UKZN Professor plays leading role in launch of Telemedicine to Rwandan Hospitals

Professor Maurice Mars, Head of the Department of TeleHealth at the Nelson R Mandela School of Medicine, played a pivotal role in last month’s launch of telemedicine to hospitals in Rwanda. 

The United Nations/Africa Fellowship on Telemedicine in co-operation with the Department of TeleHealth and the International Society for Telemedicine and eHealth (ISfTeH) facilitated the promotion of telemedicine to the Ruhengeri Hospital and Kabgayi Hospital through an intensive basic training programme developed by Professor Mar’s Department and the ISfTeH. 

Seventeen doctors from the two hospitals – which will be the first recipients of telemedicine infrastructure – were trained in the basics of telemedicine, legal and ethical issues, video-conferencing, practical digital photography and tele-education. 

According to Professor Mars, the doctors, who were not aware of telemedicine before receiving the training, responded favourably to the programme, especially the practical sessions. 

They also identified additional telemedicine services, such as tele-psychiatry, that they would like to have available at their hospitals. 

“This is the first step of an international outreach to raise awareness of telemedicine in the developing world with the aim to develop more advanced courses over time,” said Professor Mars 

Professor Mars was previously an advisor to the Rwandan Government in its bid to introduce telemedicine in Rwanda. 


UKZN’s Telemedicine Expert Recognized for Breaking Barriers to Clinical Training

National Minister of Health, Dr Aaron Motsoaledi, has appointed Professor Maurice Mars, Head of the Department of TeleHealth at UKZN’s Nelson R Mandela School of Medicine to the Ministerial Advisory Committee on Health Technology. The five-year appointment is significant as telemedicine, which falls within the scope of this committee, has been identified as a national priority. Telemedicine is the practice of medicine over geographical distances using information and communication technologies. Contrary to perceptions, it is not new. Medical services were provided using telegraphs before the age of the telephone and the first documented telephone consultation took place in 1879. The department of TeleHealth is the only department of its kind in Africa offering formal academic qualifications in the fields of telemedicine and medical informatics. 

It has been a busy time for Mars who has also been appointed to an Expert Working Group of the African Union working towards Harmonizing e-Health and Telemedicine in Africa. He is President of the newly-formed South African Telemedicine Association whose objectives are to advance telemedicine in South Africa and to provide a platform for experts in the field to interact with government and the private sector to help meet their respective needs. He also chairs the Educational Committee of the International Society of Telemedicine and e-Health and has developed a basic two-day telemedicine training course which has been taught in Rwanda, Mozambique and Tanzania. 

Mars has a longstanding interest in computer-based education and tele-education and introduced Videoconferenced Tele-education to the Medical School in 2001. This has grown to a service run by the Department of TeleHealth that broadcasts over 40 hours a week of interactive videoconferenced teaching to postgraduate and undergraduate students in and around KwaZulu-Natal. Through a Fogarty International Training Grant the small department of two academics and three technicians is currently using its distance learning expertise in assisting institutions in Uganda, Zimbabwe and Mozambique to set up medical informatics training by teaching postgraduate students at these sites and building the capacity of staff in these institutions. Some of the technologies used are video-conferencing, Skype, podcasts and the distribution of CDs with recorded lectures all co-ordinated through Moodle. The UKZN telemedicine course is also taught to students in Nigeria, Namibia, Botswana, Rwanda and around South Africa. Mars said that many of the registered students are based outside of South Africa and do not come to Durban. 

Medical informatics is a rapidly expanding field. In 2010, the United States set aside $19 billion to ensure that every medical practice and hospital will use an electronic patient record by 2015. As there is a worldwide shortage of medical informaticians, the American Medical Informatics Association (AMIA) has come up with the concept of Health Informatics Building Blocks (HIBBs) which are lectures and teaching sessions recorded using PowerPoint, and audio and video files. Over time, it will be possible to assemble appropriate education and training programmes in resource constrained settings using HIBBs. Mars’ department is the first site in Africa to develop HIBBs for AMIA as part of a pilot project. Mars said: ‘The HIBBs have a significant role to play bearing in mind the shortage of informatics specialists internationally. By archiving the teaching through recorded sessions one is able to build capacity in this field without face-to-face sessions.’ 

In keeping with the University’s Mission, the teaching of specialists across Africa is being facilitated through tele-education. Every Wednesday morning, for example, a paediatric surgery seminar is video-conferenced to an average of 65 doctors and students at other hospitals in KwaZulu-Natal and South Africa. The seminars are recorded to DVD and posted on a monthly basis to seven medical schools in Central and East Africa that do not have sufficient bandwidth to join in a videoconference. Mars estimates that a further 300 surgical specialists in training and medical students are viewing these recorded sessions each week. 

Mars is passionate about medical specialists’ training through e-communications. His department has assisted in driving specialist telemedicine services in various hospitals in the Province. In the Port Shepstone area, a medical officer communicates with ophthalmologists from the Nelson R Mandela School of Medicine by email with attached photos of the surface and interior of the patient’s eye; the diagnosis is made based on the history and the images and the management is emailed back to the medical officer. This has saved 80 percent of the patients managed in this way from having to travel to Durban to consult with a specialist. A telemedicine Diabetic Retinopathy Screening Programme involving emailed photos of the retina has also been set up at Stanger Hospital. 

At the Church of Scotland, Manguzi, Kokstad and Port Shepstone Hospitals, tele-dermatology telemedicine services have been established. This allows, through video-conferencing, for a medical officer and patient to liaise with consultants in Durban without the patient having to transfer to a Durban hospital. Mars’ said that an analysis of the service provided from Durban to Port Shepstone indicated that all patients opted for the videoconferenced consultation rather than going to Durban and that 75 percent of patients treated in this way were then managed successfully at their local hospital. Another example is the tele-orthopaedic service run from Grey’s hospital to the Church of Scotland Hospital. Local doctors place X-ray films on a viewing box and discuss the patients’ problems with a specialist through videoconferencing. 

The Department’s main research interests include the legal and ethical issues facing telemedicine in the developing world, the economics of telemedicine, factors affecting eHealth implementation in the developing world and the use of artificial intelligence and machine learning to forecast CD4 counts and drug resistance in HIV patients. 

From teaching a two-day course in telemedicine to doctors in Rwanda, to reaching out to hundreds of students across Africa and facilitating consultations across hospitals in KwaZulu-Natal, Mars remains passionate about promoting telemedicine in Africa. He said: ‘Telemedicine allows rural patients access to specialist care that they would not normally receive and provides continuing medical education to doctors and nurses in peripheral hospitals. With modern communication technology it’s a joy to be able to teach so many students across Africa from my office, home or even hotel room. This ensures that teaching is continuous even when attending a conference.


Telemedicine expert appointed to serve on Ministerial Advisory Committee on Health Technology

National Minister of Health, Dr Aaron Motsoaledi, has appointed Professor Maurice Mars, Head of the Department of Tele-Health at UKZN’s Nelson R Mandela School of Medicine onto the Ministerial Advisory Committee on Health Technology. Mars’ department is the only department in Africa offering formal academic programmes leading to specialization in the field of telemedicine and medical informatics. 



Should Telemedicine be regulated?

At a recent South African Telemedicine Conference, UKZN PhD student, Ms Caron Jack’s presentation scooped first prize. Her study titled, “Informed Consent for Telemedicine in South Africa: Clinical Practice versus the Legislators” aimed to understand whether in a developing country, written informed consent is obtained by healthcare professionals when transferring clinical information about a patient through telephone, fax or e-mail communication tools. In other words, how relevant would it be, in a developing world, to regulate telemedicine? 

Due to the growing shortage of health practitioners in developing countries, telemedicine is regarded as a new, efficient way of offering medical services. However, regulators feel that telemedicine presents many ethical challenges. The Health Professions Council of South Africa (HPCSA) has proposed that clinical, operational and ethical guidelines should be developed by the governing bodies or associations of the various clinical disciplines using information and communication technologies in the provision of healthcare. It is proposed that a regulated telemedicine environment would ensure improved access, service delivery and quality of care for rural communities in South Africa. 

The proposed HPCSA guidelines suggest that for every telemedicine encounter, written, informed consent should be given by the patient to the clinician for every aspect of that telemedicine encounter, based on full and frank disclosure of all the material facts. This would include the transfer of patient records, storage of information, clinical examinations and consultation with another practitioner electronically. Through her study, which consisted of 400 healthcare professionals from the private and public sectors in the province of KwaZulu-Natal, Jack found that the majority of healthcare professionals only obtained verbal consent from the patient when transferring clinical information, referrals to other specialists, clinical examinations and ordering investigations. 

She concluded that the imposition of signed informed consent by regulators would impede telemedicine use. ‘Legislation should be enabling and not obstructive. In a country like South Africa, regulators assume that every citizen, including healthcare workers and patients, is technologically literate and that every one of our 11 official languages contains words for technology and data security measures employed by telemedicine,’ Jack said. 

Jack has recently published a study titled, “Language, Cultural Brokerage and Informed Consent: Will Technological Terms Impede Telemedicine Use?” Her findings suggest that a direct translation of most computer terminology into isiZulu is very limited. She concluded that the lack of a lexicon of technological and computing terms in a language may well make it impossible to meet the full legal requirement for valid informed consent, as set out by the HPCSA. 

‘Ensuring that patients are provided with information of sufficient quality and quantity in their own language, to ensure that they will be genuinely informed and able to make an autonomous choice as to their preferred treatment will require appropriate consent tools,’ said Jack. ‘Telemedicine laws and the issue of informed consent for telemedicine remain controversial,’ she added.


UKZN’S PhD Student aims to create a HIV Virtual Clinic

Mr Yashik Singh, a summa cum laude Master’s graduate in Medical Informatics is spearheading research for his PhD into creating an HIV treatment management tool. This tool includes forecasting changes in the HI virus which would affect resistance of the virus to certain drugs, forecasting changes in the CD4 count of HIV-1 patients, and an integrated interpretation algorithm within an electronic medical record system. The study titled, “A Physician Administered Artificial Intelligence Based Decision Support System Tool that Facilitates the Management of Patients on Anti-retroviral Therapy”, is conducted using artificial intelligence. 

Singh’s pioneering research in this field integrates several computer software packages with existing medical records to determine resistance of the virus to several drugs. Whilst this assessment is done through artificial intelligence, the Inkosi Albert Luthuli Central Hospital phenotypically measures blood samples of HIV positive patients to see if they get the same results. The Hospital uses interpretation algorithms which Singh believes can be improved. Results obtained from Singh’s study indicate that the algorithms he developed are more accurate than current interpretation algorithms including those created at Stanford University in the United States. 

Data sets are obtained from internationally standard 20 to 30 000 data elements. The data includes several genome sub-types which are culturally specific. The aim of the study is to produce a stand-alone computer system (a virtual clinic) that can be accessed by any physician internationally. Physicians would enter key data pertaining to a patient and receive advice generated by bioinformatics and artificial intelligence algorithms. 

Through usage of the system, Singh believes that physicians would be able to predetermine how their patients would react to various medications over several different time frames. This would assist in providing the most effective medication based on individual results. 

Singh’s supervisor, Professor Maurice Mars said that Singh turned down an offer from Stanford University in order to pursue his PhD at UKZN. Singh said: ‘It’s a lot better to be physically located in a developing world when conducting this study, as one understands the needs of the community much better. There is more work to be done here in the Province of KwaZulu-Natal and we have the expertise here in the Department of Tele-health.