Can Telemedicine Actually Work on the Frontlines?

In a rapidly transforming and ever-globalizing world, countries continue to advance unevenly in technology, development and infrastructure. As a result, low- to middle-income countries have struggled to respond to the widening wealth gap, which leaves marginalized populations without access to basic resources, including health care. In certain hard-to-reach spaces, such as conflict zones, specialized medicine and technology are often inaccessible or unavailable.

In a recent study published in the Journal of Global Health in December 2018, authors Delaigue et al. examined the use of of “store-and-forward medicine” by Médecins Sans Frontières (MSF), an international and independent medical humanitarian organization that delivers emergency aid to vulnerable people who are excluded from healthcare, including those impacted by war and conflict. The study sought to document the experience of developing a telemedicine service in low-resource and humanitarian settings, and the authors studied MSF telemedicine service from its induction in 2010 through 2017.

Medical staff in low-resource settings are challenged to diagnose complex medical cases and treat patients without the ability to directly consult with specialists. To combat this challenge, MSF developed a multilingual telemedicine network to equip field staff with direct access to specialist advice, and the pilot program was initially developed as a web-based messaging system. The telemedicine program established three categories of users: referees, who were MSF health workers that had access to telemedicine services; specialists, a network of health professionals known as MSF headquarters advisors; and coordinators, who were active clinicians with MSF field experience.

The study was conducted in three phases, and over 5,600 cases were submitted from 63 countries. These cases came from countries that suffered from armed conflict and internal instability, and covered over 54 medical and surgical specialities. Thirty-five percent of referrals were sent to pediatrics, 35 percent to radiology, and 19 percent to internal medicine. Each case was categorized as radiological or clinical, based on the type of specialist that was consulted.

Overall, the researchers found that telemedicine performed well, and that improved access to specialist opinions for multidisciplinary care could be implemented at an international level. Moreover, the medical services received improved performance indicators and stable quality assurance scores. Finally, the MSF telemedicine program successfully utilized “store-and-forward” messaging because real-time communication with medical specialists is expensive and susceptible to technical issues. The areas in which MSF staff are placed are often prone to power outages and irregular connection.

However, this study had several limitations. One weakness of telehealth evaluation in low- and middle-income countries is the emphasis given to pilot programs without thorough evaluation and follow-up. While this is largely due to capacity and limited resources, it poses a threat to the credibility of telemedicine as a sustainable concept. Furthermore, the clinical benefits of telemedicine were not well-documented—another limitation of the study. Lastly, while telemedicine may prove highly successful, it is crucial to acknowledge operational barriers, such as the high turnover of field staff, as well as cultural barriers, since a change in clinical process requires a development of trust between health professionals across countries.

Looking ahead, “store-and-forward” telemedicine may serve as a successful model in low-resource settings if there is a focus on the sustainability of this system. This includes ongoing maintenance and a stable and consistent medical coordination team to improve follow-up and reinforce trust between practitioners. Similarly, increasing the use of mobile phones among field staff may increase the efficiency of coordinator and specialist interactions. With these considerations, telemedicine may in fact be the solution to addressing barriers to health on a global platform.

Article source: Delaigue, Sophie, Laurent Bonnardot, Olivier Steichen, Daniel Martinez Garcia, Raghu Venugopal, Jean-François Saint-Sauveur, and Richard Wootton. “Seven Years of Telemedicine in Médecins Sans Frontières Demonstrate that Offering Direct Specialist Expertise in the Frontline Brings Clinical and Educational Value,” Journal of Global Health 8, no. 2 (2018).

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