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Successes, challenges of telemedicine adoption in Nigeria clinical settings

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This article addresses the successes and challenges encountered by international healthcare practitioners who implemented telemedicine in their clinical settings, and how the lessons learned from their experiences can assist our healthcare practitioners should the nation adopt telemedicine.

Successful implementation of telemedicine shows that telemedicine increases access to general and specialized healthcare services, delivers medical care to rural areas, offers health care providers greater flexibility in scheduling, and saves patients’ time and money in seeking care. These successes are were amply illustrated in a recent study conducted in the US Department of Veterans Affairs which found that delivering health care through telemedicine saves the patient an average of 145 miles and 142 minutes per visit according to Clemens et al. (2018). In a similar vein, a teleneurology study also in the US showed that patients saved an average of two hours travel time and US$70 per visit. An orthopaedic study conducted showed a total savings of US$5,538,120 for 921 patients living in remote areas over 5.5 years (Clemens et al. (2018).

Studies in developing countries show that proximal boundaries could be bridged through the use of text messages for prenatal and post – natal care in Africa to overcome the challenge of communication. It is surprising to observe that great challenges abound in the adoption of telemedicine by both developed and developing nations.

Though many scientific studies have identified numerous challenges in the adoption of telemedicine with specific reference to certain countries and regions, many of these studies mentioned here, were carried out about ten years ago and thus dated, regretfully, they were not ab initio designed for international comparison.

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Barriers to Telemedicine Adoption in Clinical Settings Physicians using telemedicine can provide a workable solution for rural residents to access care (Wade & Eliott, 2012). Adoption of the technology is low in the Southern part of USA. Thus, Martin et al. (2012) examined implementation barriers between rural and primary care providers in this region. Martin et al. surveyed four rural hospitals as part of the data collection technique. Questions included planning, implementation, disaster recovery, and adequacy of telemedicine. The results of a response rate of 50% showed telemedicine is a viable solution for bridging the gap in a variety of speciality care facilities between geographic location and patient access.

The results of the study concluded by revealing hospitals located in rural areas appeared ready to embrace facilities that successfully implement telemedicine and follow their examples in their implementation strategy.

Wade and Eliott (2012) noted that proponents of telehealth are passionate individuals who endorse the use of the technology. Wade and Eliott interviewed 39 participants residing in Australia as part of a qualitative study exploring the participant’s views regarding the convenience and sustainability of the technology. The results indicated that proponents initiated most services, and the role of the telehealth promoter is an important factor in continued operations. Zanaboni and Wootton (2012) revealed a debate about why telemedicine adoption has not progressed. Zanaboni and Wootton stressed that apart from tele radiology, which is a variant of telemedicine, application of this technology in other areas is still in the early stages of development. The theme of the research was to attain an in-depth understanding of adopting best practices in the field of telemedicine, to assist people trying to move applications from the pilot stage to routine delivery. Zanaboni and Wotton’s findings are that the widespread adoption of telemedicine is a major challenge that needs strengthened through new research directions. Zanaboni and Wootton formulated four hypotheses, which require further experimental verification because the researchers believed that more data regarding the adoption of telemedicine is necessary.

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Singh, Mathiassen, Stachura, and Astapova (2010) examined the perceptions of 19 managers and six health care providers in the adoption of telehealth in a rural community between 1988 and 2008 in the state of Georgia. Singh et al. used semi structured interviews, field observations, and published papers and other written materials. The findings included strong collaboration within the district and local community, and energized external partners including telehealth clinical outreach 35 members. Singh et al. concluded that building strong internal and external relationships and a combination of technology could sustain rural telehealth innovations.
Licensing, Legal, and Regulatory Issues in Telemedicine

Organizations that adopt telemedicine technology must include technical, regulatory, licensing, and legal issues. Bandyopadhyay and Hayes (2009) explained health care leaders working in the U.S. ignored matters such as competition, patient safety, increasing health care and liability insurance costs and Medicare and Medicaid payer reimbursement changes. Government regulation officials control remote medical care technology (Silberman & Ciark, 2012). Silberman and Ciark (2012) used a questionnaire survey for their study and formulated a framework for continuous improvement in health care management policies and for understanding the impact of U.S. government oversight. Bandyopadhyay and Hayes (2009) noted as the competition between organizations intensified; operational issues became more widespread, which resulted in many hospitals closing. Bandyopadhyay and Hayes stressed that hospital leaders have become aware of how the consequences of such uncontrolled operating practices could jeopardize even a large business’ landscape. Measures to improve hospital procedures to meet the needs of its stakeholders and the expectations of patients might help physicians deliver affordable and quality patient care.

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Silberman and Ciark (2012) claimed health care would require continued development of technology-based applications. Physicians can use mobile health (mhealth) hardware or software to deliver wireless health care services. M-health is a term applied to hardware or software technology permitting physicians to deliver health care 36 wirelessly. M-health includes patient and provider-oriented medical applications. Online medical records store information such that patients could manage health care needs by scheduling doctor’s appointments, reviewing test results, and renewing prescriptions online. The appropriate personnel can use medical hardware devices to send health readings back to the patient’s physician (Silberman & Ciark, 2012). The field of mobile health care is a growing opportunity for hardware and software application developers.

Ethical, Confidential, and Privacy Issues in Telemedicine
Blumenthal and Tavenner (2010) purported the use of electronic health medical records could pose a potential ethical and confidentiality breach, which providers must address. Hu, Chen, and Hou (2010) explained that lawmakers enacted the Health Insurance Portability and Accountability Act (HIPAA), which set privacy and security regulations for health care organizations to abide. A hybrid public key infrastructure solution complies with HIPAA regulations. The infrastructure is a security access platform for use by the medical service provider during the contract period (Hu et al., 2010) with the intent of protecting patient’s sensitive health information. The strong written computer code use by the appropriate person is to verify, allocate, store, and transmit sensitive medical information securely.

Arriaga et al. (2010) researched privacy, legal, and potential use of telemedicine in a neurological practice, which includes a full-time audiologist, a nurse practitioner, and an ear nose and throat doctor, where physicians were only available 3 days a month. Physicians used telemedicine to evaluate patients residing in Baton Rouge, Louisiana while the examining neurologist connects through a secure, remote server in Pittsburgh, 37 Pennsylvania.

Physicians helped 450 patients using telemedicine technology during the first year of operation and doubled the on-site visits. Telemedicine is a practical model for neurology care delivery (Arriaga et al., 2010).

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Telemedicine and Mortality Rate Reduction in Remote and Rural Areas
Gorman (2011) found the use of telemedicine shows an advantage to saving lives. Rural occupants sometimes live hours away from emergency room services, which put people at an additional risk in not receiving timely treatment. Mortality rates among rural occupants changed significantly, by 36% in rural areas, with a form of telemedicine, called tele-ICU technology. Anker, Koehler, and Abraham (2011) conducted research on patients with chronic heart failure. Anker et al. asserted that by getting patients involved 39 in their health care management practices with technology and communication tools, a reduction in morbidity and mortality rates among patients could occur. Anker et al. concluded observing data early would allow doctors to detect medical conditions and intervention plans that might help alleviate unfavorable outcomes. Some patients chose to decline any form of treatment during end-stage heart failure, and supporting the decision of patients to live without treatment is difficult. The use of tele-ICU technology by physicians could provide some patients with an alternative treatment plan. The tele-ICU alternative is more appropriate from a clinical and economic basis as physicians could become complacent as to only focus on patient death rates and not consider other options (Anker et al., 2011).

Computer Equipment Costs, Training, and Education in Telemedicine
The use of telemedicine includes high costs and training for health professionals who service rural areas. Adelstein (2013) presented information on information supplied by the United States Rural Utility Service of the U.S. Department of Agriculture regarding the Distance Learning and Telemedicine Grant Program. Adelstein used innovative technological services, such as telecommunications and computer networks, to advance the knowledge gained from distance learning capabilities for rural areas. Mackert, Guadagno, Donovan, and Whitten (2014) recounted more than 40 years of the telemedicine service that advanced organizational leaders in their aim to improve patient access. Mackert et al. asserted that the use of telemedicine could decrease the number of health challenges throughout the world, and improve the health access problems facing society.

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Telemedicine is widely used in many countries as a means to increase the access to healthcare through the elimination of proximity from the equation of care. However, technology barriers and lack of computer literacy prevailed as a major issue in successfully implementing telemedicine. Although telemedicine shows promise in its ability to increase access and efficiency, ease and acceptance of this modality of care is necessary for its diffusion.]

The methodical review shown above, offers a way for public policy decision makers to intercede across international borders and ease the obstacles currently experienced in healthcare delivery.

Below are eight major barriers that may hinder the successful implementation of Telemedicine in Nigeria Clinical settings:
1.Lack of Institutional framework, policies and legislation to regulate the standards and practice of telemedicine.
2.Erratic supply of electricity and the dysfunctional communication infrastructures and equipment such as high-speed Internet, and dedicated communication lines.
3. Little cooperation between healthcare providers, agencies, and all the three tiers of government (Federal, State, and local) regarding the need to embrace the use of telemedicine technology.
4.Lack of continuity of policy when Government changes hand
Pecuniary interest of Approving Authorities.
5. Lack of locally trained experts, training facilities, and high cost of foreign trained experts salaries, coupled with inadequate knowledge of billing for services rendered by healthcare practitioners on telemedicine platform.
6. Lack of education and skills to understand telemedicine by rural inhabitants and their low purchasing power.
7. Lack of privacy and security of patients’ data and confidential data.
8 Inadequate pharmaceutical support in the countryside.

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In conclusion, for the telemedicine innovation to be successful in Nigerian clinics and hospitals, within the 36 states (and the Federal Capital territory), some of the barriers enumerated above, need to be given serious consideration. Telemedicine (according to American Telemedicine Association) is the future of Medicine. Failure to start planning for it now may spell an immeasurable healthcare doom for the future of Nigerian inhabitants.

*Dr. Femi Obikunle, Certified Telehealth Clinical Presenter (CTCP) -USA, Doctor of Business Administration – Healthcare Management (Telemedicine), and USA.

He is currently the Founder and Chief Executive Officer of Elvote Consulting Services (A Venture Capitalist Company that specializes in Telemedicine, Telehealth(Telesoftware) Data Analytics Consulting, Medical Research, and Information Technology) in USA. He has presented papers to The Project Management Institute (PMI), and The American Telemedicine Association (ATA).

He is currently the Founder and Chief Executive Officer of Elvote Consulting Services (A Venture Capitalist Company that specializes in Telemedicine, Telehealth Data Analytics Consulting, Medical Research, and Information Technology) in USA.

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