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KANEZA DIVINE 13/4/2019 2017/ Mmed/085/PSRadiology Department TECHNLOGIES OF TELEMEDECINE IN LOW RESSOURCE SETTINGAbstract Literature shows that telemedicine has been used in almost all developed countries of the world, but for developing countries, telemedicine is embedded in few. Uses and needs of telemedicine in developed and developing countries are not the same; the developing countries are struggling with both communicable diseases and no communicable diseases, and with very few resources and shortage of health care workers. Common clinical applications that are used to overcome that problem include teleconsultation, telecardiology (transmission of ECGs), teleradiology, and teledermatology. Many telemedecine projects exist throughout developing countries of Asia and Africa; there is also multiple sustained humanitarian networks. Application of mobile solutions is also being increasingly on the rise in many developing countries. Telemedicine is still not integrated into existing health care systems in low resource settings.Keywords: telemedicine, low resource settings, technologies, reviewIntroductionTelemedicine is referred to the delivery of health care services, at distance, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities” (Ryu, 2012).Telemedicine can also be referred to as “the use of information and telecommunication technologies (ICT) in medicine” (Ingenerf, 1999). Low resource settings especially Sub-Saharan Africa are facing a high burden of disease, growing populations, poverty, and shortages of healthcare workers. Africa has almost a quarter of the World’s burden of disease is encountered in Africa and this is serviced by 3% of the world’s health workers; the access to the world health expenditure is less than 1%. On the other hand, there is luck of specialists some disciplines of medical schools; likewise, some countries have no specialists in certain fields. This shortage causes an increase in maternal mortality and infant mortality rates. Some solutions have to be found in order to build and develop capacity in low resources setting.(Wootton and Bonnardot, 2010) Telemedicine offers an obvious solution to some of the clinical problems associated with the issue of shortage of doctors in low resource setting.In developing countries, telemedicine in most cases is an alternative, or even the only alternative, to conventional health care while it works side-by side to conventional health care. It is why telemedicine technologies in developing countries need to be studied and implemented to provide wide population with basic health care services and to close the distance between rural areas and specialized hospitals usually located in big cities, which make big part of the population in developing countries suffer.(In, 1997)Objective: This paper aim to examine different technologies of telemedecine that can be used in low resource setting.LiteratureThe first use of ICT for health started in the 1860s .At that time telegraph messages were sent to seek help for treating wounded soldiers during the American Civil War. The use of ICTs to exchange health information and provide health care services across geographic, time, social, cultural, and political barriers can be done by using any form of ICT device (from a desktop PC, through laptops and i-pads, to smart devices and sensors). Simple or complex multimedia to videoconferencing to virtual reality; or interactive (synchronous – “real-time” person-to-person or person-to-software engagement; or asynchronous – delayed messaging such as e-mail) can also be used. ICTs can help in low resource setting in different scenario(Combi et al., 2016): Remote diagnosing and teleconsulting system in which Data (including signals and images) are locally (patient-side) acquired and stored, and then forwarded to the main hospital, where physicians can analyze those data. The remote (physician-side) hospital will then send back the diagnosis. Such a situation typically occurs in rural locations of developing countries. Teleconsulting is performed among physicians, where a non-specialist physician requires a remote consultation with one or more specialist physicians: typically, such a situation occurs in minor hospitals of developed countries, or in any location of developing countries. Remote monitoring system: the patient is monitored in the remote location; his/her signals are continuously acquired, forwarded to the main hospital, and, possibly, locally analysed. Alarms are remotely detected and transmitted back to the patient-side. The monitoring system can be managed and locally controlled by a physician or by a nurse. Remote intervention system: the patient is in the operating room; the intervention is performed through a local (patient-side) robot that is remotely controlled by a physician in the main hospital. The remote intervention requires that some local assistance be performed by a physician or by a nurse. Remote education (e-learning) system: here students or caregivers (physicians, nurses, and technicians) attend classes taught from remote academic institutions, and possibly, by a bi-directional communication interact with the teacher by making questions. A local tutor can locally assist remote education, during and/or after the classes.MethodsThis analysis of telemedicine technologies relies on information obtained from different articles published. This collection of articles shows the rich diversity of applications for telemedicine. Examples come from different low resources setting and from a range of clinical settings and medical specialties.Few articles were getting data from the center for health market innovations. This centre was launched in 2010 and with daily update. Data were collected from public and private actors that have the potential to improve health system in low-income countries. Their programmes were using innovative delivery mechanisms to improve access to health services.Another part of information used in this review was obtained from programmes launched in developing countries (Bangladesh, Uganda, Tanzania, Kenya, Pakistan, South Africa, Burundi, and Rwanda).Those programmes were driven by technology as core function.ResultsTelemedicine services that have been used into routine service in low resources setting of sub-Saharan Africa include store and forward telemedicine services. Swinfen Charitable Trust is one of the example, which offered free store, and forward telemedicine services to 153 hospitals and clinics in 50 countries around the world. Among those Hospitals and clinics, 13 of them were African countries. Wootton and al described seven of nine long-running networks (operating for 5–11 years); and these networks were providing clinical tele-consultations using store-and-forward methods. One used videoconferencing for trauma cases, and five provided educational activities. Between 2006 and 2011, three showed a positive trend in network activity.(Wootton and Bonnardot, 2010)In Egypt ,teleconsulting project were established between the Italian Hospital Umberto I in Cairo and the ARNAS-Civic Hospital of Palermo in Italy, They were using both biomedical images and ECG signals for a second opinion service, and the mode used were both real time and off-line mode) since 2002. Egyptian Telemedicine Network (ETN) was also used to provide the Egyptian population with a range of medical services, including radiology, electronic stethoscope, tele-pathology and ECG. The Pan Africa Project providing Teleconsultations services using video-conference sessions between the health care organizations in Alexandria (Egypt) and 12 hospitals in India in 2009 was in place .Beside that Egypt national PACS in 2010, established a centralized Picture Archiving and Communication System (PACS) covering the six major hospitals in Egypt.(Hussein and Khalifa, 2012)In Zambia, Congo and Madagascar, laboratories to perform preventive examinations to fight cancer in developing countries had been set up by the project from the Italian association Patologi Oltre Frontiera. Micro and macro images are stored locally (patient-side), and expert physicians from Italian hospitals perform remote consulting. (Combi et al., 2016)The web application also enabled users to perform video conferencing.In Burundi, telemedicine project, funded by the Veneto Region and by the University of Verona, were providing local physicians of the Hospital of Ngozi, with expert second opinions from their colleagues in the University of Verona, Italy, on interpreting ECG signals, ultrasound and X-ray images. (Combi et al., 2015).The University of KwaZulu Natal, Durban, South Africa has been using ICT-facilitated teaching, simultaneously broadcasting (and recording) lectures to four University of KwaZulu Natal campuses locally. They were also teaching graduate telehealth and informatics degree programs throughout sub-Saharan Africa using various video-based software programs (eg, Scopia) and Learning Management Systems (eg, Moodle), and even simply record and distribute CD/DVD lectures for continuing education.(Scott and Mars, 2015) Mobile phones have great potential in the delivery of health care in low-resource settings. Piette et al reported that automated telephone monitoring and self-care support calls have been shown to improve some outcomes for chronic disease management, such as glycemia and blood pressure control, in low- and middle-income countries.(Su et al., 2016)A mobile-phone application was developed to enable non-doctors to diagnose episodes of epilepsy. In a pilot trial with health workers in Nepal who used the app in small numbers of patients, there were no false diagnoses.(Bhatta et al., 2015) This represents a potential method of empowering health workers to help people in low resources setting. Ndlovu et al. conducted trials with mobile-phone telemedicine in Botswana, in four medical specialties: radiology, oral medicine, dermatology, and cervical cancer screening. (Ndlovu et al., 2014)The benefits reported by pilot project users were sufficient to convince the government to scale up the program, which is now in progress. Low-cost web-based tools have been used for transmitting video have been used. For example, Jefee-Bahloul (Jefee-Bahloul, 2014)conducted a pilot trial of telepsychiatry in Jordan using Skype, while Adambounou et al. (Adambounou et al., 2014) used the file transfer facilities of the LogMeIn web service for tele-ultrasound between Togo and France.Conclusion Teleconsultation has enabled local treatment in low resource setting, mainly using store-and-forward programmes .Video telemedicine is possible in low-resource environments, but it is also the case that non-real-time (store-and-forward) telemedicine is more common in these settings, not only because it is usually cheaper but also because the non-synchronous nature of the interaction between the parties makes . Other different technologies are found to overcome the huge constraints imposed by low-resource settings (web -based application, mobile phone applications,…). We can expect that in the future, the use of telemedicine – practising health care at a distance will become a norm. 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