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Health Care: Delivery, Education, Communication

An Internet-Based Telemedicine System in Nigeria

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3. Internet-Based Telemedicine System Architecture

The main objective of this system is to provide efficient and convenient methods for the remote rural healthcare workers and physicians located at the cities to collaborate with one another over patient cases. It also allows the rural healthcare workers to send the patients' demographic and clinical data, X-rays and ultrasound images through the IP-based wireless telemedicine network for consultation and diagnosis of any patient's illness. This allows for a circumstance for patient's case diagnosis and consultation remotely. Others are to reduce healthcare delivery cost without loss of quality, increase the access to expert-supported healthcare services based in hospitals located in larger cities and mitigate the isolation of rural health workers by bringing them in regular contact with the physicians in the urban city hospitals.

This system consists of four major modules. These are Administrative, Consultations, Referral and Monitoring modules. The Administrative module consists of four sub-modules, which allow nurses to add/update patient demographic data, admit/discharge management, admission of drugs/injection for the patient and add payment made by the patients. The addition/update of patient's multimedia information sub-module is handled solely by the physicians and the remote rural health workers.

The major objective of this module is to improve the workflow of healthcare practitioners, both clinically and administratively. In essence, this will provide support for clinical and administrative services, investigation of request, result retrieval, diagnosis, treatment, drug prescriptions, etc. All the functions of this module will contribute directly towards on-the-ground support of medical practitioners, thereby allowing more accurate and informed diagnosis, more effective treatment and enhanced level of healthcare. The need for the transformation of patient data into an electronic format is driven by the necessity of obtaining patient's medical history during contact with a medical professional. This process often consumes a substantial portion of the practitioner's time, especially during episodic encounters with patients possessing a potentially complex case history. New information must also be recorded and integrated in an organised manner before an appropriate diagnosis can be attained and treatment administered. Ensuring the availability, accuracy and completeness of medical records will therefore be of great value to medical professionals.

3.1 Consultation Module

Bringing the benefits of the expertise of hospital-based specialists to the rural populace has been the goal of telemedicine systems. This system provides a store-andforward approach mechanism to enable consultation between the remote health workers and the specialists on any particular patient's cases. This approach is typically for non-emergent situations, when a consultation and diagnosis may be made in the next 24-48 h and sent back. This makes use of check boxes to include pertinent patient data such as a subset of his health history, clinical data, X-rays and ultrasound images which the rural health worker wants to transmit over the IP-based wireless telemedicine network to the queue server where the specialist could have them and respond accordingly. The rural health worker uses the check box of the consultation form to attach the pertinent patient's data to be forwarded to the appropriate specialist in the urban city. The consultation could also be between general physicians and specialists within urban cities on any complex situations. This is done with the objective of enhancing and extending basic work processes.

Apart from the stored-and-forward approach as stated above, an interactive two-way remote consultation and diagnosis between the patients in the remote rural areas, remote rural health workers and specialists in the urban cities is supported by using H.323 standard over an IP-based telemedicine wireless network. Using videoconferencing technology and specially adapted medical tools and devices interfaced to the computer, the remote specialist can see his patient, talk with the remote rural health worker, hear heartbeat through remote stethoscope, see images from ear through otoscope, nose, and throat or skin conditions or make some other remote measurements of vital signs through a device such as Tandberg's HealthCare System III (Tandberg, 2003). The interactive two-way remote consultation and diagnosis videoconferencing terminal is made up of a digital camera (to capture local live video), a display unit (to display remote video), a microphone (to capture local audio), and speakers (to play remote audio). In addition to these obvious components, a videoconferencing terminal also includes medical digital devices, a codec, a user interface (a videoconferencing application software) and a computer to run on. Both the video coded and medical digital device are connected through the computer to the wireless telemedicine network. Multimedia data is transported over the wireless telemedicine network from remote rural location to the specialist in the urban cities in a real-time manner for consultation and diagnosis and the result of diagnosis is forwarded back in a real-time manner with prescriptions and the rest. The system is easy to follow, and provides step-by-step instructions for the medical health workers. The system does require the medical workers have minimal competence to use the system and this will be achievable through an intensive training.

Public telemedicine centres could be located within urban cities, where full interactive two-way remote consultation and diagnosis between remote patients in the public telemedicine centres and the specialists happen, to take care of immediate and emergency healthcare cases. The videoconferencing terminals are the same as the above. This approach also could be initiated in the Nigerian higher institutions in order to augment the institution's health services by allowing nurses in these institutions to consult with specialists. The system could also be initiated in correctional institutions, where the costs and danger of transporting prisoners to the hospitals can be avoided. However, the system is very patient-ready, easy to follow, and provides step-by-step instructions for the patient and does require that the patient to have minimal competence to use the system and in handling the medical equipment at his disposal.

Using videoconferencing techniques, it is possible to obtain a patient's medical history, diagnose patient, educate patient, and make prescriptions among others. The above scenarios mean that the patient does not have to travel to urban cities to see specialist, and in many cases, receive access to specialty care where none has been available previously. This also opens up new possibilities for continuing education for isolated or rural health professionals, who may not be able to leave a rural practice to take part in professional meetings or educational opportunities.

Home healthcare is common to many people's healthcare routine across the world, a situation whereby home-bound patients could communicate daily with specialists. An Internet-based telemedicine system in Nigeria has the capability to support a very large number of patients who may need specific health support at home. This is achievable through an interactive two-way videoconferencing that runs over ISDN or telephone line and Internet protocol using videoconferencing standards H.320 and H.323 and a TV for patient's interaction. The videoconferencing terminal setup in a patient's home consists of patient's existing TV set and remote control, an interface to TV, which also housed conferencing application software, and medical digital equipment. The multimedia data is transmitted through USB and RS323 ports to the telemedicine network. The video screens are very patient-ready, easy to follow, and provide step-by-step instructions for the patient. The system does require the patient to have minimal competence to use the system and in handling the medical equipment at his disposal. Using this approach, it is possible to obtain patient's medical history, examine the patient for immediate healthcare, make remote measurements of vital signs, educate the patient and make some prescription if need be.

3.2 Referral Module

Referring a patient to another physician or another hospital is one of the most common transactions in healthcare. When a patient is referred, a subset of his record that is pertinent to that the referral is transmitted to the appropriate specialists or hospitals through the IP-based telemedicine network. This system provides a mechanism by which physicians can compose a package of referral information from the patient record and submit the same to the appropriate server queue. The process automatically processes the submission in order to select the appropriate specialists or hospital for the patient's condition based upon the information available.

The basic component of the Internet-based healthcare system's infrastructure is presented in Fig. 1. This includes a user interface made of access devices at the remote rural areas and urban cities, a high-speed, highly reliable and scalable regional network and content management gateway. This approach allows users to access the system through the Internet and a common content management gateway, which in turn takes request for any services from the users (physicians and other health professionals) and passes it to the appropriate backend systems.

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Figure 1: Proposed Internet-based healthcare system Infrastructure in Nigeria (click image to see larger view).

The common content management gateway provides a single point entry to the system via a URL. Once a user logged on, JSP presents the main module of the system to the user. Based on the user's selection and successful authentication, JSP presentation logic redirects the user to submodules or forms to perform the task selected by the user. Furthermore, a servlet provides the presentation logic for processing the service request, for example, submission of a form to register a new patient or update an already existing patient health history. This is invoked by the action of the user. It uses XMLTransform's methods to convert the HTML form data into XML documents. This conversion provides for structured data format that would be recognised by the backend systems in the hospitals.

After the data conversion, the servlet then invokes the TelemedicineBean. The Telemedicine- Bean provides a set of operations for JSPs and servlets to use when accessing the system. The servlet invokes, for example, the add/update method of the TelemedicineBean to add/update patient data into the appropriate backend system. In case a patient is to be referred, a form where the physician will specify the referral information from the patient data and others is presented. After the submission of the completed form, a servlet is invoked and it converts the HTML form data into XML document. This in turn invokes the TelemedicineBean referral methods to transmit and queue up the patient information into the appropriate queue server where the appropriate physician could have access to them. In both cases, it dynamically creates and returns to HTML page with the results of operation specified by the user to the browser.

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