Design and Evaluation of

Two Way Interactive Video eConsult System

(TWIVES)A Web-Based Care and Continuity Solution

Enabling Secure and Private Patient-Provider Connections

When Mobility is Limited or Commuting is Not an Option

Kenneth Nwosu B.Eng., MBA

Agenda• Introduction

o About Telemedicine

• Research Question• Development of TWIVES

o Development Processo Technologies Utilized

• Analysis and Discussions• Conclusions & Recommendations

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Introduction• There are critical shortages of healthcare providers in developing

countries (WHO, 2006)

• Shortages of healthcare providers in rural and remote communities are usually due to migration to urban centers (Ehman & Sullivan, 2001)

• Expecting excess providers from urban centers to spillover to remote areas has been shown to be ineffective in solving this workforce problem (Strasser et al, 2009)

• For some patients, travelling to see a healthcare provider could be difficult due to cost and may not even be an option (Lightman et al, 2005)

• Task shifting - transfer of primary care roles to community health workers - is prevalent in remote settings for efficient use of available human resources (Mit, Rony, & V., 2008)

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About Telemedicine• The American Telemedicine Association defines Telemedicine as the

use of medical information exchanged from one site to another via electronic communications to improve patient health status (ATA, 2011).

• Shreveport (2011) defines telemedicine as the delivery of healthcare and the exchange of healthcare information across distances.

• Telemedicine encompasses diverse varieties of services delivered to the patient when distance is an issue (Cipolat & Geiges, 2003).

• Sorrells-Jones et al (2006) further added that videoconferencing, transmission of still images are considered part of telemedicine and Telehealth.

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Modes of Telemedicine

Store and Forward

• “Store and Forward" proves to be very efficient in cases where immediate response is not required (J.C. Lin, 1999)

Real Time

• Real time telemedicine requires the presence of both parties at the same time (Kale, 2010)

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Previous Work in Telemedicine

• Underserved regionsTelemedicine enabled people in rural areas, conflict and crisis areas,

the “Third World”, and on airplanes and boats to be cared for and treated by medical facilities located far away (Schmid-Grendelmeier et al, 2000).

• Critical CareAn intensive care specialist provided daily consultations to patients in a

small private hospital using a two-way audiovisual link (Grundy et al., 1977)

• Home MonitoringHome monitoring via telephone and television allows doctors to

observe the patient’s vital signs (Michaels, 1989)• Mobile TelemedicineMobile telemedicine enabled the care provider of cardiac patients to

provide remote non-invasive cardiac diagnostic services, using a smartphone gateway (Sparkes, Valaitis, & McKibbon, 2012)

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Telemedicine in Canada

• The cost of referring patients has been estimated to be 10-20 times higher than using telemedicine, due to travelling and accommodation cost and missed income (Kruger & Niemi, 2012)

• In Canada, the Ontario Telemedicine Network (OTN) has been very successful at reducing the need for patients to travel to specialists (OTN, 2012c)

• However OTN telemedicine studios are located at Health centers and hospitals requiring travel for participants

• The enabling technology to facilitate remote patient-provider encounters are now available

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Telemedicine in Developing Countries

• Telemedicine has been used for many years to support in developing world (Wootton et al, 2011)

• Most of the systems often use ordinary email for obtaining specialist advice from other consultants or colleagues in other countries (Bonnardot & Wootton, 2010).

• Results of medical specialist consultations sampled from several rural clinics located throughout India indicate that remote expert opinions can improve the speed and accuracy of diagnosis (Amble et al, 2004)

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Research Question

• Given the significant cost associated with the setup of telemedicine networks, how feasible is it to develop a web-based solution for community health workers and patients in rural and remote areas, including developing nations, in an environment of low speed Internet connections, limited infrastructure, and relatively small budgets for eHealth systems?

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Development of TWIVES

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Planning Design Development

Planning

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Design

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Development

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Technologies Utilized• Drupal Framework

o On Open source LAMP

• Video Whisper Scripto On Open source Red5 RTMP Server

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Landing Page View

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User Registration and Consultation Process

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Video Consult View

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Simulations and Testing

• Internet Connection Bandwidth Test

• Bandwidth Emulation Tools - Sloppy

• Slow Internet Simulation – Charles

• Page Load Analysis - Pingdom

• Web Browser Testing - Chrome, Firefox and Internet Explorer

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Analysis and Discussion

• Landing Page Analysis

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Pingdom

Analysis and Discussion

• Page Speed Performance

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Pingdom

Analysis and Discussion

• Server Load Time Analysis

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Pingdom

Analysis and Discussion

• Size and Request Analysis

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Pingdom

Analysis and Discussion

• Web Browser Test

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Analysis and Discussion

• Web Browser Market Share

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Analysis and Discussion

• Page Load Times at Different Internet Connection Speeds

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Analysis and Discussion

• Test Results at Various Charles-Simulated Low Speed Connections

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Limitations

• TWIVES has not been tested using human subjects

• Technical tests conducted in simulated low bandwidth environments

• Not all identified features were implemented

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Conclusions

• TWIVES was a proof of concept intended to examine the suitability and feasibility of developing a low cost video consult system that could be applied in rural communities with limited access to healthcare facilities, health providers and Internet resources.

• TWIVES POC accomplishes those goals, offering a sleek user interface, a solution appropriate for restricted bandwidth, and a simplified process for registration and consultation management

• TWIVES performed well in simulated low-bandwidth settings.

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Further work• Full feasibility and Usability testing

• Using WC3 standards in the areas of privacy, internationalization and web accessibility

• Rollout and use in an actual remote setting

• Benefit Evaluation

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Thank You

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