Telemedicine as a Means to an End, Not an End in Itself

Telemedicine (TM)—the management of disease at a distance—has potential usefulness for patients with advanced respiratory disease. Underscoring this potential is the dramatic expansion of its applications in clinical medicine. However, since clinical studies testing this intervention often provide heterogeneous results, its role in the medical management of respiratory disorders remains inconclusive. A major problem in establishing TM’s effectiveness is that it is not a single intervention; rather, it includes a number of divergent diagnostic and therapeutic modalities—and each must be tested separately. Reflecting the discord between the need for further documentation of its approaches and effectiveness and its rapid utilization without this needed information, a major challenge is the lack of international guidelines for its integration, regulation, operational plans, and guidance for professionals. Tailored TM, with increased flexibility to address differing healthcare contexts, has the potential to improve access to and quality of services while reducing costs and direct input by health professionals. We should view TM as a tool to aid healthcare professionals in managing their patients with respiratory diseases rather than as a stand-alone substitute to traditional medical care. As such, TM is a means rather than an end.

Orphans in post-conflict Liberia: Seeking care in fractured communities

Orphans in post-conflict settings have unique needs that have not been well-characterized. In post-conflict Liberia, maternal orphans are more likely to be without care than paternal orphans. This study examined the experiences of maternal orphans in Liberia, as they attempted to care for themselves and seek care from others, and the barriers they faced. In-depth interviews were conducted with 75 post-conflict Liberian orphans. We performed a secondary narrative analysis of interview transcripts from all maternal or double orphans (n = 17). We identified similar elements across narratives: traumatic loss, disconnection from family and community, and the desire for a savior. Female high-risk orphans were more likely to have formal substitute caregiving arrangements in which they were living with someone who was a relative or had been selected by a relative. Male orphans more commonly lacked arranged substitute care, but this allowed them to form relationships with substitute caregivers of their choosing. Sex also played a role in the provision of caregiving; substitute care was provided by women. Findings highlighted the syndemic relationship between poverty, violence, transactional sex, trauma, and substance use that traps high-risk Liberian orphans. Interventions are needed to improve access to mental health care, sober communities, housing, and education support. The need to integrate these services into indigenous institutions and address barriers related to stigma is explored.

Initial drafting of telemedicine’s code of ethics through a stakeholders’ participatory process

Telemedicine can improve access to healthcare services; however, it has raised ethical concerns demanding special considerations. This study aimed at developing the codes of ethics for telemedicine, and hence several approved national and international ethical guidelines related to telemedicine practice were reviewed, and 48 semi-structured interviews were conducted with medical ethics and medical informatics experts as well as with physicians and patients who had telemedicine experiences. Content analysis was then performed on the interviews’ transcripts and a draft on code of ethics was prepared, which was further reviewed by the experts in the focus group meetings to reach a consensus on the final document. The final document consisted of a preface, five considerations, and 25 ethical statements. Considering the growing trend of adopting telemedicine worldwide, this document provides an ethical framework for those who use telemedicine in their medical practice.

COVID-19 and the Digital Transformation of Education Lessons Learnt on 4IR in Zimbabwe

This study assessed the influence of the COVID-19 pandemic in motivating digital transformation in the education sector in Zimbabwe. The study tracked the rate at which the Fourth Industrial Revolution (4IR) tools were used by various institutions during the COVID-19 lockdown. Data were obtained from secondary sources. The findings are that, in Zimbabwe, during the lockdown, a variety of 4IR tools were unleashed from primary education to higher and tertiary education where educational activities switched to remote (online) learning. These observations reflect that Zimbabwe generally has some elements of excellence to drive the education sector into the 4IR, which has the potential to increase access. Access to education, particularly at a higher education level, has always been a challenge due to a limited number of spaces available. The pandemic has presented an opportunity to assess successes and failures of deployed technologies, costs associated with them, and scaling these technologies to improve access.

Assessing Cognitive Function in Multiple Sclerosis With Digital Tools: Observational Study

Background Cognitive impairment (CI) is one of the most prevalent symptoms of multiple sclerosis (MS). However, it is difficult to include cognitive assessment as part of MS standard care since the comprehensive neuropsychological examinations are usually time-consuming and extensive. Objective To improve access to CI assessment, we evaluated the feasibility and potential assessment sensitivity of a tablet-based cognitive battery in patients with MS. Methods In total, 53 participants with MS (24 [45%] with CI and 29 [55%] without CI) and 24 non-MS participants were assessed with a tablet-based cognitive battery (Adaptive Cognitive Evaluation [ACE]) and standard cognitive measures, including the Symbol Digit Modalities Test (SDMT) and the Paced Auditory Serial Addition Test (PASAT). Associations between performance in ACE and the SDMT/PASAT were explored, with group comparisons to evaluate whether ACE modules can capture group-level differences. Results Correlations between performance in ACE and the SDMT (R=–0.57, P<.001), as well as PASAT (R=–0.39, P=.01), were observed. Compared to non-MS and non-CI MS groups, the CI MS group showed a slower reaction time (CI MS vs non-MS: P<.001; CI MS vs non-CI MS: P=.004) and a higher attention cost (CI MS vs non-MS: P=.02; CI MS vs non-CI MS: P<.001). Conclusions These results provide preliminary evidence that ACE, a tablet-based cognitive assessment battery, provides modules that could potentially serve as a digital cognitive assessment for people with MS. Trial Registration ClinicalTrials.gov NCT03569618; https://clinicaltrials.gov/ct2/show/NCT03569618

Expanding Virtual Health Capabilities Into Trainee Health

ABSTRACT Virtual health and secure messaging gained newfound relevance in medicine during the coronavirus disease (COVID)-19 pandemic. For a military trainee health care clinic located on Joint Base San Antonio, the McWethy Troop Medical Clinic (TMC), implementation of virtual health and secure messaging services meant decreased risk of COVID-19 exposure for trainees and clinical staff. Through ongoing utilization, these services also made impacts to reduce loss of instruction time and improve access to care for the McWethy TMC trainee population. In defining the challenges, successes, and future implications for virtual health and secure messaging at the McWethy TMC, key lessons emerge for other military trainee clinics. The key concepts explored in this article are virtual health and secure messaging.

Enabling Rural Telehealth: Focus Group Study with Older Adults in Underserved Rural Communities (Preprint)

BACKGROUND Telehealth is often suggested to improve access to healthcare and has had significant publicity internationally during the Covid-19 pandemic. However, there is limited research examining the telehealth needs of underserved populations such as rural communities. OBJECTIVE The aim of this study was to investigate enablers for telehealth use in rural underserved populations to improve access to healthcare for rural older adults. METHODS 7 focus group discussions and 13 individual interviews were held across 4 diverse underserved rural communities. 98 adults, aged 55 years and over, participated. Participants were asked if they had used telehealth, how they saw their community’s health service needs evolving, how telehealth might help provide these services, and perceived barriers and enablers to telehealth for older adults in rural communities. Focus group transcripts were thematically analysed. RESULTS The term ‘telehealth’ was not initially understood by many participants and required explanation. The likelihood of using telehealth varied between those who had used telehealth and those who had not. Those who had used telehealth reported very positive experiences (time and cost savings) and would be more likely to use telehealth again. Two main themes were identified through an equity lens. The first theme was “trust” with three sub-themes – trust in the telehealth technology, trust in the user (consumer and health provider) and trust in the health system. Having access to reliable and affordable internet connectivity and digital devices was a key enabler for telehealth use. Most rural areas had intermittent, unreliable internet connectivity. Having easy access to user support was another key enabler. Trust in the health system focused on waiting times, lack of/delayed communication and coordination, and cost. The second theme was “choice” with three sub-themes – health service access, consultation type and telehealth deployment. Access to health services by telehealth needs to be culturally appropriate and enable access to currently limited or absent services such as mental health and specialist services. Accessing specialist care by telehealth was extremely popular but some participants would rather be seen in person. A major enabler for telehealth was deploying telehealth by a fixed community ‘hub’ or on a mobile bus, with support available, and especially when combined with non-health related services such as online banking. CONCLUSIONS Overall, participants were keen on the idea of telehealth. Several barriers and enablers were identified. The term ‘telehealth’ is not well understood. The unreliable and expensive connectivity options available to the rural communities has limited the telehealth experience to phone or patient portal use, for those who have connectivity. Having the opportunity to try telehealth, especially using video, would increase understanding and acceptance of telehealth. The study highlights that local rural communities need to be involved in the design of telehealth services within their community.

Access to and Barriers to Access for Essential Medicines in Nephrology and Related Non-Communicable Diseases: A Scoping Review Protocol

Objective: This scoping review aims to understand the extent of evidence regarding: 1) access to essential medicines, 2) barriers to access, and 3) interventions to improve access for chronic kidney disease (CKD) and related non-communicable diseases (NCDs). Introduction: Access to essential medicines for treatment of NCDs is lacking in low- and low-middle income countries. In nephrology, access to essential medicines is especially important to reduce risk of CKD progression, as kidney replacement therapy is unavailable or cost-prohibitive in many regions of the world. As part of the International Society of Nephrology Emerging Leaders Program’s mandate to improve health promotion and access to prevention and management of kidney diseases globally, this scoping review serves as an initial step towards designing implementation studies to improve access to essential medicines. Inclusion criteria: Articles of any study design involving populations with chronic kidney disease, cardiovascular disease, hypertension, and/or diabetes will be included. The core concept of essential medicines will encompass access to essential medicines, barriers to access, and interventions to improve access. All geographical regions and all World Bank Income categories will be considered. Methods: Methods for this scoping review are based on the Joanna Briggs Manual for Evidence Synthesis. MEDLINE, EMBASE, Web of Science, CENTRAL will be searched. Included studies will be restricted to English language. Screening of title/abstract of each article and subsequent review of retrieved full-text articles will be performed by one reviewer, followed by a second reviewer checking the excluded lists for accuracy. A data extraction tool will be customized using Covidence software. Data will be summarized narratively, and in tabular and diagrammatic format. Studies assessing barriers to access or interventions to improve access will be categorized by patient-level, provider-level, organization-level, community/regional-level, and national/health policy-level.