Central Referral Mechanism
4.1 Rationale for methods
4.1.5 Rationale for variable categorisation
machine to the other to test voioo clarity and messages were ""nt betw~'Cn the two machi,,,,". In addition, messages were creatod when the laptop. ".,.rg not conn~ctoo and then a connection w"-' establishoo to te"t, the function,.!ity of the store fIIld forward component. The entire t~"ting prOC<'ss was "'peated in implementation phaocs in subsequent L"Yd~", after any change was made to the MuTI prototype. Testing usually occurred over 1-2 weeks. When the prototype
wa"
thoroughly test.ed anrl fUtlCtioning corrpdly. it was co,,,,irieroo rearly for deployment.:\IuTI's main advantage i" its multi-modality that combines synchronou. VoII' with tw, asyn_
chronous storage anrl £)rwaxding of mf1lSaj,'-es. The oontact list allows the u""r to determine if the peroon s(he w:i>ilie" to oontad i" available. lHellli',dicin~, con.uitations c"n be ronrlucted syn-chronously if both parties are available and if the power and network arc up. If the power or network i" down, m if both part.i~" arc UIlavailabl~, to tfl.lp, part in a synchronous communication.
MuTT allows a store and forward approach for the data. Text, yoice and imag<l!l can be captured "t any time il.Ild they arc forwarded when a conne~t:ion is "vailable. Thi. ""yn~hro'\OUR aspect meaIlll that an O\·erwo.-ked doctor Can nOw proce8Ilmessages at his Own conyenience and reply when he h""
time. Digital im"l':~'; in r~'Cords offer " gr~.ater uwci of deWl anrl voicemail cuts down On typing.
The fonner improyed On the poor qU<l.lity yideo in the previou" telemedicine "}"Stem and the l"tter saved time for uscr" with poor typing skilk
Tt was anticipated at thii; .ta,o:e that th~, syst",m would lead to coot and time saving" for patients since they would not have to travel to the hOtlpital to sw the doctor, if not ne.c""sary. Thii; was particulaxly signifkant in TRilitwa Rince a hlrgg proportion of the patients tire unemployed or living on govermnent grants. Also, inter-village traye) is erratic and expensive for locals. The following secti<lll describes h",,' "" p-valuated MuT!.
4.4.3 The Fir~t MuTI Trial~
In order to evaluate the action implem<>nted for thg """ond project cycle, i.~ .. , :'IInTI, we arranged a field vi.it. The purJXlf'" of this viRit was to introduce thg first version of :'IIuTI to the project participrults. Tn tenn. of equipment, we proyirlerl two Dell Inspiron 5150 laptops on which to run :\!u'TI, one for th€ clinic and one for the hoopital The mtld!in€S had Intel Pentium -1 proceosors (3.06 GHz), 512 Mb R.AM and :'IE<:rosoft Window .. XP Prof"""ional Operating SysteJns. Headsets were also pr""irlgd 00 that paxticipants coulrl make VoIF' calls with :\IuTI. Furthermore, "'" prO'i'ided
"pare battery packs for each laptop 80 that in the event of a power failure, additional battery power was availablg and patient dat" could ,;till be c"pturoo.
During this trip, "" paxt of th~, evaluation of this software prototype, <l. discuS>lion group wru;
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CHAPTER J. ATULTI_ATOD.4.L TELR\fEDICL';'E INTERCOATMUl"rrCATOR
held with the partirjpantH. Am, a que;\iOllnaire ,,'lIS administered to gat"";r b"""line data and <l.
demollbtmtion of :).!uTI w&"< arranged. In addition, training was provided fOl t.he users and MuTI was te"i<'Ji aero" the \\'iFi network from the clinic \(l the hao;piW.
To increase validity of the ra;ults, data triangnlation was employed. Le., multiple sources of data were compared for aecuri\C>·. Addit.ional data gathering techniques employ",d were mainly qualit<l.tive including intervlcws and ob"'l"vations from ethnography which were rE'<X>rded in field n()l€". Alw, th~, wftl>.·I\N', prowtype wa" ine(rumented to gather <juantit<l.tivc statistics W indicate usage of "'uTI. The following 5(.'Ctions describe the proj!'Ct partiei pa.nt., the d;,;cussion group; held.
the baseline fjU(ffi\ionnaire admin;,;tered as well as the demonstration. training and wRting ""Rei()n"
for this projDCt cycle.
Participants
The proj!'Ct participant, con"ifited ()f two health care profCffiionals. a XhOba-speaking South African nurse frolll Tsilitwa primary health care clinic and a Spanish-ep"aking Cuban doctor froul ::-<es8ie Knight Hoepitfl.i in Sul~nkamil.. The nurse had some priOl experience with computer" fmm u"ing the prc-.·ious telemedicinc s}"btem. She w&"< cl.a&ifu>Ji as a novke computer nser. The doctor, on the oth<>;r hand, had \IOOd compm"," extRneivel>' and was familiar wit.h email and the internet. He was d""siJied as an average computer user. The nurse had ,,"orIPJi at Teilitw'a for "..,.-eral >-ears and the oortOl', at tlw, time, was completing hi" three >-ear oontract at the hoopiW.
The doctor was the sole doctor at the hoopital at tlw, time of the project, respon"iblc for 200 r",U", treating ()n average 1(XJ ont-patients per d<l.Y· The other two participanU; in thi" experiment were the two network maintenance staff from Teilitw'a who WP.1'<', trained by the
csm
to maintain the wil"<'.1<>,,", netwOl'k. B()th had been trained in baok net."'OIk mauagemellt. The network admini"tratoro ()nly t""k part in the dif;c\lffii()n group whereas t.he nurse and the docwr al"" partidpawd in the demOllfitration, training iUld testing 8E"&Siom using MuTI. Next, we df'Mxihe the dif;cnssion group wE' held wi~h the participallt6.Diseussion Group
w~, held a di""uAAion group with t.he nurse. the doctor and the 1'1';0 network mainten<l.nce st.ati'. This group was contained by rCl'<."arcll<."l'5 through foeus on a ""t agenda. The group WM given an. outline of the purpose hehind our work, i.e., that the work was being undertaken for re",arch reaSOlIfi. \Ve also clarified our rpjati""ehip with the CSTH and highlighted Our role as trying to improve the 01<1
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tel!lTIl<'dicinc ~y~tem. The cyclical n(\ture of the overall research pr0<:<J6S was emphasised and we explained our fU"lnre plans for revision" and follow-up".
Thi" was necessary pfLrticuiarly for the doctor fLt the hospha.l since we h~d no~ met him pre-viously. The doctor we met at thc previous vi><it had ><ince returned to Cuba. We also gnve all the participants a typed one pa.ge IX'ojcct "ummary to augment ~he talk. To end the first part of the meeting, we discussed the ethical consideration" for the stady. This included mentioning
~hat we would not be collecting personal dat(\ MId only statistics. Attendees were formally asked if they wi"h to participate in the fltudy flJld we ~trcssed that this Wall on a voluntary ba.5is. We also informed all attendees that participants could opt to withdraw from the study at any point.
After the explanation!;. we haJld"" out COllS<'nt forlllli for all the participants to sign !IS a contract of g()()dwill between the researchers and the community members. The next part of the discll,,"ion group WAA dl'rlicated to talking about the MuTI tool. We provided an o\'N"icw of the purpooo of the tool and its capabilities fLnd prompted attendee!; for feedback. In the following section, "'"
deocribe the ba.seli.ne qUClltionnaire we administered.
Questionnaire and Clarification Inte.-view
We administered a questionnaire during the second project cycle to determine bMeline data and U"agc of the previous telemedicine system developed by the CSJR. This included questions on how often the "ystem Wll.'l uood in the past, whn.t it was w;ed for and also how it could be improved. The que;tionnMre Can be viewed in Appendix A.1.2. Afterwards, MI interview was held to clarify re8ponOO!< to the questionnaires and a.nnotatioll~ were made on the re;ponsc shcct~. Only the doctor and the nurse completed the qU""tionnaire ll.'l they had llSed the previous telemedicine
~ystem whereas the maintenance stllJf were only involved in the network wministration_ 'Ye aOw give " brief dc&:ription of the demonstration that wok place in this evaluation phase.
Demonstration
A demollStr~tion was set up using two laptops connected with a erQt;S cfLble in the hoopital moeting room. Here; the principal rese~rcher demOllstrfLt"" how to send a MuTI message (\nd make calls nsing MnTI to another party using MuTI. All the fmlction" of MnTI were shown to the doctor and the nurse and we observed their responses. Scenarios of use demollstratoo included how to log in to )'IuTI, how to call another MuTI uscr, how to create a record and how to ""nd a record to another MnTI user. Once we had demonstrated !lluTI, we made mrangemelll" to train both the nurse and the doctor individually in how to use MuTL This is described in detail below.
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• •
• •
Figure 18: This picture show. one of the training OOtl8ionH with the mll"oo. In the foreground from left to right: Mr Vuza (Roleardmr), "lr Tucker (IWs<>Al"cher), TAHitwa Clinic H"",d Nnroo and 1>.1;,;..
Chetty (Reooardler). In Ih" background, from left to right, Network Admini.trator and Tffilitwa
&.hoolteM'.her, ~etwork AdminiAtrator and Yodacom Phoneshop .\Janager (bending over) and a Tsilitll.ra ,;('hoolchild.
Training the nurse
The nurse was trained at the ~hool, as 00<''' in Fignre 18, "inoo the clinic did not have power on the morning that the training wail sclledUkrl. Again, two laptop" "rere oot up and connected via a c.rOflfl cable. On each bptop, "JuTi was set up with a pr~reated M'-oount, the "Hospital" account for Ih" ho"pital machine with a simple password and the "Clinic" accOUllt On the clinic machine also with a simple pas.word. For each fLCconnt, a COlltact "'!IS ru::ldcd - the contact being the name of the other machine. For an example. the "HOlpit.u" a<:-oount had the contact with tb" name "Clink' and with the address being clinic laptop's Internet Protocol (IP) addre8A and vice versa_ Tl"aining for the nurse took approximately one and half to two hour •. She was walked through the Hy.tem by the principal researcher and shown the following items:
• Logging in
• Adding a patient