Tele-reading

 The WFPI is collaborating with Médecins sans Frontières/Doctors without Borders (MSF) to provide pediatric imaging telereporters to support MSF’s global telemedicine network, using platforms and technology already set up in project sites. See this MSF video explaining how the system works, "bringing some of the best medicine to some of the worst off patients in the world". 

 

Three WFPI volunteers are enlisted on the Collegium Telemedicus platform to tele-read for MSF: Drs. Savvas Andronikou, Arzu Kovanlikaya and Kieran McHugh. Drs. Ronald Cohen, Farooq Chaudhry and Anne Geoffray are about to join the team as MSF tele-reading expands. Over 150 radiographs have been read to date, with subsequent exchange occurring on some cases. Projects covered are in the CAR, Tajikistan, Malawi, DRC and Cambodia. The platformworks well, though the quality of images referred is highly variable.


See WFPI's mini-symposium, "Outreach in the Developing World" for articles on MSF's tele-radiological history and quality assurance/lessons learnt. 

Discussions are underway with MSF's diagnostic imaging network for expanding WFPI's support. Our strong tuberculosis focus dovetails with MSF's massive TB drive: see here for MSF's TB overview, associated literature and films 

 

Another priority topic shared by MSF and WFPI: point of care ultrasound in lower resource settings. With field use on the rise in MSF, pediatricultrasound experts have joined under the auspices of WFPI to co-author MSF's new pediatric ultrasound manual (internal use only for now)


© Raghu Venugopal/MSF


Other MSF work

MSF sends doctors to South Africa for HIV training where pediatric imaging sessions are delivered by the WFPI.

One of WFPI's active volunteers, Savvas Andronikou (former WFPI outreach leader), assists in the production of MSF diagnostic guidelines and recently co-authored an article on a quality assessment of X-rays interpreted via tele-radiology for MSF, accepted for publication in the Journal of Telemedicine and Telecare. The growing body of MSF-led publications on tele-radiology is available here.

 

Two "Seven Minute Snippets" (short videos) on the interpretation of pediatric tuberculosis CXR films were co-produced with MSF in South Africa; now incorporated into WFPI's online library here. 

IGICH

Indira Ghandi Institute of Child Health, Bangalore, India

 

Project identified by Drs. Catherine Owens & Samantha Sonnappa, GOSH, UK. IGICH lead: Dr. Ramagatta. L. Ramesh. WFPI project lead: Dr. Cicero Silva

 

A WFPI tele-reading project is underway at the Indira Ghandi Institute of Child Health (IGICH), Bangalore, a 250 bed children hospital supported by UNICEF and WHO. The hospital's radiology department performs an average of 1000 X-rays, 500 US and 150 CT scans per month with only one radiologist onsite. Click here for more information on the IGICH. 

Update, May 2015. Since the project began:

  • 36 referrals on SUSTOL teleplatfom: mostly chest CTs, a few abdominal CTs , a few head CTs
  • 8 referrals on Collegium Telemedicus platform: mostly CT chest (infection, congenital), a few CT head  (mostly perinatal hypoxia)
  • Time range from request to report: 0 to 4d, mean 2d, median 2d excluding w/ends - i.e requested Saturday, reported Monday: = 2 days
  • Most patients: findings suspicious for tuberculosis or fungal disease Referring radiologist, IGICH: Dr. Ramesh Nayak Active WFPI volunteer readers: Drs. Aadil Ahmed (South Africa),   Jon Brandon (USA), Preeyacha Pacharn (Thailand), Cicero Silva (USA)
  • Recently joined the WFPI volunteer team: Dr. Goran Djuricic

The main issue for referrals from IGICH: internet speed. Slow!!! This holds back the flow considerably.

     
Dr. Ramesh R.L., radiologist, IGICH 
              
 
Dr. Cicero Silva, WFPI coordinator (Yale, USA)

Drs. Ramesh and Silva meet up at last! ISPR Annual Conference, Vellore, India, September 2014


Khayelitsha

Khayelitsha, Western Cape, South Africa


Project identified by Dr. Savvas Andronikou MD and the South African Society of Pediatric Imaging (SASPI)

 

Project start-up

WFPI began tele-reading chest and other plain X-rays  for Khayeltisha Hospital, Western Cape, South Africa, in July 2012. For project backround: click here. Starting with 5 South African readers, the team reached  50 volunteer tele-readers worldwide and read over 500 X-rays within a few months. Radiographs are digital, converted to JPEG. Their quality is adequat for interpretation.

Image left: Dr Harlem Gongxeca, a SASPI member and practicing pediatric radiologist in South Africa who voluntarily tele-reads for Khayelitsha and the WFPI 

Project roll-out: ups & downs!

The project wound down in early 2013 following the departure of the onsite technician (responsible for referring films to WFPI). It re-started in September 2013, with a transfer of tele-reading from WFPI to Stanford University Hospital, USA, as part of WFPI's drive to set up partnerships between facilities in lower resource and modern medical settings. Referrals come from the facility's clinicians as opposed to the technician team, resulting in a reduced flow of problem cases only: an excellent development which avoids WFPI substitution of basic imaging services and places us in a role of "provider of expert second opinions".

The activity flow has been through further stops and starts since. Each clinician needs internet access for tele-platform use, which has proven problematic. 

Update May 2015: The Stanford-Khayelitsha tele-reading partnership now operates through the Collegium Telemedicus platform. Referral levels remain low for the time being (2 cases; XR chest: infection).


 

PAST ONSITE TRAINING

As part of the preparations for WFPI's work with Khayelitsha Hospital, Savvas Andronikou delivered an on-site training session for non-radiologists in October 2012 and January 2013. The visits proved useful for exposing problems and re-orientating the WFPI’s work accordingly  and reinforced the necessity to back up WFPI tele-reading with training and education. Some can be delivered online, but onsite visits are key to success.

Project reports: click here


AUDIT & EVALUATION

WFPI has published an audit and sustainability evaluation of its tele-reading for Khayelitsha in WFPI's mini-symposium, "Outreach in Developing Countries": click here.

 

 

PROJECTS IN THE PIPELINE OR JUST STARTED

Angkor Hospital for Children, Siem Reap, Cambodia

Angkor Hospital for Children (AHC) is a 103 bed charity pediatric hospital serving children affected by poverty and disease. Founded in 1999, the hospital has grown to include a 12 bed intensive care unit, a surgery program including open heart surgery cases assisted by visiting teams, the beginnings of a cancer care program, a neonatal ward and a newly renovated and expanded outpatient department. More information can be found at www.angkorhospital.org.

AHC’s two radiology modalities are X-ray and ultrasound (no CT scanner or MRI Machine. CT scans are occasionally obtained at other facilities in Siem Reap on an as needed basis.) The good quality images are done with a very simple mobile machine. A phosphor plate system is in place, thus X-Rays and descriptions can be reached from the ward. ACH uses SONIX SP (ultrasonix) ultrasound machine with three probes:  C7-3/50 , L14-5/38 and PA4-2/20. Since its repair in early March 2014, the machine has ceased to function with Pulsed and Power Doppler. There are 15-20 ultrasound examinations/day, mainly severe  soft tissue masses and eye injuries. There is no small convex probe. Generally speaking there are no normal finding, just severe pathologies. AGH has one radiologist and plans to add an additional physician to train as a pediatric radiologist. Since November 2014, WFPI has given opinions on 24 cases, largely on plain radiographs and contrast exams with only a couple of Ultrasound studies. Opinions were returned within 24 hours (often sooner)

Site coordinator: Dr. Seng Hap. WFPI coordinators and tele-readers: Drs. Veronica Donoghue and Eva Kis. Project identified by Dr. Catherine Owens/Royal College of Radiologists, UK

© Cambodia images: George Taylor 

Other imaging interventions at Angkor Hospital for Children 

WFPI is far from the only organization to offer assistance to this facility. AHC pediatric staff members are trained by ultrasound faculty at UMass Memorial Medical Center through onsite lectures and hands on training. UMass physicians travel to Siem Reap about 3-4 times per year for onsite education. Pediatric radiologist Dr. Joe Makris has been among them. See here for more. 


May 2015: NEW!!! Laos Friends Hospital for Children

Laos Friends Hospital for ChIldren opened its doors in Feburary 2015. Set up and supported by Friends Without a Border (as is Angkor Hosital for Children in Cambodia, above), LFHC is the first full-service pediatric hospital in northern Laos, offering inpatient & outpatient departments, 24 beds, emergency room, intensive care unit, operation theater, laboratory, pharmacy, radiology, lecture rooms & library to teach pediatric medicine to the future leaders of the hospital, kitchen & laundry for families visiting the hospital, and a vegetable garden to teach families how to prepare nutritious meals. See Friends Without a Border website (here) for more background information on the initiation of this new and much welcomed hospital. 

As of mid-May 2015: LFHC offers a growing outpatient clinic seeing up to 100 patients per weekday (which includes approximately 5-10 ultrasounds and 5-10 radiographs per day). Any patient requiring inpatient care is immediately transferred next door to the adjacent Provincial Hospital which has its own radiology department. This Provincial Hospital department is staffed by approximately 6 radiographers who perform both the radiographs and ultrasounds. The ultrasounds are interpreted by the radiographer with an example image(s) often printed and sent with the patient including an interpretative hand-written note, while the X Rays are sent back with the patient to be interpreted by the ordering MD. This radiographer team has no specific pediatric radiology training, and the hospital has no onsite radiologist. Subspecialty pediatric care is available in the capital of Vientane, 340 km and several hours by vehicle away, the transportation cost of which is prohibitive for many families in the region (despite government- provided health care for children under the age of 5). 

RAD-AID's pediatric coordinator for Asia, Dr Michael Reiter, visited LFHC in May 2015 to assess future collaboration and support. Following the visit, Dr Reiter and LFHC contacted WFPI for tele-second opinions for LFHC's embyronic imaging department (the hospital does not have a radiologist hired yet to interpret the images for a newly installed US and portable radiography unit). First referral (neuro X Ray) received on 23rd May! Watch this space.  

More information on this project is available here.


Bustamante Children's Hospital, Kingston, Jamaica

Bustamante Children's Hospital offers 283 beds, including 5 in the ICU. The hospital is usually overcrowded and has long waiting times for diagnostic and medical interventions as well as outpatient consultations. The Accident and Emergency department operates on a 24/7 basis and sees approximately 77,000 patients per year.

The imaging department serves an overwhelming number of about 4000 patients for examinations per month from all over the Island (the vast majority is outpatient). CT scans and MRIs are done on about 80 and 20 pediatric patients respectively per month. Update May 2015: 2 casesreferred; MR brain and spine: tumor, multiple sclerosis. MRI machine broken down for many weeks. 

Site coordinator: Dr. Marcia Lawrence. WFPI coordinator: Dr. Ramon Sanchez. Project identified by Dr. Ramon Sanchez and PAHO/WHO.

Click here for more information 

  

 

Hospital de Cobán, Alta Varapaz, Guatemala

This hospital is the only third level hospital in the region. It offers 180 beds, 1 general radiologist, 1 U/S, an X-ray room, 1 portable X-ray. The site is non-digital. CT belongs to a large private group and cases are sent and read outside (external PACS). More details available here

Compute internet access is hampering the referral of images from Cobán: the team prefers to refer via mobile phone applications for now. (See below). Update May 2015: average of 1 referral received/month via WHATSAPP, combination of plain film cases, CT and MRI. More X Ray than anything else. 

Site coordinator: Dr. José Pineda, WFPI coordinator: Ramon Sanchez. Project identified by Dr. Ramon Sanchez.


 

Centro de Salud Santa Clotilde (CSSC), Napo River, Peru.


This 30-bed hospital includes a general medical area, a labour and delivery room, an operating room, a clinic and a laboratory. The CSSC is the head of a network of 12 health facilities along 400km of the Napo River and serves 100+ villages and a population of over 20,000. In 2010 there were 15,000 outpatient visits and 903 admissions to the hospital with 62 deliveries and 71 surgeries. Patients unable to be treated at the CSSC are stabilized and transferred to Iquitos via a one day boat trip and if needed flown to Lima. The Centre offers 1 U/S machine and no X-ray machine (work in progress). Update May 2015: 4 cases referred; CT head, CT chest, XR chest, US fetus: varied pathology

 
Site coordinator: Dr. Brian Medernach, WFPI coordinator: Dr. Ramon Sanchez. Project identified by Dr. Ramon Sanchez 

   More images here

    

  

Palestine

Following Dr. Aadil Ahmed's visit to Gaza in June 2013, WFPI is now providing tele-opinion support to Nasser Children's Hospital with extension to Rantissi Hospital planned. The team from SIDRA Medical and Research Centre, Doha Qatar, plan to join this tele-reading team; there are hopes for later onsite training. Update May 2015: 1 case referred; XR chest: surfactant deficiency. It is hard to maintain contact with this facility, especially given its "hot spot" location. WFPI remains on standby with its support.


 

CT, Rantissi Hospital, Gaza


Site coordinator: Dr. Hossam Ahmed ELNajili, WFPI coordinator: Dr. Aadil Ahmed. Project identified by Dr. Aadil Ahmed.



Wendy Fitzgerald Paediatric Hospital, Trinidad 

This pediatric hospital, managed by a regional health authority, is part of the national health system. It is the only pediatric facility for 2 regions (out of 5) and offers 275 beds. There are 7 general radiologists on its staff. A new national children's hospital is under construction and will eventually offer all pediatric imaging services. The 9 year old 16 slice CT is in working order. Pediatric CTs and sonography are performed in a separate building in the nearby campus of the Eric Williams Medical Sciences Complex. There is a plain radiology unit in the emergency department of the Wendy Fitzwilliam Paediatric Hospital. Update May 2015: 1 case referred; XR pelvis: femoroacetabular impingement

Site coordinator: Dr. Paramanand Maharaj, WFPI coordinator: Dr. Ramon Sanchez. Project identified by Dr. Ramon Sanchez and PAHO/WHO.

Click here for more details





The needs are vast - yet uptake slow.... What's the deal with telereading?

Telereading has not always proved the hoped-for panacea in terms of providing affordable and ongoing imaging support to medically underserved areas and the difficulties this entails. 

Apart from the key challenge of lack of control over image quality/safety at the radiology-site, which limits the usefulness of remote interpretation, there is also a frequently observed reluctance to implement teleradiology referrer-side. RAD-AID, in its 2013 White Paper, suggests that this could come from the
suspicion in many countries that outside interpretation (i) lacks accountability, (ii) drains local health care economy of necessary expertise, and (iii) distorts communication across health care providers when radiology personnel are physically absent.

WFPI would add an item to this list: access to computers with internet. Many Ministry of Health cannot secure this access easily, and when they do, their internet bandwidth speed is cripplingly slow. Already challenged by financial issues and towering patient loads, there is simply little time to spare for the hours required uploading.


It bears noting that when tele-reading passes through an NGO (MSF/DWB, Imaging the World), with project-dedicated, remunerated staff onsite, the sky is potentially the limit in terms of telereading flow! Is this "middle man" a necessity or can we find success when working directly with MOH/other facility staff?

To this end, WFPI is planning research on secured mobile applications, including one offered by our tele-reading platform Collegium Telemedicus. Hopefully this will facilitate many sites that need imaging support but do not have the facility-based infrastructure required to receive tele-opinions. Smart phones, however, are ubiquitous. 


Dr. Isabel Jimeno, a pediatrican, kindly allowed us to enlist her services to help Collegium Telemedicus develop its mobile interface during her recent 6 months' work in Equatorial Guinea.

Smart phones: who doesn't have one?

The situation has been pithily summed up as follows: "The great leveller: New information technologies are reaching the world’s poor much faster than food and toilets. A recent UN report suggested six billion people have access to mobile phones, while only 4.5 billion have access to working toilets. There are around one billion mobile phones in both China and India. Africa is home to twice as many mobile phones as the United States and is the most advanced continent when it comes to “mobile money”. Developing countries accounted for 80 percent of new mobile subscriptions in 2011, with the number of Internet users doubling over a four year period. Technology offers great potential to enhance education opportunities, dramatically improve health outcomes, promote free speech and democracy, and offer greater access to global markets. The Internet is the key driver of global connectivity and opportunity, but different bandwidth speeds, limited access, and contrasting levels of openness can mean that the Internet exacerbates rather than offsets inequality." ("Now for the Long Term", a report written by the Oxford Martin Commission for Future Generations, Oct 2013)



There is an increasing body of literature on tele-reading outcomes and the spread to mobile phones which we will keep posting and hopefully add to! CLICK HERE for what we have so far.