April 24, 2009Telemedicine Symposium, Bryn Mawr College

Nyaya Health's Ultrasound Program in Rural Nepal

Implications for Teleradiology in Resource-Denied Areas

Duncan Maru, PHD

Overview

About Nyaya Health and AchhamGlobal Need for Radiology ServicesNyaya's ProgramUltrasound Design SpecsHuman ResourcesQuality Assurance and TeleradiologyImplications for X-Ray and Beyond

Achham, NepalNumber of citizens: 250,000Number of doctors: 199.5% of babies are delivered

outside a health center1 in 125 deliveries result in death of

the mother60% of children are chronically

malnourishedAverage person makes $150 a yearNearest functioning airport and

hospital: 10 hour bus ride away, costs 1-2 months' average income

80% households have one male migrating to India

Mission 1:

Facilitate resource distribution to resource-denied areas

Mission 2:

Foster local human capacity and grassroots collective action

Mission 3:

Apply evidence-based medicine principles and data monitoring

Mission 4:

Involve the central government in pro-poor health infrastructure

Mission 5:

Achieve transparency and collaboration in global health delivery

Global Need for Radiologyover 50% of the world's population lack access to X-Ray and ultrasound

effective technology exists

what is lacking: financial support, training, evaluation, monitoring

Ultrasound: Uses in Rural Areas

Referral to higher level facilities

Assistance in guiding procedures

Point of care diagnostics

Ultrasound: Uses in Rural AreasCondition View InterventionObstructed Labor Abdominal Cesarean sectionEctopic pregnancy Abdominal SurgicalRetained products of conception Abdominal Dilation and CurrettagePeripartum hemorrhage Abdominal Medical managementCholecystetitis Abdominal Medical management; SurgicalTuberculosis (intra-abdominal) Abdominal Antibiotic medicationHydronephrosis Abdominal Medical managementAbdominal trauma Abdominal Medical and surgical managementAbdominal masses Abdominal Medical and surgical managementPleural effusion Chest PleurocentesisCardiac failure Chest Medical managementCardiac valve disease Chest Medical management; SurgicalPericardial effusion Chest Medical management; pericardiocentesisPneumothorax Chest Chest tubeHemothorax Chest PleurocentesisLong bone fracture Limb Reduction and fixationDeep vein thrombosis Limb AnticoagulationIntravenous Access Variable ProceduralAbscess Variable Drainage

Nyaya’s Ultrasound Programstarted August 2008

from donation of GE Logicbook E through International Aid

with assistance from Yale Emergency Medicine faculty

Ultrasound Design Specs

small, portable

power needs of a small laptop

robust; used in extreme environments

produces high-quality images

Human ResourcesFocus on physician initially

Gradually building up capacity of midwives

Need to improve overall computer literacy

Can improve job satisfaction, retention, cost-effectiveness

Oversight is critical

Quality Assurance

store-and-forward

review of static images by Yale faculty

Simple data collection and review

Open-access to datawiki.nyayahealth.org/UltrasoundProgram

First 6 Months: Snapshot

primarily physician-conducted

Training of midwives ongoing

70 Obstetric, 99 Non-Obstetric

23% of OB and 40% of non-OB significantly changed management

Selected Diagnoses and ProceduresHepatic massHydronephrosisCholecystitisEnlarged abdominal lymph nodesRetained placentaFetal demiseNormal pregnancyTuberculosisIV accessAbscess drainage

Implications: TeleradiologyEffective teleradiology can be quite “simple” technology-wise

Key is regular oversight and data review

Investments in telecommunications can be well worth the expense

Implications: X-RaySimilar issues in technology, staffing, evaluation, monitoring

Again: need financing and collaboration

Simple store-and-forward teleradiology can be highly effective

Open-access standards to improve transparency

What you can do…Join the social movement. Donate, spread the word, fundraise.

Volunteer. Need for dynamic, financially and tech saavy global health leaders

More info at www.nyayahealth.org