number of technical problems still need to be solved. These include:

1. The user interface has to be simplified. Users are still required to go through a number of steps before they can send an enquiry. Automating these procedures would encourage correct use of the system.
2. Image files are large. Transmission of large images is either not permitted by the network that is being used or is slow.
3. Ensuring the security of information sent needs to be addressed.

Despite these problems medical and paramedical staff have been enthusiastic and are learning to use the telemedicine system. It will however be some time before the true benefits of this telemedicine application can be quantified."

Partners: Rotary Club (Signal Hill, Durbanville, Helderberg Basin, Stellenbosch).

Source: Bridges.org, ICT-Enabled Development Case Studies Series: Africa and Pambazuka News

For More Information Contact:

Department of Paediatrics and Child Health

PO Box 19603, Tygerberg, 7505 South Africa

Tel: +27 21 938 9570

Fax: +27 21 938 9138

edn@sun.ac.zaOr see the Department of Pediatrics Website