LESSONS LEARNED FROM RUNNING A WORKSHOP TO DISSEMINATE A TELEMEDICINE APPLICATION

LESSONS LEARNED FROM RUNNING A WORKSHOP TO DISSEMINATE A TELEMEDICINE APPLICATION Sruti Sridhar, Biomedical Engineering Student, Padmashree Dr. D.Y.Patil University, Mumbai, India Email: sruti.sridhar@gmail.com Chetan S. Sankar, Professor, Department of Management, Auburn University, AL 36849, USA Email: sankacs@auburn.edu Jagjit S. Bhatia, Executive Director, CDAC-Mohali, India Email: jsb@cdacmohali.in Sanjay Sood, Coordinator of Healthcare Information and Electronics Division and Head, the Academic and Consulting Services Division, CDAC-Mohali, India Email: spsood@gmail.com ABSTRACT A case study on telemedicine was presented at a workshop to medical practitioners, students, and telemedicine software developers in India. This paper provides the results of an evaluation of this workshop and discusses how such efforts can serve patients in rural areas in developed and developing countries. Keywords: Telemedicine, Pedagogy, Workshop, Evaluation, India INTRODUCTION Telemedicine is the use of audio, video, and other telecommunications and electronic information processing technologies to provide health services or assist health care personnel at distant sites [1]. Telemedicine is particularly of greater importance in a developing country like India where 90% of secondary & tertiary healthcare facilities are in cities and towns away from the rural areas, where almost 70% of the population lives. Rural areas struggle with providing basic sanitation and healthcare services despite various efforts in this direction. Some of the reasons leading to this lack of adequate healthcare facilities include the high cost of health care and lack of investment for it in rural areas, the difficulty of doctor retention in rural areas, the lack of fiscal incentives for specialist doctors to practice in rural areas, the lack of cultural and economic attractions in such rural areas and various geographical barriers. Thus adapting telemedicine on a wider scale will be a suitable solution and will help in revolutionizing the healthcare setup not only in rural India, but also in the rural regions of the USA (e.g., Appalachia) and various geographically isolated and remote areas (e.g., much of Alaska and Canada). 2281

One of the major steps towards popularizing telemedicine would be to effectively disseminate the knowledge of telemedicine to various healthcare professionals and students. Inclusive case studies that bring real world issues into the classrooms and encourage students to think and develop solutions are one of the important tools that can be used to do this. We prepared a case study entitled Sanjeevani: Telemedicine Applications in Medical Diagnostics and Specialty care based on these principles. The case study highlights various issues like the need for adequate and timely funding, the cooperation between various technical and medical personnel, the need for trained staff, concerns about political, legal and ethical aspects, medical liabilities etc that have to be coordinated to ensure the smooth operation of any telemedicine venture. This paper discusses the case study development and the use of this case study in a workshop attended by practitioners and graduate students. It also provides the results of an evaluation of the workshop and discusses how the workshop format could be improved to meet the educational objectives in a better manner. The paper concludes by discussing how students can benefit from use of such instructional methodologies in their classrooms. DEVELOPMENT OF THE CASE STUDY DURING SUMMER 2009 During the summer of 2009, the case study entitled Sanjeevani: Telemedicine Applications in Medical Diagnostics and Specialty Care was developed by a faculty member and students from Auburn University with help from CDAC-Mohali management. The study attempts to bring attention to the rapidly expanding field of telemedicine. It discusses how important telemedicine can be in remote areas, where patients have little or no access to specialized medical care. For a telemedicine venture to be successful, many factors, like the technology (hardware, software, biomedical instruments and communication links), the finances, and the concerned individuals involved (the physician, specialist, patient and developers) have to work in concert. In addition, legal, ethical, and political issues must be suitably resolved. The case study sheds light on this coordination by telling a story from the eyes of the patient, the primary healthcare provider, the specialist, and the software developer. By exploring the story of a patient consultation from each perspective, a student can formulate a greater understanding of telemedicine capabilities and applications. The case study explains the interactions that must take place for a patient examination to be conducted remotely. The patient and physician must explain the situation to the specialist through a videoconference or store-and-forward method. The specialist then has to recommend diagnoses to the physician, and decide if the patient needs to be seen in person. Finally, the software developers and administrators work to improve the systems after hearing the doctors' criticisms and suggestions. Learning about these interactions can be very useful for both prospective engineers and physicians, as they will likely encounter professionals from various disciplines many times in their careers. The case study reflects on the benefits that telemedicine offers to both doctors as well as patients. The study also examines some of the difficulties associated with implementing and using a telemedicine system. Privacy and security are especially important concerns, as are some of the 2282

ethical issues that arise from telemedicine use. It also examines how doctors implement various technologies and use them in their own line of work. This case study is available for use by faculty members and students without charge from www.liteecases.com. Course placement Students pursuing computer, MIS, software, biomedical, or wireless engineering fields would likely benefit the most from technical aspect of the case study. The study examines some of the real-world problems that arise from modern technology and its use by individuals who lack a technical background. The study can also be beneficial for students interested in medical and healthcare related fields. IMPLEMENTATION OF THE CASE STUDY WITH PRACTITIONERS AND STUDENTS USING A WORKSHOP In order to evaluate the utility of the Sanjeevani case study in training biomedical engineering and medical students and other healthcare professionals, a workshop entitled Bringing Theory and Practice Together Using Telemedicine Applications was conducted at CDAC, Mohali by two faculty members from Auburn and Southern universities. The workshop leaders were experts in case study methodology, experienced in leading teams, and enthusiastic about the topic. It was a one-day workshop conducted on 18th August 2009 at CDAC, Mohali. The goals of the workshop were for participants to: (1) Obtain experience on the use of telemedicine applications, (2) Explore new applications for telemedicine in India & other developing countries, (3) Use case study methodology to come up with new ideas, (4) Work on teams to achieve objectives, and (5) Understand telemedicine from different perspectives. Twenty-six medical practitioners, administrators, graduate business students specializing in telemedicine, MIS personnel, and software developers attended this workshop. The participants were recruited by CDAC-Mohali and were not charged any fees for attending the workshop. The number of participants was limited to fewer than 25 so that the participants could work in teams, so some potential participants had to be turned down. The group could be termed heterogeneous, as the participants of the workshop were from different disciplines of healthcare. However, this heterogeneity served as a very important factor in understanding telemedicine from each of their points of view during the participants interactions. The duration of the workshop was one day, which was divided into 4 sessions. The sessions were structured to ensure that the participants got a comprehensive idea of telemedicine in developing countries. Session I focused on the Importance of Telemedicine in India & Cameroon: Status & Progress. Session II was entitled Teaming Session and Case Study Assignment. This session concentrated on the importance of teamwork. The case study materials were handed over to the participants at the end of this session. Session III required the participants to analyze the case studies and make group presentations. Session IV involved an interactive question and answer session, a quiz, and a discussion about e- Sanjeevani and the future of telemedicine. A computer 2283

and overhead projector were needed to conduct the workshop. The workshop leaders used several exercises to foster team work among the participants. Assignment Scenario provided to the participants: The assignment provided to the participants was as follows: Sanjay Sood stated on August 1, 2009, I got a call from Dr. I.J.S. Bhatia - the nodal officer at Mohali hospital. He confirmed to me that the Broadband connection at their telemedicine centre has been withdrawn. Similarly the connections across the telemedicine centers at all the hospitals in the State (18 sites - hospitals) have been withdrawn too. The telemedicine project has come to a standstill. The reason for this is nonpayment of telecom bills from past 2 months (the project finished on 30th April 2009). To the best of my understanding, the connectivity will get restored only after the funding is received from the Ministry of Information Technology. The project review and steering group meeting is scheduled on 7th August (in Delhi) and the decision would be taken at this meeting. Meaning that at present only one link (CDAC to PGI) is working. All others are temporarily down (till the connectivity is restored). The funding required is Rs. 10 lakhs/month. The participants were assigned to the following four groups and had to assume the role of a patient, a primary care physician, CDAC s development team leader or the director of CDAC: Group 1: Assume the role of a patient living at Ropar, Punjab, with an illness that requires specialist medical assistance. Explain the advantages and disadvantages of using a telemedicine system at a local clinic versus travelling to PGIMER (a specialist hospital) in Chandigarh for treatment. Propose suggestions that CDAC may employ to minimize the effects of the disadvantages, while maximizing the advantages. Group 2: Assume the role of a primary care physician working in a district hospital at Ropar. Discuss the advantages & disadvantages of using CDAC s telemedicine system, and propose suggestions to improve the system s performance. Group 3: Assume the role of CDAC s development team leader. Analyze the current operations and discuss steps that can be taken to popularize and improve telemedicine in India. Please provide revenue-generating schemes so that the Sanjeevani system can be self-sustaining. Group 4: Assume that you are the director of CDAC-Mohali negotiating with a mobile phone company provider to enhance patient compliance using the Sanjeevani system. Patient compliance-- adherence to a regimen of physician-recommended care and continued over time -- has been a common concern in medical practice for over decades. While patient compliance has been much studied, little seems to have been done in everyday practice by the healthcare community. The National Health Interview Survey revealed that 56 million individuals between 18 and 65 have one or more of 12 chronic illnesses including heart disease, diabetes, arthritis, cancer, stroke, emphysema, hypertension, asthma, bronchitis, liver condition, server migraines, and depression. Presently, only 40% of the people with chronic disease comply with their physician s recommendations, irrespective of disease, treatment, age, or sociocultural considerations. Produce a list of recommendations on how mobile technologies & Sanjeevani can be used to enhance patient compliance. Analysis of the Case Study by the Participants The groups were given a one-hour duration in which they were to analyze the case study provided to them and make group presentations providing solutions to the tasks given to them. 2284

The 26 participants were divided into four teams with participants from administration, practice, students, and laboratory joining each team. The teams were formed in a manner so that at least one administrator, one R&D person and one physician were in each team. The team members were provided access to a computer room and discussed the case study and their assignments for an hour. After an hour, they developed PowerPoint slides and made presentations. The first team, representing role of a patient decided to play-act the scenario. They were able to show the difficulties a patient might have when using a telemedicine system, such as the line breaking in the middle of the consultation. They also displayed the difficulties encountered when the patient and the doctor might be conversing in different languages. This short play of theirs depicted the usage of a telemedicine system in a rural set-up. The second team, representing the primary care physician, also decided to play-act the scenario provided to them. Some of the team s members were doctors, so they presented a play that was very accurate in medical aspects that at the same time conveyed the importance of a primary physician in telemedicine applications. They emphasized how important it is for a physician to convince the patient to use telemedicine and make them comfortable in using the technologies to diagnose the problem. The third team representing the CDAC development team leader discussed the steps that can be taken to popularize and improve telemedicine in India. They provided several suggestions to make the Sanjeevani system self-sustaining. The fourth team representing the director of CDAC-Mohali displayed a very clear understanding of the scenario presented to them. They generated ideas on how mobile technologies can be integrated into the software system so that patients are reminded to take their medicines on time and to provide feedback to the doctors and nurses about the compliance behaviour. They offered several innovative proposals for using the technologies to enhance compliance behaviour. In summary, the participants were enthusiastic about the assignments given to them, were able to grasp the contents of the case study, and made well rounded presentations. While the first two teams focused on the medical aspects and the difficulties in using the telemedicine system from the point of view of the patient and the primary care physician, the other two teams focused on improving the technologies used in telemedicine. On the whole, after completing their assignments and watching the other teams presentations, the participants understood telemedicine from different perspectives. Finally, a short quiz session of about 5 minutes was incorporated as a part of the workshop. The quiz served the following purposes: review the key facts and concepts about telemedicine in an entertaining manner and refresh the participants from a very intense teaming session and presentation. EVALUATION OF THE WORKSHOP S EFFECTIVENESS An evaluation questionnaire was developed based on a past study. This questionnaire was provided to the participants at the end of the session. Analyzing the results leads to four findings: 2285

The case study pedagogy was a valuable method of delivering information on telemedicine applications A workshop on telemedicine applications motivated the participants to use the system in future Hands-on exercises were needed to convince the participants to use telemedicine in their practice, and Workshop logistics could have been improved CONCLUSIONS The workshop serves as a place for brainstorming and coming up with innovative solutions for current problems. Discussions with experts widen participants knowledge and stimulate the participants to come with innovative ideas and solutions. For example, during the interactive session of the workshop, the discussion veered towards the application of haptics in telemedicine when a particular participant (a medical college professor) expressed the absence of physical contact between the patient and the doctor during video consultations. Such discussions open new avenues for research and innovation. The results of the evaluation conducted show that using case studies in workshops is helpful to the participants in learning about effective implementation of telemedicine practices. The teaming exercise complemented the case study. In the absence of the case study and the accompanying teaming exercise it would have been difficult to explain the importance of telemedicine effectively, given the duration of one day. Only having speakers to impart knowledge about telemedicine would have been monotonous and a come and go experience, as one participant described. It was due to the case study cum teaming exercise approach of the workshop that the participants perceived that they were fully involved in the entire process. Such workshops that include case studies as part of the instructional pedagogy have the potential to motivate students and faculty members to innovate and discover new devices, instruments, and systems so as to serve patients in rural areas in developed and developing countries. Acknowledgements The material presented in this article is based partially upon work supported by the National Science Foundation under grant numbers: OISE 0623351, OISE and the Institute for STEM Education and Research. Any opinions, findings, and conclusions or recommendations expressed in this paper are those of the authors and do not necessarily reflect the views of the National Science Foundation. We also thank Victor Mbarika, for presenting a keynote speech at this workshop and working with us on this project. REFERENCES 1. Sood, S.P. Telemedicine Engineering, Presented at National Conference on Computers and Devices for Communications-2001 (CODEC-2001) (21-23 February, 2001) at Regional Engineering College, Jalandhar, India. 2286