Use of ICT in Reduction of Blindness caused by Refractive Errors and Low vision: Focus on possibility of using Village kiosk in vision 2020 plan in AfricaAUTHORS1. DR. ENECHI GILBERT

(B.Sc. OD Optom, M.Sc Comp. Scn/Engr., CACLv (Low.Vis)Principal Optometrist, College of Medicine, University of Nigeria,

Clinical Optometrist, Dept of Ophthalmology, University of Nigeria Teaching Hospital (UNTH), Enugu – Nigeria.

Email:elimehi@yahoo.com, Phone: +234-803-324-40642. PROF INYIAMA H.C Professor of Microprocessor-Based Electronic Control,

Dept of Computer Science, Ebonyi State University, (EBSU), Nigeria

3. DR. OGUAMAH FELIX B.Sc, OD Optom.

Chief Optometrist, ESUT Teaching Hospital.Parklane, Enugu, Nigeria.

At the inaugural World Congress on Refractive Errors and Service Development at ICC, Durban, South Africa, March 2007

BACKGROUND Over 60% of African population resides in rural areas where basic social and health infrastructure are lacking. Majority of those who are in need of Refractive error services and visual rehabilitation are poor and resident in these rural areas. Vision 2020 targets to salvage the needlessly blind through a four-level Eye care delivery approach with Community level at the root.

The eye care manpower currently available is a far out cry from what is needed. Hence there is need for adoption of other strategies (where enabling environment permits) which can work in synergy with existing plan.

Definitions:Teleoptometry is a procedure in Optometry where clinical data of a patient can be sent from a remote source via Information Communication Technology (ICT) network channels to another optometrist, authority or specialist irrespective of distance and time barriers with the aim of receiving direct feedback information in the diagnosis and treatment of the patient.

Teleoptometry is an aspect of Telemedicine. Telehealth is a comprehensive delivery of health care services and other related health care activities in which the barriers of distance and time have been removed.

Teleoptometry is the practice of Telehealth within the scope of Optometry and therefore is the channel through which ICT can be used in Reduction of Preventable causes of Blindness in Africa.

ICT Village Kiosk:

This is a small computer workstation or terminal in a community which is usually linked to other stations and is capable of carrying out basic information processing with further ability to permit small digital information shopping.

Patient ICT Device

Local Eye care Personnel/DR Wireless ICT

ICT network Server

Wireless ICTRemote DR

Fig 1: TELEOPTOMETRY Demo

Legends:Physical Connection Wireless Connection Logical Connection

Channels of Communication

Fixed Telephone Lines (Analogue)

Wireless Mobile Telephone: GSM, WCDMA

Broadcast One-Way Transmission: Radio, Television.

Fax

Internet, Extranet, intranet

Videoconference

Application of Teleoptometry

A] Diagnosis of Ocular Pathology:

Glaucoma, Retinal Diseases, Cataract, Corneal Diseases, Tropia, etc. are some of the conditions that can be diagnosed through Teleoptometry. Digitized images of the above ocular conditions can be sent to remote center for analysis and diagnosis (Ex: Cannon Camera)

Retinal Camera: Cannon

Digital Slit Lamp

A: SPECTACLE AND OTHERSI] Contact Lens: fitting of contact Lens can be enhanced through Teleoptometry. With the use of Fluorescene dye and Cobalt blue light, it is possible to take the picture of the contact lens in situ (Canon Camera). Also a patient can try out various types and models of digitized contact lenses. The digitized images can be sent to specialist at remote center for analysis of best fit.Ii] Spectacle Fitting: Digitized frames (by Maxseen) and physical frames of various sizes, shapes and models can be tried out by patient. The digitized image of the photograph can be sent to remote center for evaluation.Iii] Clinical Measurements : The information on IPD, bifocal and varilux settings can be gotten in real time and sent to remote specialist for analysis and input.(Courtesy of Maxseen Technology)

Optical Dispenser: MaxSeen

C] Exchange of ideas between OptometristsAn Optometrist can share information about a case at hand online with another Optometrist as the patient is being examined.D] EducationAn Optometrist can learn some clinical procedures online from another specialist in a remote center.E] Research:Sharing of patient’s data between optometrists brews a good background for research endeavors.F] Low VisionBy documenting and forwarding a video clip of a low vision patient at work/Task, it is possible for a low vision specialist to render useful suggestions on the environmental modifications for the activities of daily living.

REVIEW OF TELEOPTOMETRY IN AFRICA

The use of Teleoptometry in Africa is currently at low level and is limited in most countries to use of land telephone and GSM lines as the ICT channel. There is not yet a remarkable success in the use of internet channels, video conferencing, etc in Africa as is the case in Asia.

The telephone communication is used in the following directions:

I] Patient to OptometristIi] Optometrist to OptometristIii] Optometrist to other Professionals

I] Patient to Optometrist: In this case a patient from a remote source (Villages, Towns, rural communities, etc) initiates a distress telephone call to an optometrist who usually resides in the city. Calls from the villages are mainly via GSM and fixed wireless while calls from the city may in addition include via non-wireless land line. Cases encountered in calls from villages are mostly trauma (Mechanical, chemical, penetrating injuries) and ocular emergencies resulting from application of harmful ocular concussions. Calls from the cities are mostly cases of broken or lost spectacles, contact lenses and low vision devices. [The above data are the unpublished experience of some of the optometrists who are active in community based optometry]…contd

In responding to such distress call, the African optometrist gives immediate ocular first aid directives and instructions to the patient or his care giver in Real time. In situations where the immediate remedy cannot be resolved after the first aid treatment, the patient is invited to the city for proper treatment.Some eyes were saved from blindness by this approach as without such professional intervention from the optometrists, the patient in a remote city would have resorted to use of traditional harmful ocular medication on self help.

2] Optometrist to Optometrist: In this situation, an optometrist makes a phone call to another optometrist (usually a senior colleague or specialist) to get clinical opinion on a case he is currently examining.

3] Optometrist to other Professionals: In this situation, an optometrist makes a phone call to another professional/ authority (ie, Ophthalmologist, psychologist, Special Education teacher, Contact lens dealer, etc) to get his opinion on a case he is currently examining. In most cases this enables the optometrist to make an intelligent referral.

JUSTIFICATION FOR TELEOPTOMETRY IN AFRICAI] Situation in Africa :

60% of African population resides in rural communities where there is poverty, lack of social infrastructure, lack of appropriate health facilities, inaccessible roads and where doctors are very reluctant to go. Optometric services in these areas are very low. The rural dwellers in Africa need better information and eye care services which can be bridged by the concept of Teleoptometry..

Ii] Recent Communication Explosion: Africa is a promising IT environment for the future. For the past five years Africa has outpaced other global IT markets in terms of new subscription with 58.2% growth. Nigeria has a large chunk of this share!The network service providers in Africa are at severe competition to get the largest chunk of the IT market. The result is that many of them are now expanding their network services to penetrate the interior parts of the continent with a special target on rural communities. This has provided a fertile environment for Teleoptometry.

Iii] Inaccessibility of rural communities

Most of the rural communities in Africa are not quite accessible by roads. Optometrists and other health care professionals find it extremely difficult to reach the rural dwellers in the above areas.

Iv] Lack of social infrastructure: Lack of pipe-borne water, electricity,

hospitals/health centers, recreational centers, etc, have made African villages unattractive to doctors and other health personals. Most optometrists therefore prefer to stay in the cities but those who are interested in community optometric practice visit the areas from time to time. These short trips are not enough to handle ocular emergencies. Hence Teleoptometry will help to deliver necessary services to the multitude of the underserved in a real time.

V] Lack of information and practice of obsolete tradition:

Majority of the rural dwellers still live in ignorance. They do not have reliable source of information on their ocular health. Some of them therefore resort to practice of obsolete traditions which are inimical to ocular health. Some harmful traditional concussions are still being used in some villages. Such concussions include Urine, Breast milk, Alum, Pepper, Garlic, bitter-leaf juice, etc. Implementation of Teleoptometry through the establishment of Village Kiosks and ICT VISUAL centers will help to neutralize these negative behaviors and traits as the kiosk will double as information center.

Vi] ClimateSome rural communities in Africa do not have favorable climate. The temperature in the North is high during the Dry seasons but in Rainy seasons, it becomes comparatively low. Some areas usually experience water logging and mud during the rainy seasons. The climatic conditions have made the areas unattractive to Optometrists and other NGOs who are desirous to bring refractive services to the rural dwellers. Teleoptometry will tend to neutralize this effect.

Vii] Existence of TeleHealth working group in Africa

Optometry is a health profession and therefore works within the ambit of its legitimate scope in synergy with all other health professions. Hence, Teleoptometry will not exist in isolation but will operate within the ambit of teleHealth facilities and legislature in Africa. Fortunately, a group of health professionals whose desires are to promote the practice of telehealth in Africa are already in existence. This group is already active lobbying the government and its agencies in their different countries towards legislature of Telehealth laws. It will be therefore easier to establish Teleoptometry in Africa as some interest groups are already doing some underground work in this direction.

RESOURCE REQUIREMENT

Teleoptometry involves use of ICT and other ophthalmic devices to transmit patient’s data to remote optometrist/authority.

The following resources are required:

1] ICT Devices RequiredI] Mobile station: GSM mobile phones / Tabletop handsetsFeatures: SMS, Multimedia, MPC(Multiple Party Calling), MDS (Mobile Data Service), VPN( Virtual Private Network), WAP (Wireless Application Protocol), GPRS, Edge, IR, Blue- Tooth, UMTS (Universal Mobile Telecommunication System), DTM (Data Transmission Speed) => 2Mbps, etc

Ii] Fixed, Wireless, fixed-wireless channelsIii] Laptop computers with appropriate softwareiv] Digital Videov] Digital Camera

Network Service Providersi] GSM servers: Base station (BS),

Base Transceiver Station (BTS), Base Station Controller (BSC)

ii] Internet Service Providers (ISP)

GSM NetworkBSC

BS

BTS

2] Ophthalmic Devices

A] Digital Ophthalmoscope

B] Slit-lamp With Digital port

C] Diagnostic Camera

D] Diagnostic Video

e] Virtual Optical Dispenser

( Ex: MaxSeen)E] Other Standard Ophthalmic/Optometric

instruments

3] Support Facilities

A] Electric Power Supply: National Grid system or Generating set

B] Solar-powered Battery charger

C] Office space

4] Personnel

A] CHEW, Nurse, Teacher, etc.

b] Optometric Assistant

c] Optometrist

d] Experienced Programmer & Optometrist

5] The Patient

6] Coordinating Authority

A] The Government

I] To provide enabling law for all the stake holders in the scheme.

Ii] To subsidize the optometric services rendered

Iii] Provide basic infra structure

Iv] Establish a coordinating agent

B] The Ministry of Health

I] Regulate the practice of Telehealth in the country with aim of protecting both the patients confidence and the doctors’

Ii] Helps in recruitment of personnel in actualization of Telehealth.

Iii] Provide all other health related logistics as may deem fit.

C] The Ministry of Information and Communication

I] Through the Communication Commission, regulates the activities of various service providers.

Ii] Monitors network service production and quality.

D] The Optometric BoardI] To regulate the activities of its members in the application of Teleoptometry in the country.Ii] To Organize update courses for new and practicing optometrists in the art of Teleoptometry.Iii] To establish Teleoptometry Working Group which will be a research arm of the board on this procedureIv] To Encourage optometry schools in the country to include Teleoptometry

in the academic curriculum.

IMPLEMENTATION

Teleoptometry can be implemented in Africa by adopting the primary health care delivery system already employed by vision 2020 working group. This involves the following levels”

I] Community/Primary level

Ii] Secondary level

Iii] Tertiary level

Fig 3: ICT VISUAL CENTER MODEL

Eye care Delivery Level

ICT Network Centers Refractive Eye Care Personnel

Tertiary Level State ICT Optometrist

Secondary Level Local Govt. ICT Optometrist

Primary/Community Level

Village Kiosk Chews, Teachers, etc

I] Community/Primary level: VILLAGE KIOSKThis shall be the lowest level which operates within the rural community. The eye care personnel is either CHEW, TRADITIONAL HEALER, NURSE, COMMUNITY DWELLER, TEACHER, etc who shall be given basic training both in computer usage and in recognition and treatment of some minor ocular conditions and emergencies…contd

The patient visits the village kiosk to get services. The channel of communication at this level may be limited to wireless telephony. Here a patient through the assistance of a primary eye care personnel is able to explain his condition to the optometrist in the secondary level. The patient through the assistance of the personnel in charge may be given an instant direction by the optometrist on the treatment. The patient may also be invited to come over by the optometrist (in the secondary level) for further treatment/examination.

Ii] Secondary level: Local Govt ICT VISUAL center

An optometrist shall be in charge at this level as he oversees and is liable to all the Teleoptometric activities in the zone or district. Patients can come directly to him or are referred from the community/primary level. For cases beyond the facilities of the optometrist at this level, a connection via the GSM Phone or internet if present can be made to another optometrist or authority in his zone.

.

Iii] Tertiary Level : State ICT VISUAL Center

This shall be the highest level or authority in the scheme where services or clinical queries could be sought. The optometrist at this level can connect another optometrist or authority in another state or country to get instant guidance on the treatment of patient in question. Fortunately, interstate referrals can be possible in some countries as they do yet not have any legislation that forbids this.

MERRITS OF TELEOPTOMETRY IN AFRICAA] The Patient:I] Gets Access to professional care easily Ii] Does not ALWAYS have to take a trip outside

his domain to get optometric services.Iii] Improves patient satisfaction and better health economicsIv] Understands and gets more involved in his conditions as he views his Ocular images on large computer screensV] feels more comfortableVi] less intimidated by the doctorVii] Pays less overall medical bill in the treatment

of his ocular conditions

B] The Optometrist

I] Learns from the process as he experiences from another specialist’s diagnosis of his patients.

Ii] Can send patient’s information to schools of optometry for analysis and learns in the process

Iii] Has Job satisfaction

Iv] Monitors his patients in remote areas.

C] Optometrist and Patient

I] It enhances a mutual trust between the patient and optometrist

Ii] It reduces language barriers between patient and optometrist

Iii] REAL TIME: It removes barrier of time and distance.

THE CHALLENGES

Full implementation of Teleoptometry in Africa will not go as smooth as may be expected. There are several logistic issues that will practically affect the tempo of the program. Such issues and their alternative solutions are mentioned below

A] Power Supply

There is lack of Electricity power supply in most rural communities in Africa. The urban cities experience epileptic and low voltage power supply. Most of the ICT and ophthalmic devices used in Teleoptometry require stable and constant electricity supply. It may not be cost effective to run generating plants on 12hrs-6days-4weeks-12months basis. There is therefore need for a more reliable and constant power supply…contd.

Solution: Fortunately Most towns in Africa have plenty of sunshine. Hence use of solar electricity shall be exploited to fullest. Some devices like PC laptop, digital camera, digital video, etc, run on rechargeable DC batteries. Solargised inverters and multi-purpose battery chargers can be used to power the ICT devices. Small low-cost less than $100.00 generating plant can also be used to power the battery chargers for less than 2hrs a day.

B] High cost of providing internet /GSM services.It is very expensive to operate internet /GSm services in Africa. The following may be some of the reasons:I] High Registration cost: To register and operate as service provider is very expensive. Some operators had to cough out several million of dollars in a bid to register its operation in Africa.Ii] Lack of Constant power supply: The power supply in some African countries is not stable and since the operators must provide their services 24hrs-7days a week, they cannot rely on national grid Hence they invest a huge sum of money in purchase and maintenance of standby electric power generators in every of their base stations.

Iii] Fuel scarcity: The incessant fuel scarcity in some African countries has been a nightmare to service providers as their numerous base station plants consume diesel on 24hrs-7days basis. During scarcity the fuel is sourced at exorbitant cost.All the above adversities have made the overhead running cost of GSM/Internet services in Africa to be very high...contd

In self defense some of these providers tend to recover and sustain their investments by resorting to following practices:

i] Limited band width

ii] Oversubscription of their channels to their clients

iii] High service charges to clients

Solution: Government shall look into the plight of GSM/internet service providers in the country.

c] Congested Band width and lack of internet facilities

Internet facilities and network are completely lacking in most rural communities. Even in urban cities where the network exists, there is congestion of channel capacity in the available band width as GSM operators and service providers tend to oversubscribe their limited band width. This has led to slow data access speed. To download or upload a 10MB file may take several minutes to achieve. This low speed has already negated the philosophy of Teleoptometry which implies diagnosis in REAL time!, especially where the average data size of image/movie file runs in hundreds of megabytes.

Solution: The Government through its regulatory body/agent shall forbid existing ISPs from oversubscription. New ISPs shall be encouraged to start business in the country. All the GSM operators in the country shall be stimulated to include internet services (WAP,GPRS, etc) as one of their primary service products. They shall also be encouraged to exploit the recent 3-D meshwork and fibre optics technology for mass internet connectivity. The Registration fees for ISPs in the country shall be drastically reduced or waived. [However, competition in the IT market will naturally force the ISPs and GSM operators to improve their services in this regard].

d] Job Threat

Introduction of ICT and computers into activities of man has been viewed by some categories of individuals (including some professionals) as a direct threat and competition to their means of livelihood. For instance one does not need to be a professional photographer before he can comfortably cover an event with his digital video. So also some optometrists may feel that with Teleoptometry, their job will be threatened. The traditional healers and those who make a living by providing ocular therapies may not feel at ease. If these pockets of resistances were neglected in the program, they might assiduously fight to the demolition of the program in time…contd

Solution: Public awareness campaign and advocacy shall be done prior to introduction of Teleoptometry in any community.

The individuals who are already providing some ocular services in the area can be incorporated or integrated into the system if they so desire.

e] Finance and Sustainability of the project

Establishment of Teleoptometry will require some funds. Some of the ICT and optometric devices used in Teleoptometry are relatively expensive. The officer(s) who will man the program will require appropriate remuneration. If everything were left for government, the program may not survive as it cannot continue to inject funds into the system forever.

Solution:

1] Small amount of money shall be charged for any service rendered.

2] There shall be community participation in the project where the residents are encouraged to make donations and regard it as their own.

f] Legal Backing, Responsibility issue and Public Safety

There is no legislation in place in most African countries that stipulates the practice of Telehealth and Teleoptometry. However if Teleoptometry is regarded as a procedure and not a specialty in optometric profession, then it will be covered by “ethics and code of conducts” for optometrists. This is necessary as to avoid and discourage unwholesome practices and maneuvers which may be invented by practitioners in future. ..contd

The issue of responsibility is very important. For instance, in Teleoptometry, when a patient receives treatment from a second doctor through the help of the primary doctor, who will be responsible for the services? How will interstate and intercontinental consultations be resolved? Both the practitioner and the patient need legal protection as to avoid unnecessary litigation.

Solution: The African governments through its legislative arms shall put in place spelt out Criteria and Scope for the practice of Telehealth and Teleoptometry in the country. This advocacy can be done by the TWG and respective Societies For Telemedicine and e-Health

CONCLUSIONThere is both clinical and digital divide between the urban and rural communities in Africa. New graduating doctors keep on populating the cities while the rural communities keep experiencing acute shortage or total absence of optometrists. If ACTION is not taken fast, the target period for elimination of avoidable Blindness by vision 2020 may experience serious setbacks. VILLAGE KIOSK or ICT visual centers can be used through Teleoptometry in rural communities in Africa to render refractive services yet undreamt of in the spirit of vision 2020. This will translate to reaching and treating more people who have refraction and low vision needs, thereby reducing the prevalence of Blindness due to refractive Errors in Africa.

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