Integrating Dermatology Consult Services Into Existing Rural Healthcare System Piloting Telehealth Dermatology in Haiti

Tuesday, 31 October 2017: 9:20 AM

Scott Paul Sloane, DNP, MSN, MS
School of Nursing and Health Sciences, University of Miami, Coral Gables, FL, USA

This project proposes to develop a collaborative relationship, culminating in a pilot project between the University of Miami, School of Nursing and Health Sciences, a third-party web-based telemedicine platform, to assist Physicians assess dermatological conditions in Haiti remotely along with U.S. based dermatologists. The objective of this proposal is to illustrate that web-based telemedicine technology is affordable, easy to use, allowing for providers to routinely consult with medical specialist globally to increase diagnostics and improve the health of their population.

The challenges of not being able to fully diagnose medical conditions and arrange for appropriate treatment and follow-up care are frustrating for the primary care providers of rural populations, but may be detrimental to the population they serve (Bartelme, 2015). The goal of any healthcare program is to build capacity and to assure that it is sustainable over time. This pilot project has the potential to provide access to premier medical specialists through the use of telemedicine. Literature supports how telemedicine enhances healthcare capacity, and has also been proven to be sustainable. For example, the Virtual Doctor Project in Zambia used telemedicine to access vulnerable rural populations (Mupela, 2011). In the virtual doctor concept, the program utilized asynchronous store and forward technology where images and patient information was collected and emailed to doctors at a distant location (Mupela, 2011). The associated diagnoses and treatment recommendations where be emailed back within 24-48 hours. Following this model, they were able to show a considerable impact in reducing illness and disease within their targeted region. This implementation project will utilize similar technology that was employed in Zambia. However, the option of introducing synchronous encounters, where feedback would be instantly provided and treatments initiated by the use of real-time communication between nurse practitioners in Haiti, and dermatologists in the United States is encouraging. This is beneficial because patients would not need to return for follow up care, as many of them take the entire day off work to attend the clinic or travel long distances.

This project proposes integrating this telemedicine pilot project with the NGO that currently operates two public health clinics in Thomonde. This pilot project is designed to have dermatologists available for consultation by reviewing images via live synchronous video feed. 3G Broadband Internet capacity allows the providers at the clinic to communicate with the dermatologist in real-time via a video link.

Patients in Haiti with advanced dermatology presentations will be triaged and presented to the dermatologist during prescheduled select times of the day in either the preferred live video synchronized format, or using the asynchronous email store-and-forward platform. Either way, consultations between the Haitian Providers, and the Dermatologist will enhance clinical capacity by increasing diagnostic and treatment accuracy of advanced dermatological conditions. The goal of this proposed pilot project is to enhance the capacity of the providers in Haiti by connecting with premier dermatology specialists. The overall objective of this project is introduce a telemedicine platform that is affordable, easy to use, and improves the health of the population in Thomonde, by providing Doctors affordable access to consult with specialized medical providers.

This project will be utilizing two surveys instruments: The IHI has developed a guide to measuring a population’s health. This tool is the Functional Health Survey-6, and is used to measure the Health/Functional Status. The FHS-6 is a self-reporting tool that generally asks a patient “Would you say that in general your health is: Excellent, Very Good, Good, Fair, Poor”? (Institute for Healthcare Improvement, 2015). Another survey questioner, The Caring Professional Scale, will utilize to measure the experience of care provided by the doctors, particularly when telemedicine is employed to aid in diagnostics and treatment modalities (Swanson, 1998)(Hooshmand, 2010). The questions measure if healthcare providers displayed an acceptable degree of comfort, where informative, supportive, caring, clinically competent, technically skilled, respectful and attentive listeners (Swanson, 2002)(Hooshmand, 2010). Patients in Haiti will be asked to rate the items based on their experience with their interaction with synchronous (live) teledermatology interactions. Internet connectivity will also be measured during phase 2/3, to assure that appropriate measures are in place to maintain 3G broadband access that supports video feeds. When this project is deemed successful, we will utilize any additional funding to expand upon this system by adding OB/GYN, and radiology consultations to the program, as well as nutritional counseling, and breast feeding classes.

Upon arrival in Thomonde Haiti, and prior to actual implementation of this project, broadband compatibility was tested for accessibility and clarity. This project utilized an iPad Pro with high resolution camera and international broadband access to communicate with Medweb, our third-party web-based telemedicine platform partner. The initial telecommunications check went extremely well with excellent broadband 3G Video connectivity, between the Medweb technician in the United States, and our equipment in Haiti. The next three days of mobile medical clinic operations would attempt to utilize this technology on selective complex dermatological cases.

Over the next three days we discovered that the rural clinic sites where we provided medical care only had 2G (Edge) broadband access, which does not support live broadband video applications. At one site on day three we could acquire a strong 3G broadband at the top of the ridge from where we were conducting our mobile clinic, but at the clinic 100 feet below the ridge we were only able to acquire a 2G (Edge) signal. We quickly migrated or efforts to our backup plan of “store-n-forward” asynchronous type consultations. Our project presented four complex cases to our U.S. based dermatologists via this platform, with consultations returned in less than 24 hours.

These consultations were very effective in enhancing provider capacity with diagnosing and expanding typical treatment regimens. On all four cases the providers in Haiti did initially diagnose and treat the dermatological conditions appropriately. These cases consisted of complex Impetigo, Tinea Capitis with multiple boggy Kerion’s, Bullous Lesions (Staph), and a pediatric surgical colostomy co-infected with HPV. Additional treatment regiments suggested by the dermatologists were forwarded to the Project Medishare Clinical Staff to arrange for appropriate follow-up care.

Although we were not successful in implementing live video consultations, this project does illustrate that the capacity does exist for an expanded asynchronous, store-n-forward program to be initiated.

This project did achieve its overall objective of introducing a telemedicine platform that is affordable, easy to use, which improves the health of the population in Thomonde, Haiti by providing them access to specialized medical providers utilizing something as simple as an iPad. However, there is considerable concern with the availability of timely follow-up evaluation and treatment with this type of system, versus live consultations.

Prior to departing to Haiti for this project, both surveys instruments: The Functional Health Survey-6, and The Caring Professional Scale, were professionally translated into Creole. Upon arrival in Haiti, and in consultation with the Project Medishare Medical Staff, along with our translators, the surveys were deemed to be illegible and thus unusable for this project.

Live "synchronized" video consultation is preferred due to the limit capacity for medical follow-up with this extreme rural population. Exploration of 3G Broadband Enhancement Options are essential to the success of this project as it continues. There are many different areas that can still be explored to accomplish this, such as utilizing low-cost mobile broadband repeaters, or mobile balloon antennas to enhance broadband signal. With appropriate funding, even enhanced satellite capability with advance auto-connect capacity can be explored.

Patient surveys must be conducted to gauge the perception of technology within the Haitian population.

Creole is a very complex language with many different dialects, making translation of measurement tools very difficult. A possible solution to adopting future measurement tools for use in continuing this project, is to research existing measurement tools that have been previously translated to Creole, and validated in previous studies.

This project with need additional financial support to continue efforts moving forward. Funding is currently being explored and potentially applied for through entities like the Clinton Foundation, Bill and Melinda Gates Foundation and the World Health Organization. This project has proven that it is now possible to build professional partnerships through telemedicine in Haiti that is affordable, and very easy to use.