Dr. Abdul Rahaman Ishak,
Consultant Pediatrician,
Director of Yemen Telemedicine Center
What is telemedicine?
Telemedicine is defined as health services via communications. It is a range of medical services that enable medical personnel working in hospitals and clinics to transmit medical images and data to one another so that the diagnosis (decision over the case of a patient) can be confirmed or verified. In particular it allows doctors working anywhere in the world to call upon specialist and sub-specialist skills located at leading centers of medical excellence worldwide and obtain a second opinion over a case.
Patient information; medical images (X-ray, CT, MRI, etc.) and patient data (reports) can be sent and then read by specialists and sub-specialists who in return make a detailed written diagnosis with necessary advice on patient case management. The full report is then sent to the attending physician.
Telemedicine services have been introduced in Yemen which followed most of the Middle East countries, Asia and Africa. It is an efficient method which proved to have an overall effect on the community represented by the public (patients) and in raising the level of local medical services.

Is telemedicine an essential need?
The need for medical and health services is increasing, as well as public and private facilities. The majority of people are more conscious of the need to explore all possible resources for treatment.
Patients get service in different places according to methods of treatment, which represent large number of schools and languages. There are many practices that are not controlled by simple rational methods of practice. As such, it is very difficult to find an evaluation as to what is happening in the practice of the market of medicine. The practice has been affected by major factors, the most important of which is the commercial factor.
It may be difficult to measure the outcome of the practice of medicine in general, the general impression can be expressed in the huge number of patients going abroad for treatment and the cost involved.
Travelling abroad is in many cases is due to many factors, the most pronounced is the lack of proper diagnostic information and communication. The need for care is growing very fast but the ability to develop information is so primitive and the application of the patient to get information as to what to do to solve his problem. This affects all sectors of the community, and makes it difficult to measure the outcome of practice inside and outside the country. It also creates a situation of uncertainty which is a big obstacle in the development of medical service both public and private.

Every single day many patients seek medical care in many centers in Yemen both public and private. However, many more do not approach the medical establishments as they either obtain drugs directly from the drug stores or use available traditional medicine. The outcome is not possible to measure, the waste of human life and the suffering of many who develop chronic diseases, and the huge economic loss is definitely worth noting. All efforts must be pushed towards what may be called a prevention program.
One of the outcomes of the failure of the health system is the need to travel abroad. The drawback is not necessarily in giving the service, but in many situations it is the failure to convince the patient that he can get the same benefit inside the country. The desire to travel abroad for treatment is becoming so attractive that many people think they will get a definite cure to their problems even though the truth is not the same. The facts about the need for travel abroad has never been investigated properly. There is a definite need to know the cases that are obliged to go abroad because of the delays in diagnosis and the complications for local treatment.
Telemedicine (TM) can provide one of the most important modern means of reaching any place for medical help without the need to travel. It is a means also for making travel for medical service more safe and efficient. The whole activity would essentially introduce a definite and clear documentation and storage of knowledge. This will provide one of the most important means of developing literature, of improving education, and of developing an information system. Telemedicine facilities provide the chance to get information about medical problems from the following points of views:

• The field of medial problems
• The stage of illness at the time of travelling
• Complications arising due to late diagnosis
• The cases where telemedicine can provide the service while the patient is at home
• Areas which are early about the cases, which are difficult to manage or need further laboratory facilities

The rate of advancement in medical technology is so huge that it is becoming merely impossible to keep up to date with the changes in concepts, means, methods and to have all equipment and manpower for all specialties and subspecialties under one roof. It is even more impossible for developing countries to have highly specialized centers (equipment, manpower, running costs etc.) for the very large number of subspecialties.
The compensation for this defect is to travel abroad. Traveling abroad is needed not only for finance but for the knowledge and experience of the places, the people, and the very large number of problems associated with medical cheating, ineffectiveness, lack of quality etc.
By using telemedicine, traveling abroad will be minimized. If needed it would be much more organized and studied.
Travel abroad is costing the country several millions of dollars, besides the human sufferings and the continued weakness of local medical services.
It undermines all aspects of health services, with the need for a second opinion via local and international services. Telemedicine networks justify the support of any activity which may help in solving the problem of traveling abroad for treatment and of getting a second opinion for the purpose of service and education.

Facilities that may be made available for TM are:
Local network:
The presence of such facility is expected to decrease the need for traveling abroad by at least 30-40% (according to the regional experience), while increasing the confidence in local treatment and the investment in local medical facilities several fold. The following are just examples for the application of TM.
The field of cardiology: The general practitioner or even the medical assistant in a remote area can use simple means of collecting data, such as ECG, chest X-ray and clinical data for a patient who is unable to travel to the city and get a quick and perhaps immediate response from the specialists in the city.
The field of accidents and thaumatology: The practitioner can make consultation to get an opinion in the field. Accidents are increasing tremendously and the knowledge and experience to deal with the immediate effects is very minimal and primitive. First aid workers can get instructions to increase the efficiency several fold, and at the same time it is educational and provides documentation.
The field of community medicine and public health: Our community needs urgent and important means which help the process of diagnosis, reporting, notification, control and prevention of the spread of disease. The doctor in the remote area can reach an expert opinion about selected number of public health problems which are important in his area.
The industry of tourism: Tourists would be encouraged to visit the country and visit remote areas if there is a facility for telemedicine. From all medical emergencies, good and qualified medical attention may be provided with the backup of telemedicine service.

International link:
Second opinions from highly specialized centers from sub-specialists on on-going treatment increases the confidence of patients in the treatment, and helps to eliminate some of the practices which may be harmful or less efficient.
Telemedicine provides information for patients who need to go abroad (place, reservation, cost, prognosis, liability etc.) A significant number of patients may be convinced to go on with the treatment locally if provided with a convincing second opinion.
It provides continued education and the exchange of experience while at home. The local network allows remote areas, which are deprived of everything, to get some share of the exchange of experience and continued education.

Conclusion:
Medical services utilizing all means of communication can bridge the gap between developed and developing countries and can also significantly strengthen the process of education. It is an urgent need in Yemen in particular to decrease the loss of millions of dollars and support local medical services through providing more efficient services to the patient.
Live examples of local experience of the Yemen TeleMedicine Center will be discussed in the coming episodes.

Mahfouth A Bamashmus
FRCSEd, FRCOphth
Consultant Ophthalmic Surgeon
Ibn Al-Haitham Clinic
University of Science & Technology, Sana'a
bamashmus@y.net.ye
Until recently the cost of laser pens and keychains was fairly high which precluded sale to the general public. But a dramatic reduction in the price of small laser pens has altered their market and, because of the low price, lasers fall within the hands of the public, including children.
These lasers, available from many retailers, are often sold as "laser pens" or "laser keychains". These laser-emitting objects are potentially harmful and should not be used by untrained personnel.
The ability of the laser to cause focal burns within the eye makes it suitable for treating conditions such as diabetic retinopathy and retinal holes. Focusing the laser onto a spot on the retina can produce permanent retinal lesions. Likewise, the laser emitted from laser pen or laser keychains, when held 10 meters from the eye, will form a retinal spot and burn.
Unfortunately the damage produced by these lasers can be permanent. If the laser only was pointed on the outer part of the eye (the cornea) it only produces an abrasion that heals within few days without any residual damage. But if is concentrated on the retina especially the yellowish spot (the macula) concerned of the main central vision the damage can be permanent. The person loses the clarity and the ability to see clearly forever with the eye affected.
Children sometimes are playing an alarming game of "chicken" to see how long they can stare into the laser beams of these pens. Not surprisingly, this makes lasers potentially very dangerous in the hands of children.
Most developed countries have produced regulations on using these "laser pens" and "laser keychains" and are not sold to the public as they used to be. Unfortunately in Yemen you can buy them easily and we need to find a way to limit its distribution and the damage it produces to the public especially the children.

Reference: The damaging effects of light on the retina by J Lanum.