Feasibility of developing a pediatric telehealth network in Honduras with international consultation support

Introduction: Honduras is the second poorest country in Central America, and roughly 50% of the population lives in rural areas. A telehealth network linking these areas to larger health centers may improve patient access to care, and physician access to educational opportunities. This pilot study assessed the feasibility of establishing a pediatric telehealth network between underserved clinics in Honduras and the Medical University of South Carolina (MUSC). Methods: Two underserved Honduran clinics were identified and invited to participate in the telehealth network. Providers from these clinics connected remotely to educational conferences at MUSC, and received teleconsults from MUSC physicians and physicians from the other Honduran site. Honduran providers completed five-point Likert scale satisfaction surveys following participation in the conferences and teleconsults. Results: Survey feedback was positive, with 100% of respondents stating they would utilize telemedicine in the future. Dissatisfaction was expressed subjectively in the survey comments with regards to poor Internet connectivity and unreliable electrical power. Conclusions: The establishment of a telehealth network between Honduras and MUSC is feasible, and rural providers were receptive to the clinical and educational opportunities this network provides. Future projects will expand telehealth capabilities to other Honduran sites and focus on intra-country collaboration to ensure sustainability.


Introduction
'Telehealth' is a term that refers to the electronic delivery of clinical and educational health resources to remote regions 1 .Telehealth has been used extensively in recent years in developed countries for both clinical and educational purposes [2][3][4][5] .Linking patients in rural and underserved areas to remote physicians may address the lack of access to quality care 6,7 and poor health outcomes 8 , which are common in these regions.In addition to connecting distant providers with international specialists for clinical support, telehealth could also increase communication between regional healthcare facilities, thereby strengthening local professional interactions and mitigating the sociocultural differences that intercountry interactions typically entail 9,10 .In addition to providing clinical support, telehealth offers a means for distance learning and training.Continuing medical education (CME) opportunities through telehealth may encourage providers to remain in or return to remote and underserved areas 11,12 .Telehealth programs have been found to be cost effective for certain patient populations 13,14 and cost neutral for others 3 , and are well received by patients and providers alike 15,16 .Certain barriers exist that make the implementation of telehealth programs challenging.Limited Internet connectivity, unreliable electrical power, low bandwidth, lack of technical experience, and cultural and language barriers are often cited reasons that telemedicine programs are slow to succeed 17 .
Honduras in particular lacks adequate access to health services, with a coverage rate of nine physicians per 10 000 population in 2008 18 .Approximately 50% of the population lives in rural areas, which are especially deficient in access to health care and basic health infrastructure.In 2013, the infant mortality rate in Honduras was 18 deaths per 1000 live births and the under-five mortality rate was 19 per 1000 live births, significantly higher than the regional average 19 .These statistics suggest that Honduras would greatly benefit from the establishment of a telehealth network, particularly one that aims to improve regional professional communication.
Little data exist regarding telehealth in Honduras, particularly networks that connect providers within the country.
The purpose of this study was to assess the feasibility of establishing a telehealth network between underserved sites in Honduras and the Medical University of South Carolina (MUSC).The ultimate goals of the telehealth network are to facilitate a bidirectional education exchange, and to improve access to primary and specialty care for underserved pediatric patients in Honduras.

Establishment of a telehealth network
In February 2015, investigators from MUSC established network connectivity at Cliníca de Especialidades y Neurocentro, an inner city neurology clinic in Tegucigalpa, and Clínica el Buen Pastor, a rural community health clinic in Santa María del Real, Olancho.The Honduran coinvestigator identified both sites as clinics that are committed to caring for underserved populations.Investigators delivered a computer and monitor, a medical examination camera with lens and a Logitech BCC950 web camera (Logitech; http://www.logitech.com/en-au/product/conferencecam-bcc950)to both of the participating sites.VidyoDesktop v3.4.0 videoconferencing software (Vidyo, Inc.; https:// www.vidyo.com/video-conference-systems/vidyodesktop)was installed on the computers at both Honduran sites and at MUSC.MUSC IT personnel trained at least two Honduran providers from each site to use the network equipment.

Educational conferences
Physicians and physicians in training at the Honduran sites were invited to remotely connect and present patients at morning and noon pediatric educational conferences over a period of 5 months.Educational conferences are held regularly in the Pediatrics Department at MUSC for medical students, residents, fellows and faculty, and typically consist of either an interactive case presentation followed by a brief lecture on a pertinent topic, or a didactic session focusing on a specialty topic within pediatrics such as pediatric neurology or rheumatology.All patient information was de-identified.Honduran providers were asked to complete satisfaction surveys immediately following the conferences, which assessed the ease of connectivity, connection quality and technical difficulties, as well as overall satisfaction with the conference.An IT specialist from MUSC was available during the conferences to assist sites with any technical problems.All educational conferences were conducted in English.

Physician consults
General pediatric and subspecialty consultations were conducted for the Honduran by a general pediatrician and a pediatric neurologist at MUSC using the telehealth equipment.These consults were primarily for general pediatric ailments, as well as chronic pediatric neurological conditions.No emergency consultations were performed.The Honduran sites were also instructed to hold teleconsults between each other in the absence of the MUSC providers (referred to as intracountry consults going forward).Physicians and physicians in training at the Honduran sites were asked to complete a survey immediately following each consult assessing the ease of connectivity, connection quality and technical difficulties, as well as satisfaction with the consultation.All physician consults were conducted in English, with the exception of the intracountry consults, which were conducted in Spanish.

Data collection and analysis
Satisfaction surveys for the educational activities and pediatric consults were adapted from existing MUSC telemedicine satisfaction surveys and translated into Spanish, and asked providers to assess connection quality and technical difficulties using a five-point Likert scale.A section for comments was also available.Respondents completed the surveys electronically through the RedCap study database.Descriptive analyses were performed.

Ethics approval
This study was reviewed and approved by the Institutional Review Board of MUSC and the National Autonomous University of Honduras (Pro00034887).

Educational conferences
Seven educational conferences were included in the study period.For each of these conferences, two to nine providers attended the session and completed the satisfaction surveys (Table 1).Overall satisfaction with the conferences was positive, with 100% of the respondents stating that they would utilize telemedicine again as an education exchange.Poor image quality, volume level, Internet connection problems and low voltage posed issues for some of the respondents (Table 2).

MUSC physician consults
MUSC providers completed a total of eight consults, and eight Honduran providers completed satisfaction surveys.Responses were overwhelmingly positive, as 100% of respondents completely agreed that they would utilize telemedicine in the future.A few subjective complaints were made regarding the image quality (Table 2).

Intracountry consults
A total of three consults were conducted between the two Honduran sites, and three to six providers completed the satisfaction surveys after each consultation (Table 3).Overall responses were positive, with 100% of respondents reporting that they would utilize telemedicine in the future to improve patient health.

Positive comments
Negative comments An excellent educational and helpful tool for professionals who need a second opinion, and for the benefit of the patients.
We had a little trouble connecting, but due to connection problems not procedural problems.Very interesting clinical cases.
Some technical issues but then we got connected.I liked the trust and openness to be able to give opinions, ask questions and make observations.In all of the sessions we have had connection problems.We always arrive before 6 am and always enter the session late.Well timed.
Olancho had severe fluctuations of the voltage, they have problems with the quality of electricity in that city.At the end of the consult (second case), the voltage was not enough to allow the camera to work, we were left only with sound.I liked the punctuality.It's a matter of habit.Here in Honduras the discussion is a little longer.But it was fine.
With respect to the presentation, I think the entire group would benefit more if you could enlarge the screen with the information for the case, since some cannot understand when listening, but can when reading.It would be excellent to be able to have that screen maximized.They were very punctual!Due to small inconveniences with the voltage, we lost about 10 minutes of the beginning, and the low volume made comprehension of the material a little difficult!A unique experience with a lot of learning.
There were audio failures due to electrical energy problems in the headquarters of Santa Maria del Real.The sound shut off.It is a great opportunity to continue educating ourselves and so we can help others!The language is a small limitation.The presenter spoke a little fast, but the writing helped us.I find it excellent that they are doing telemedicine.Either offline when they are just sending information, or live like we want to achieve.Little by little we are going to arrive at that point of extreme flexibility.But the trick really is simply in sharing the information well from one side to the other with extreme image quality.
Maybe the quality of the internet connection here is low sometimes, and for this reason the video quality is low.† There were no connection problems.† At times the image goes still, maybe because of the internet signal.
There might be connection problems because using the white camera to enlarge freezes [the image] for a long time.¶

Discussion
The Likert scale data from both the educational conferences and the telemedicine consults suggest that the use of telehealth is well received by providers working in underserved facilities in Honduras.Of particular significance were survey responses from consults that occurred between the two Honduran sites.These consultations demonstrated that internal networking and communication between local health facilities could be established in Honduras.Using telehealth to reach underserved practitioners for learning opportunities in the USA has been done successfully 4,5 .The advantage of extending these types of telehealth activities to other countries is the opportunity for two-way learning.

Conclusions
The data generated by this project provided valuable insight into establishing a telehealth network in Honduras.The primary challenges encountered were poor Internet connectivity and low bandwidth, which are likely to improve as technology progresses in Honduras.The positive responses from the Honduran providers were encouraging, since user satisfaction is essential to the success of any telehealth program.The most significant limitation to this study was the small number of facilities and providers that participated.
While the results of this study may not be generalizable to the country as a whole, they provide ample qualitative support for future exploration of telehealth in Honduras.The longterm goal of this project is to expand telehealth capabilities to other underserved areas in Honduras by integrating this technology into existing infrastructure to support routine incountry collaboration for clinical care, learning and professional development.
The participation of the consulting healthcare provider was beneficial in the care of this patient.University of South Carolina.

Table 1 :
Pooled provider responses from educational conference surveys (n=41) MUSC, Medical University of South Carolina.

Table 2 :
Provider survey comments following educational activities and consults