Teledermatology: An Approach to Improve Dermatological Care in Bangladesh

Dr.Pritish Barua,
MBBS(CU) Dip.Dermatology(Australia) Dip.Genito-Urinary Medicine(London) SKIN VD PHYSICIAN Lab One Health Services Jamal Khan Road, Chittagong. e-mail: dr.pritish@yahoo.com

An Overview: Skin Health in Bangladesh

Bangladesh has made a significant progress by providing PHC since Alma Ata Declaration. But surprisingly Skin Health for All failed to get the rightful place in the PHC system of Bangladesh. Skin care services are still based on the century back concept, which have failed to reach the whole population. Dermatologists often provide primary care due to unnecessary but unavoidable over referral by the primary care physicians or patient themselves. Moreover their skill & knowledge is mostly underutilized due to lack of financial & technical resources.

cont: skin health overview

Skin care means costly & time-consuming services provided by the specialist or trainee dermatologists at the govt. hospitals or private clinics. covers only around 20% of the population. Remaining 80% of the population, who are largely poor, rural and remote, have little access to proper skin care. So Skin health in Bangladesh reflects the statement-3 billion people in 127 countries

are deprived of basic care for their skin diseases."

Skin Health Picture at the PHC level

Few dermatology posts at the Upazila Health Complexes and private sector dermatologists are not interested in rural and remote practice. Population at this level has to depend partly on just a few registered doctors or largely, on other informal heath workers who do not have the proper dermatology knowledge & training. A cocktail prescription of an oral and topical antihistamine-antibiotic-antifungal-steroid combination without focusing community & public health aspects of dermatology. Results in Persistent disease burden & wastage of resources on ineffective & dangerous treatment.

Why is This Scenario?

Policy makers often fail to recognize or ignore the importance of skin care. Skin disease is poorly taught because it does not possess the high drama. Poor allocation of teaching & training time. So when a young doctor is posted at upazila level, he has to face a lot of problems regarding the diagnosis and treatment of dermatological disorders. Failed to utilize the informal health care workers, who are the first point of contact for rural populations, although they have proven their ability for improving health status in Bangladesh after getting some training in other fields of PHC

-serious impact on peoples quality of life. -causing low productivity at work & school. -discrimination due to disfigurement. -indicate presence of serious diseases.

Importance of Skin Health:

To address the problem, there are many options that can be discussed but in this presentation, I would like to give emphasis on Teledermatology- which could be an effective, easy and fast solution for providing both primary as well as specialist skin care in Bangladesh.

Teledermatology Bow to Target!

Telemedicine & Teledermatology

Telemedicine is an Information
Technology network of medical and allied expertise linked together for the purpose of delivering medical services at a distance.

Teledermatology is the delivery

of skin care through telemedicine technology using telecommunication equipments to evaluate clinical images & information, as well as to diagnose, prescribe therapy & advice on health education & referral for patients located at a remote area.

 Derm atologists have relied on

im ages as diagnostic aids for centuries.

The visual nature of

derm atology m akes this discipline an obvious candidate for telem edicine techniques, and the feasibility & reliability of Telederm atology is already w ell established fits w ell to telem edicine in term s of treatm ent, diagnosis, advice, research and education.

Derm atology is a specialty that

Diagnostic accuracy of Teleconsultation compared with Face-to-Face (FTF) consultation.

Global Community towards Teledermatology

Benefits of Teledermatology
-Enhanced access to a trained dermatologist -Prompt opinion, more accurate diagnosis & treatment -Reduction of patients waiting time & travel expenses

Benefits to patients

-Improved & efficient access to dermatology care -Improved management of patients with skin problems -New opportunities for CME -Enhanced professional collaboration & research -Access to online atlases and databases -More efficient screening of patients with skin problems -Better follow-up of patients with selected skin problems

Benefits to local health care workers

-Reduction in health care costs -Reduction in patients and physicians travel costs -Reduction in total number of hospital admissions -Increase efficiency in the use of human resources -Increased & effective support for local health workers -Compilation of online databases

Benefits to local health care system

Vision 2021-Digital Bangladesh promises to make Bangladesh an influential IT nation. Changed rapidly within 3 years. One of the fastest growing sectors. Mobile Phone Subscribers: 72.963 million at the end of March 2011. Internet Users: 10 million in 2010 compared to 4.8 million in 2008. Network Coverage: 99% of the people, 90% of the area E- governance, commerce, banking, book, health, education etc are in action!

cont:

Tariff Reduction: Voice Call, SMS, MMS, Internet Bandwidth, ISD, etc. Service Development: IP phone, value added services, Spectrum monitoring station, Underground optical Fiber in Dhaka, 3G Mobile services in the pipeline, etc. Guidelines & Policies: Infrastructure Sharing, National Frequency Allocation Plan, International long Distance Telecommunication Services 2010, National Broadband 2010, Rural Telecommunication Network Development & Guidelines 2010, Regulatory & Licensing Guidelines, Videoconferencing Guidelines, IP-PABX, Uniband, 2G mobile renewal guidelines, etc.

Telemedicine in Bangladesh
Form al approach w as taken only after 1999.
Government telemedicine projects are focused mainly on administrative, data & survey purpose under the broad heading of e-health, not addressing telemedicine in terms of direct or indirect doctor-patient interaction. Commercial projects are based at private clinics, dealing with real time videoconferencing, expensive & not directed towards community care. Only a few NGOs or organizations with social business concepts are working in the field of true telemedicine for the under-served, rural, remote & poor population.

Cont:Telemed BD
- UK Charity -Swinfen Charitable Trust (SCT), - Center for the Rehabilitation for the Paralysed (CRP) - Telemedicine Reference Center Ltd. (TRCL) - Development Research Network (D.Net) - Grameen Communication - Click Diagnostics - Bangladesh Rural Advancement Committee (BRAC) - Grameen Phone, - Sustainable Development Network Program (SDNP) - Diabetic association of Bangladesh (DAB) , etc.

NGOs working on Telemedicine:

Societies: Bangladesh Society for Telemedicine & eHealth (BSTeH)

Bangladesh Telemedicine Association (BTA)

Only 2 Bangladeshi dermatologists in The International Society of Teledermatology Prof. Jahed-Bin-Reza and Dr.Pritish Barua Teledermatology is still a baby.

No single focused Teledermatology project.

Tools for Teledermatology Practice (TDP)

REAL TIME TEDERMATOLOGY (RTC) : RTC uses a synchronous audio-video transm ission to

allow a live & interactive consultation betw een a patient and a rem ote physician.

MAJOR ADVANTAGES: -mimics face-to-face consultation. -allows a live interaction. MAJOR DISADVANTAGES: -not cost effective -requires higher bandwidth -requires co-ordination -time consuming

Cont: TDP Tools

history, ex am findings & digital im ages to be transferred to a derm atologist w ho evaluates the inform ation & returns his im pressions & recom m endations .

STORE AND FORWARD TELEDERMATOLOGY (SAF) : I t is a asynchronous tool, w hich allow s patient

MAJOR ADVANTAGES: -less expensive -uses easy equipments -doesn't require d-p coordination -saves valuable time. MAJOR DISADVANTAGES: -low patient satisfaction. -unsatisfactory history & images.

Cont: TDP Tools

HYBRIDE TELEDERMATOLOY: combine the advantages of both RTC & SAF Teledermatology & bring together the efficiency & the interaction with the patient. WHAT TO CHOOSE ? SAF has been the focus of interest in recent years.

-Sim ilar clinical outcom es com pared to conventional clinic-based consultations , -Easy access to skin care in rural & rem ote areas
-using a low technology, low-cost approach,

Best results are likely to be obtained by com bining the tw o prim ary m odalities-SAF & RTC. Hybrid m odels m ay w ell form the basis of Telederm atology in future

TDP: Recommendations for Bangladesh

-Concept, spectrum & benefits of telemedicine. -Application in dermatology -Different TDP models are in front us -Very good mobile & feasible computer technology -Large informal healthcare workforce.

Our strengths:

-Back dated Health Development policies & plans. -Low computer literacy. -Lack of sustainable financing. -Inertia among policy makers & dermatologists.

Our Limitations:

-Care Type, status of care provider & disease pattern. -Historical, cultural & anthropological background. -Cost-effectiveness & social acceptance. -Accuracy, reliability, confidentiality & Legality.

Points to remember!

Cont: Recommendations for BD

Main focus on primary skincare. SAF as a basic TDP & RTC for audio communication. Modification in conventional SAF process: First Contact= informal, registered PHC provider or the patient him/herself. Mid Contact= a registered doctor with basic dermatology knowledge, beside his/her clerical duties of conventional SAF tool, also responsible for making an audio communication and providing consultation for basic and emergency disorders. Mobile Phone= effective tool for first & mid-contacts. First & Mid communication= conventional SAF by e-mail or MMS and RTC by audio-mobile-communication. Mid & End level communication= web-based system. Service= Charity/commercial/social business concept?

Patient

Primary Care Provider

Specialist Dermatologist

Coordinating Doctor

Images by Mobile Camera

Images by Mobile Camera

Patient Information Sheet

NAME: AGE : day= /month= /year= DURATION OF DISEASE: day= /month= /year= (PRESS T AFTER=MARK if applicable and DELETE OTHERS if not applicable) SEX : Male= /Female= PATIENT HISTORY: Pregnant= Very ill due to present problem= Living: poor= /average= /good= Living in hostel/jail/dormitory= Family member has same problem= Family history of Asthma/Allergy= Followed by Fever= /Present fever= Metal/Chemical contact associated= Related with Food= /Drug= OTHER DISEASES HISTORY: Jaundice= /Hep B= /C= /Thyroid= Asthma= /Diabetes= /Hypertension= TB= /Contact or Drug Allergy= SKIN AREAS NOW INVOLVED: scalp= /face= /eye= /inside mouth= lips= /nose= /ear= /neck= /hair= chest= /abdomen= /back= /buttock= axilla= /upper arm= /lower arm= elbow= /wrist= /back of hand= palm= finger= /fing.web= /fing.nail= groin= thigh= /knee= /lower leg=

between toes= /feet nail= /feet top= sole= /genitalia= /all over body= MAIN SYMPTOMS: Itching?: yes= /no= /constant= /occasional= When itching/skin lesions increase?: night= /sun,hot = /no relation= Pain/Burning?: yes= /no= /constant= /occasional= DESCRIPTION OF LESION(S): Red dark scaly= /red dark non scaly= Papular= Nodular=/Pustular,infected= Blistery,Bullous= /eroded,cracked= NATURE OF RASH: has increased= / decreased= same= /comes goes= /fluctuates= SEASON RASH WORSENED: summer= /rainy=/winter=none= PREVIOUS/PRESENT TREATMENT: Steroid cream/pills= Antifungal cream/pills= Antibiotic cream/pills= Antihistamine cream/pills= Homeo,kobiraji,unani,bonaji,etc= Medication Cant remember= Didnt take any treatment= CURRENT OTHER MEDICATIONS: Antibiotics= /Bloodpressure=/Steroid= Diabetes= /Asthma= /Thyroid= /None=

How it is done?

Images by Mobile Camera

Images by Mobile Camera

Images by Mobile Camera

 Teledermatology will not be the replacement of traditional face-to-face consultation. How ever, constraints on tim e & resources w ill m ake

FTF consultation ex pensive.

Teledermatology will be for the delivery of equitable dermatology services to under-served areas & hard to reach populations. Understanding the present skin health status, despite our economic, cultural and technical limitations, we have to move forward with Teledermatology which could be the most effective, easiest, and fastest solution for Bangladesh.