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Background: Telemedicine enables new forms of medical consultation and is expanding worldwide. Patients in sub-Saharan Africa could potentially benefit substantially from telemedicine. Objective: To improve primary healthcare services, especially referrals to the district hospital, for the population in three health centres in the rural district Kingandu in the Democratic Republic of the Congo (DRC) by introducing Smart Glasses, and leveraging them for telemedicine. Methods: The project involved the design and introduction of an intervention combining community engagement with technological innovation (Smart Glasses, communication equipment, moto-ambulances, and new diagnostic tests), and with staff training. Utilisation of the intervention, use of the health centres, and referrals to the hospital were monitored through the routine health information system and project-specific registers. Key stakeholders were interviewed and the project costs were analysed. Results: The use cases for the intervention were defined in consultation with the stakeholders. Smart Glasses were used in 10% of consultations in the health centres mostly for advice during curative consultations. The total number of consultations increased significantly in the intervention health centres. The number of referrals to the hospital remained stable, but an increased proportion effectively arrived in the hospital. The Smart Glasses and moto-ambulance greatly facilitated emergency referrals, often requiring a potentially life-saving intervention in the hospital. All stakeholders involved highly valued the intervention. Conclusion: Telemedicine can contribute to improving primary healthcare services in a remote rural area, as part of a more comprehensive intervention and with intensive participation of all stakeholders. It can increase acceptability and use of the existing services; improve diagnosis, treatment, and referral of patients; and can also facilitate on-the-job training and supportive supervision.
The intervention took place in Kingandu district, a remote rural area in the DRC. Smart Glasses and a moto-ambulance system were introduced to the public health system, composed of rural health centres and a referral hospital. Health centres are staffed by nurses and midwives providing basic primary healthcare (PHC) with a strong focus on Maternal and Child Health (MCH) and care for infectious diseases. More difficult cases need a referral to the district hospital; however, due to limited road and transport infrastructure, referrals are difficult and expensive, and patients often do not arrive, or only after important delays. Malaria is by far the most frequent diagnosis, followed by respiratory infections, and diarrhoea. There are also many private clinics, mostly informal, often staffed by unqualified providers. Public services receive limited financial resources and little supplies from the government or international donors. Only a few of the staff receive regular salaries. All services have to be paid for by the users to allow for some staff income and replenishment of drug stocks. Memisa, a Belgian NGO, provided funding for investment and training and supports the overall management of the health district. The project aimed at improving the quality of services by enhancing the collaboration between health centres and the hospital. The intervention consisted of a multi-pronged strategy to improve the functioning of three health centres within the district health system by introducing in the health centres: (1) Smart Glasses to establish reliable communication to the district hospital, (2) moto-ambulances to facilitate referrals, and (3) some point-of-care tests to upgrade the diagnostic capacity of the health centre. The telemedicine solution thus used Smart Glasses (Iristick) to unlock and leverage the scarce medical expertise available in the district hospital in Kingandu to improve medical care for the population living in the catchment area of three rural health centres. It was anticipated that the intervention would improve referrals from the health centres to the district hospital; in particular, to increase successful needed referrals (for which hospital services, such as emergency surgery, are required) and decrease unnecessary referrals (for which hospital stay has no benefit for the patient, as compared to care at the health centre). Iristick, a start-up company that has developed and is producing the Smart Glasses obtained a grant of Canadian Dollars (CAD) 250,000 from Grand Challenges Canada and partnered with: (1) Memisa, a Belgian NGO that has been supporting the Kingandu district for many years, as implementer, (2) the health authorities of the Kingandu district, (3) Avanti, a satellite communication provider, and (4) the Institute of Tropical Medicine, Antwerp [18–20]. The four partner institutions conducted the project from April 2019 to December 2020. The Iristick Smart Glasses are equipped with cameras, speakers, and microphones, and after initiating the call on the smartphone, the system is completely hands-free and the health centre nurse can continue the consultation as usual while getting remote ‘over-the-shoulder’ expert advice from the hospital doctor. As the Smart Glasses are designed as an extension of a smartphone, the nurse can always use all the different features of the smartphone such as calling, WhatsApp, and immediate registration of consultation-related data. The Smart Glasses-based telemedicine system is set up as follows: A health centre nurse wearing the Smart Glasses during a consultation As there was no reliable mobile phone connection in the project area, broadband communication via satellite was installed via a solar-powered Avanti VSAT. In the district hospital and each of the three rural health centres involved in the pilot project an ‘ECO’ terminal was installed providing satellite broadband service (data speeds of 20 Mbps download and a minimum of 2 Mbps upload), using a 1.2 m antenna, 4 Ka-band satellite, and a local Wi-Fi transmitter providing a local Wi-Fi hotspot and indoor Wi-Fi Access Point. The system uses solar power cells on the roof of the health centre to power the VSAT and Wi-Fi systems. To facilitate the transport of patients needing hospital care, a moto-ambulance system was part of the intervention, covering the routes linking Kingandu’s district hospital with the three health centres participating in the intervention, which are not always accessible by car. The moto-ambulance consists of an off-road motorcycle equipped with an additional chair (trailer or sidecar) for the patient and is stationed at the district hospital. The health centres can call the moto-ambulance when needed. Initially, all consultations were performed with the routinely available diagnostic tools and medicines, including rapid diagnostic tests (RDTs) for malaria and HIV and a basic set of essential medicines. In a second phase, some additional laboratory resources were introduced in the three health centres: Hemocue HB 301 with MicroCuvette for assessing haemoglobin concentration [21], glucometer for assessing the level of glycaemia, and finger-tip pulse oximeter for assessing oxygen saturation. The intervention was introduced in three rural health centres: Sondji, Kimbimbi, and Katenda, respectively at 9, 6, and 28 km from the hospital, with an estimated population of 20,500 in the coverage areas. The implementation of the Smart Glasses pilot project was done in three phases: (1) a preparation period of five months, (2) an installation trial and training period of 12 months, and (3) a full implementation period of four months. Phase 1: Over the period April to August 2019, the project team was set up in Kingandu and prepared the project. This involved defining the precise scope and focus of the project, selecting the pilot sites, identifying and ordering the necessary equipment, consulting the different stakeholders about the project, and obtaining ethical approval. Phase 2: Between September 2019 and August 2020, the project staff organised the training of all staff involved in the use of the smartphones and Smart Glasses, installed the communication equipment (VSAT) and the solar panels, set up the processes for their safe use, and maintenance, including for calling and operating the moto-ambulances, and for use of new diagnostic tests. The system was only intermittently available during this period enabling several trial periods. Much attention was given to introducing the intervention to the community stakeholders and local authorities, and involving them in the setup of the processes. This community involvement was crucial to design the moto-ambulance system, which requires the financial participation of the community for the running costs. Also, it was decided to introduce written informed consent forms for patients receiving care. The project was initially designed to improve maternal and neonatal healthcare, especially to improve emergency care during childbirth complications. During the engagement with the community and the health staff, however, it became clear that they did not favour such specific focus and insisted on a broader application of the Smart Glasses to improve all healthcare services provided in the health centres. Consequently, three potential types of uses of Smart Glasses were identified: (1) unscheduled calls for priority and emergency advice, (2) scheduled calls during specific weekly time slots for each health centre for non-urgent advice, and (3) calls for online training and trouble-shooting between hospital and health centre staff, not only to support the introduction of the new diagnostic tools (Hemocue, glucometer, and pulse oximeter) but also for the appropriate use of RDTs and partographs. For the newly introduced diagnostic tools, initial distance training of health centre staff was provided by the hospital laboratory. First, the laboratory experts were wearing the Smart Glasses, and the health centre staff were following on their smartphones. Thereafter, the situation was reversed with health centre staff wearing the Smart Glasses while performing tests, with a laboratory technician at the district hospital following on the computer screen. Initially, there were numerous technical problems compounded by the lack of digital and technical literacy of the health centre staff, resulting in the frequent breakdown of the VSAT communication, especially due to lightning strikes and instability of the antennae due to strong winds. These problems were progressively solved, but the solar equipment did not allow for continuous 24-hour energy supply, with daily interruptions of connectivity during night-time hours. Phase 3: From September to December 2020, all processes and equipment were continuously functional and used in all sites. Project staff was still needed frequently for troubleshooting and ongoing training. We used data from the routine Health Information System of the Ministry of Health (DHIS2; national portal: www.snisrdc.com) to extract data on the utilisation of the three participating health centres. In addition, for the project, added registers were introduced to record every use of the Smart Glasses, specifying the reason, every use of the moto-ambulance, and all referrals. All activities were monitored monthly through the DHIS 2 and the added registers. Towards the end of the project, in December 2020, a participatory evaluation was organised to assess the perception of the intervention by the local stakeholders. In December 2020, an officer of Memisa, not involved in the project, interviewed 39 key stakeholders in the district about the project: health centre staff (10), hospital staff (5), community leaders (11), patients (11), and staff of the health district office (2). Semi-structured interviews were taped and transcribed. A thematic analysis was carried out by two researchers (WVD and WvdP) following the themes covered in the interviews: process of introduction of the innovation, and impact on their work and on the service to the patients. Early 2021, all relevant data were reviewed, triangulating the different data sources, reconstructing a project timeline, combined with insights from the thematic analysis of the interviews. We also analysed the project costs from the bookkeeping of Memisa, and the project reporting to Grand Challenges Canada. The project was approved by the Ethics Committee of the School of Public Health of the University of Kinshasa. In line with the demand of the Ethics Committee, no images or videos from the Smart Glasses consultations were stored; they were automatically deleted after streaming. Written consent was taken from each patient before using the technology.
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