Design and Evaluation ofTwo Way Interactive Video     eConsult System        (TWIVES)    A Web-Based Care and Continuity S...
Agenda• Introduction    o About Telemedicine• Research Question• Development of TWIVES    o Development Process    o Techn...
Introduction•   There are critical shortages of healthcare providers in developing countries    (WHO, 2006)•   Shortages o...
About Telemedicine•   The American Telemedicine Association defines Telemedicine as the    use of medical information exch...
Modes of Telemedicine       Store and                                  Real Time       Forward• “Store and Forward"       ...
Previous Work in                 Telemedicine• Underserved regionsTelemedicine enabled people in rural areas, conflict and...
Telemedicine in Canada•     The cost of referring patients has been estimated to be 10-20 times      higher than using tel...
Telemedicine in          Developing Countries•     Telemedicine has been used for many years to support in developing     ...
Research Question•    Given the significant cost associated with the setup of telemedicine     networks, how feasible is i...
Development of TWIVES               Planning   Design   DevelopmentKen Nwosu P.Eng, MBA                             10
PlanningKen Nwosu P.Eng, MBA              11
DesignKen Nwosu P.Eng, MBA            12
DevelopmentKen Nwosu P.Eng, MBA                 13
Technologies Utilized•     Drupal Framework       o On Open source LAMP•     Video Whisper Script       o On Open source R...
Landing Page ViewKen Nwosu P.Eng, MBA          15
User Registration and      Consultation ProcessKen Nwosu P.Eng, MBA          16
Video Consult ViewKen Nwosu P.Eng, MBA          17
Simulations and Testing•     Internet Connection Bandwidth Test•     Bandwidth Emulation Tools - Sloppy•     Slow Internet...
Analysis and Discussion• Landing Page Analysis                          PingdomKen Nwosu P.Eng, MBA                19
Analysis and Discussion• Page Speed Performance                           PingdomKen Nwosu P.Eng, MBA                 20
Analysis and Discussion• Server Load Time Analysis                              Pingdom Ken Nwosu P.Eng, MBA              ...
Analysis and Discussion• Size and Request Analysis                              Pingdom Ken Nwosu P.Eng, MBA              ...
Analysis and Discussion• Web Browser TestKen Nwosu P.Eng, MBA       23
Analysis and Discussion• Web Browser Market ShareKen Nwosu P.Eng, MBA         24
Analysis and Discussion• Page Load Times at Different Internet Connection  Speeds Ken Nwosu P.Eng, MBA                    ...
Analysis and Discussion• Test Results at Various Charles-Simulated Low Speed  Connections Ken Nwosu P.Eng, MBA            ...
Limitations•     TWIVES has not been tested using human subjects•     Technical tests conducted in simulated low bandwidth...
Conclusions•     TWIVES was a proof of concept intended to examine the suitability      and feasibility of developing a lo...
Further work•     Full feasibility and Usability testing      •   Using WC3 standards in the areas of privacy, internation...
Ken Nwosu P.Eng, MBA   30
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Two Way Interactive Video eConsult System (TWIVES) - for direct patient-provider consultation online

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TWIVES is a web-based video consult application for rural and remote care that allows a patient to connect with remotely. TWIVES offers a cost effective solution that patients can potentially use from the comfort of their homes and does not depend on elaborate hardware and specialized software. This in essence removes the need to commute from rural and remote communities to cities or facilities, for consultations. With a simple Internet device, community health workers who are registered with TWIVES, as well as enrolled patients, can connect with and access the services of healthcare providers at distant locations for delivery of care.

Download a copy of the thesis developed on this at: http://digitalcommons.mcmaster.ca/opendissertations/7280/

YouTube Version of Presentation:
http://www.youtube.com/watch?v=Bnyqi2VME2w

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  • Real time telemedicine can work in a more efficient way for psychiatry, internal medicine, rehabilitation, cardiology, pediatrics, obstetrics, gynecology and neurology (Ullah, Khan, Sultana, & Kwak, 2009).
  • LAMP is an acronym for a solution stack of free, open source software, referring to the first letters of Linux (operating system), Apache HTTP Server, MySQL (database software) and originally Perl (but now sometimes PHP or Python), principal components to build a viable general purpose web server.
  • Linux (operating system), Apache HTTP Server, MySQL (database software) and originally Perl (but now sometimes PHP or Python) which are principal components to build a viable general purpose web server.
  • At 28.2kbps, it took TWIVES 4100 milliseconds in total to load the application when the request was placed on the IP address. The request itself took 3660 milliseconds and TWIVES responded in 40 milliseconds after that. Latency was at 395 milliseconds and the actual initialization of the Video Interface occurred at a relatively slow rate (1.94KB/s) and the response speed between the two way conference links was 6.52 milliseconds. The positive result though is that once connection was made, the link remained stable enough for the duration of the transaction.
  • Two Way Interactive Video eConsult System (TWIVES) - for direct patient-provider consultation online

    1. 1. Design and Evaluation ofTwo Way Interactive Video eConsult System (TWIVES) A Web-Based Care and Continuity Solution Enabling Secure and Private Patient-Provider Connections When Mobility is Limited or Commuting is Not an Option Kenneth Nwosu B.Eng., MBA
    2. 2. Agenda• Introduction o About Telemedicine• Research Question• Development of TWIVES o Development Process o Technologies Utilized• Analysis and Discussions• Conclusions & Recommendations Ken Nwosu P.Eng, MBA 2
    3. 3. Introduction• There are critical shortages of healthcare providers in developing countries (WHO, 2006)• Shortages of healthcare providers in rural and remote communities are usually due to migration to urban centers (Ehman & Sullivan, 2001)• Expecting excess providers from urban centers to spillover to remote areas has been shown to be ineffective in solving this workforce problem (Strasser et al, 2009)• For some patients, travelling to see a healthcare provider could be difficult due to cost and may not even be an option (Lightman et al, 2005)• Task shifting - transfer of primary care roles to community health workers - is prevalent in remote settings for efficient use of available human resources (Mit, Rony, & V., 2008) Ken Nwosu P.Eng, MBA 3
    4. 4. About Telemedicine• The American Telemedicine Association defines Telemedicine as the use of medical information exchanged from one site to another via electronic communications to improve patient health status (ATA, 2011).• Shreveport (2011) defines telemedicine as the delivery of healthcare and the exchange of healthcare information across distances.• Telemedicine encompasses diverse varieties of services delivered to the patient when distance is an issue (Cipolat & Geiges, 2003).• Sorrells-Jones et al (2006) further added that videoconferencing, transmission of still images are considered part of telemedicine and Telehealth. Ken Nwosu P.Eng, MBA 4
    5. 5. Modes of Telemedicine Store and Real Time Forward• “Store and Forward" • Real time telemedicine proves to be very requires the presence of efficient in cases where both parties at the same immediate response is time (Kale, 2010) not required (J.C. Lin, 1999)Ken Nwosu P.Eng, MBA 5
    6. 6. Previous Work in Telemedicine• Underserved regionsTelemedicine enabled people in rural areas, conflict and crisis areas, the “Third World”, and on airplanes and boats to be cared for and treated by medical facilities located far away (Schmid-Grendelmeier et al, 2000).• Critical CareAn intensive care specialist provided daily consultations to patients in a small private hospital using a two-way audiovisual link (Grundy et al., 1977)• Home MonitoringHome monitoring via telephone and television allows doctors to observe the patient’s vital signs (Michaels, 1989)• Mobile TelemedicineMobile telemedicine enabled the care provider of cardiac patients to provide remote non-invasive cardiac diagnostic services, using a smartphone gateway (Sparkes, Valaitis, & McKibbon, 2012) Ken Nwosu P.Eng, MBA 6
    7. 7. Telemedicine in Canada• The cost of referring patients has been estimated to be 10-20 times higher than using telemedicine, due to travelling and accommodation cost and missed income (Kruger & Niemi, 2012)• In Canada, the Ontario Telemedicine Network (OTN) has been very successful at reducing the need for patients to travel to specialists (OTN, 2012c)• However OTN telemedicine studios are located at Health centers and hospitals requiring travel for participants• The enabling technology to facilitate remote patient-provider encounters are now available Ken Nwosu P.Eng, MBA 7
    8. 8. Telemedicine in Developing Countries• Telemedicine has been used for many years to support in developing world (Wootton et al, 2011)• Most of the systems often use ordinary email for obtaining specialist advice from other consultants or colleagues in other countries (Bonnardot & Wootton, 2010).• Results of medical specialist consultations sampled from several rural clinics located throughout India indicate that remote expert opinions can improve the speed and accuracy of diagnosis (Amble et al, 2004) Ken Nwosu P.Eng, MBA 8
    9. 9. Research Question• Given the significant cost associated with the setup of telemedicine networks, how feasible is it to develop a web-based solution for community health workers and patients in rural and remote areas, including developing nations, in an environment of low speed Internet connections, limited infrastructure, and relatively small budgets for eHealth systems? Ken Nwosu P.Eng, MBA 9
    10. 10. Development of TWIVES Planning Design DevelopmentKen Nwosu P.Eng, MBA 10
    11. 11. PlanningKen Nwosu P.Eng, MBA 11
    12. 12. DesignKen Nwosu P.Eng, MBA 12
    13. 13. DevelopmentKen Nwosu P.Eng, MBA 13
    14. 14. Technologies Utilized• Drupal Framework o On Open source LAMP• Video Whisper Script o On Open source Red5 RTMP Server Ken Nwosu P.Eng, MBA 14
    15. 15. Landing Page ViewKen Nwosu P.Eng, MBA 15
    16. 16. User Registration and Consultation ProcessKen Nwosu P.Eng, MBA 16
    17. 17. Video Consult ViewKen Nwosu P.Eng, MBA 17
    18. 18. Simulations and Testing• Internet Connection Bandwidth Test• Bandwidth Emulation Tools - Sloppy• Slow Internet Simulation – Charles• Page Load Analysis - Pingdom• Web Browser Testing - Chrome, Firefox and Internet Explorer Ken Nwosu P.Eng, MBA 18
    19. 19. Analysis and Discussion• Landing Page Analysis PingdomKen Nwosu P.Eng, MBA 19
    20. 20. Analysis and Discussion• Page Speed Performance PingdomKen Nwosu P.Eng, MBA 20
    21. 21. Analysis and Discussion• Server Load Time Analysis Pingdom Ken Nwosu P.Eng, MBA 21
    22. 22. Analysis and Discussion• Size and Request Analysis Pingdom Ken Nwosu P.Eng, MBA 22
    23. 23. Analysis and Discussion• Web Browser TestKen Nwosu P.Eng, MBA 23
    24. 24. Analysis and Discussion• Web Browser Market ShareKen Nwosu P.Eng, MBA 24
    25. 25. Analysis and Discussion• Page Load Times at Different Internet Connection Speeds Ken Nwosu P.Eng, MBA 25
    26. 26. Analysis and Discussion• Test Results at Various Charles-Simulated Low Speed Connections Ken Nwosu P.Eng, MBA 26
    27. 27. Limitations• TWIVES has not been tested using human subjects• Technical tests conducted in simulated low bandwidth environments• Not all identified features were implemented Ken Nwosu P.Eng, MBA 27
    28. 28. Conclusions• TWIVES was a proof of concept intended to examine the suitability and feasibility of developing a low cost video consult system that could be applied in rural communities with limited access to healthcare facilities, health providers and Internet resources.• TWIVES POC accomplishes those goals, offering a sleek user interface, a solution appropriate for restricted bandwidth, and a simplified process for registration and consultation management• TWIVES performed well in simulated low-bandwidth settings. Ken Nwosu P.Eng, MBA 28
    29. 29. Further work• Full feasibility and Usability testing • Using WC3 standards in the areas of privacy, internationalization and web accessibility• Rollout and use in an actual remote setting• Benefit Evaluation Ken Nwosu P.Eng, MBA 29
    30. 30. Ken Nwosu P.Eng, MBA 30

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