Rural Telemedicine Project
Dominican
Republic
Draft of March 24, 2014
Summary
Throughout the world, medical services are concentrated in urban areas, leaving rural populations with inadequate access to health care, both primary and acute. The problem is exacerbated in less developed regions by the shortage of communication and transportation infrastructure. But as data-capable cellular telephone networks are extended out to formerly isolated rural populations, community telemedicine offers a unique delivery opportunity for medical services. While audio and video channels can link patient and doctor without regard to distance, the bandwidth is indeed narrow compared to the traditional face-to-face, touch-oriented doctor-patient relationship. This limitation can be largely overcome by training village residents as “community medics”, essentially functioning as doctors' assistants. The community medic can operate at a much higher skill level than the traditional village health promoter, through participating in an ongoing working relationship with physicians, and through the availability of ongoing online training. The telemedicine component will emphasize effective integration with existing primary care services and patient information systems, and offer international specialist consultation to primary care providers.
Services to be Provided at the
Village Level
· Emergency
In cases of emergency… or perceived emergency… the community medic can provide triage service, in cellphone communication with the primary care physician or emergency room personnel if necessary. If the emergency is verified, the community medic can stabilize the patient, and facilitate transport to the nearest emergency room.
· Management of chronic conditions
Poor (or no) management of common chronic conditions, notably hypertension and diabetes, often lead to ill health and an untimely death. Having basic diagnostic equipment and medications available in the village, and an involved local health provider can alleviate suffering and reduce social and economic costs.
· Prevention
The community medic can identify and educate villagers about local environmental hazards. This is particularly important in this era of extensive, often uncontrolled, use of highly toxic agricultural and industrial chemicals. Other prevention areas facilitated by local knowledge include improving the local diet, control of parasite and infection vectors, and the early detection of diseases and other treatable conditions.
· Medical record keeping
Medical records for rural residents are often inadequate (or nonexistent). In this era of increasing mobility, these records can be most effectively updated by someone with immediate knowledge of the villagers’ comings and goings, i.e. another village resident. This is particularly problematic in the case of vaccination records, where a child may be passed between various rural and urban households, and there is no coordination between the various record-keeping authorities. Smartphone technology permits the maintenance of a local records data base, and automated integration with a national records facility.
Technology and Telecommunications
· Smartphones
Smartphones provide an effective platform for a rural telemedicine project. While other forms of telecommunications and internet access remain almost nonexistent in the rural areas, cellphone service now reaches the vast majority of rural villages. It must be noted that in many areas, particularly in the mountains, the signal only reaches a part of the village, and residents have to walk to specific locations, sometimes outside the village, to communicate. Therefore all functions must include a store-and-forward offline option. Many rural towers are not provided with 3-G data capabilities, but basic (slow) data appears to be universally available in the Dominican Republic. Smartphones offer the additional advantages of being relatively low-cost, and already familiar to many rural residents, particularly the youth.
· Smartphone Apps
Several apps will need to be developed:
o A simple interface for audio and video real-time communication
o A local medical database, with entry screens and a mechanism for maintaining synchronization with a national database. Initially it may be necessary to maintain the national database.
o Online and offline access to the medical instrumentation suite (see below)
o Distance education tools for the community medics
· Medical instrumentation suite
A set of external, low cost diagnostic tools which connect to the smartphone, and provide for local and remote reading of blood pressure, oxygenation, ekg traces, stethoscope sounds, ultrasound images, etc.
Personnel
· Community Medics
Village residents who will function as the intermediary between the primary care physician and the villagers. Each participating village will have at least two community medics, and may form a team to divide technical and medical functions where appropriate. They will receive a small stipend, but are primarily motivated by a commitment to serve their community. They will take an introductory class, be certified, and have a defined work plan (several hours a week plus emergencies). They will be strongly encouraged to continue their education in the medical area, possibly through graduated incentives.
· Primary physicians
Primary physicians generally will be the official primary care physician for the village. They will take an orientation workshop in the functioning and technology of the telemedicine project, be formally certified, and be expected to develop a working relationship with the community medics. Many primary care physicians in the rural clinics are recent medical school graduates, with limited clinical experience. In situations where the primary care physician does not participate, the nearest participating primary physician will be assigned to the community.
· Consulting physicians
Consulting physicians will provide specialized backup for the primary physicians, many of whom have limited clinical experience. They may also work directly with the more advanced community medics. They may be located nationally or internationally.
Activities
· Outreach and Recruitment
Establish contact with the participating villages and explain the project; work with local leaders and organizations to identify and recruit a minimum of two community medics in each village. Identify and recruit a primary physician for each village, preferably the existing primary care physician, but seek alternatives if this is not possible.
· Training
Community medics will take an introductory three day workshop in how the project functions, introduction to basic medical and emergency care, and use of the equipment. Ongoing training, mostly through distance learning but also some limited participation in presential workshops, is expected. Primary physicians will take a one-day orientation and training workshop.
· Certification
Successful completion of the introductory workshop will result in basic certification. Additional certification will be by examination as the community medic completes more education.
· Health Survey
The first activity in each village will be a community health survey, with all residents receiving a brief checkup and providing a history for the data base.
· Training process and materials development
Initially this will be the development of the introductory workshop curricula and training materials. Then a curriculum for the ongoing training of the community medics will be designed, mostly using distance learning techniques.
· App development
Developing the smartphone apps, as described above
· Medical instrumentation development
In cooperation with work already being done in this area
· Consulting Physicians
Outreach, recruitment, and orientation of consulting physicians, on a national and international basis.
Development Phases
· Phase 1: Initial model development with 3 semi-isolated communities in the southwest mountains of the Dominican Republic. These communities already have internet access, residents with computer skills, and experience in collaborative projects. The communities are: 1) El Limon: Population 300, 30 minute drive to the provincial capital Ocoa. Base community of CAREL. 2) Los Martinez: Population 150, 45 minute drive to Ocoa, has a rural clinic staffed by an intern; 3) Los Naranjales, population 150, 55 minute drive to Ocoa.
·
Phase 2:
Extension to 25 communities around the Dominican Republic, based on the
existing network of communities committed to sustainable development (REDSER)
· Phase 3: Telemedicine project available nationally
About CAREL: CAREL is a Dominican NGO dedicated to improving the quality of rural life. CAREL is based in the mountain farming village of El Limon de Ocoa, population 300, and has extensive experience with participatory development methodology, specializing in village scale technologies including hydroelectricity, wireless Internet access, and innovative construction techniques.
Contact: Jon Katz
Resident Consultant, CAREL
Email: jon@el-limon.org
Web: www.el-limon.org