City University

Project Description

The project looks at different aspect of the feasibility and need to roll out and support store-and-forward telemedicine applications in rural KwaZulu-Natal, South Africa.

Project Abstract

An abstract is not yet available, but following is the project proposal as submitted and accepted by City University.



Unequal health distribution in South Africa is a longstanding challenge that demands an urgent solution. Urban areas have ample health facilities, while some remote clinics cope with a visiting doctor.

The origins of inequality in healthcare provision are diverse, ranging from insufficient government financial backing, shortage of medical personnel in rural areas to the remoteness of some locations. Financial constraints results in resources channeled to more pressing needs, like procuring medication and surgical consumables. Lack of funds also contributes to the shortage of medical personnel. A large portion of the South African population lives in geographically remote areas. They are also the most vulnerable. The levels of education are generally poor with children leaving school early to help support the family. Employment opportunities in rural South Africa are in short supply and those with a secondary education regularly move to urban areas in search of better jobs or to pursue higher education. Many problems, like the medical personnel shortage and insufficient funds are dependant on other factors such as the economy and cannot be solved rapidly. These are some of the reasons why healthcare provision to the rural population of South Africa has need of innovative solutions that will not deplete much needed resources.

Telemedicine or “medicine at a distance” can potentially address some concerns on the subject of access to healthcare. Rural areas, generally, do not have telecommunication infrastructures with the necessary capacity or the equipment for real-time telemedicine, which prompts the question: Will store-and-forward telemedicine with its relatively modest bandwidth requirements be the way forward to combat rural isolation of both clinicians and their patients?

TeleMedMail was introduced in response to the need of primary care clinicians in remote hospitals to exchange clinical data with specialists for the benefit of second opinions and advice. Many remote clinicians have set up their own system using digital camera and e-mail, but it requires the use of several software packages, such as photo-editing programs, HTML editors, Zip utilities for archiving, e-mail programs and the camera’s own system. This approach, although effective, requires the user to be proficient in several software packages and provides no data security measures.

TeleMedMail is a simple store-and-forward open source telemedicine application (GNU Public License) written in Java 1.2 that simplifies the process of importing and sending medical images over the internet. It combines the above functionalities and incorporates data encryption. Patients, X-rays, pathology slides or documents are photographed with a digital still camera and the images e-mailed, together with textual annotations.

The “open source” approach has several benefits for South Africa. Expensive licensing fees are eliminated, access to and adaptation of the source code allows system development independent of any proprietor and system maintenance is possible without the original developers. Using Java allows for cross platform software compatibility.

TeleMedMail is currently installed in four remote sites in northern KwaZulu-Natal, South Africa, allowing practitioners to send text and image referrals to the Nelson Mandela School of Medicine at the University of Natal and to a radiologist at Grey’s Hospital near Durban. The system is not used much at present. This may partly be due to training issues and partly about defining the most important diagnostic problems, according to Dr Fraser. Interest at national level to this approach has been expressed and should it prove successful, an application such as TeleMedMail can be effectively deployed to other remote parts of South Africa. However, national uptake will rely on evidence demonstrating the suitability of TeleMedMail as a store-and-forward application.


The primary goal of this study is to determine the prospect of advancing the use of store and forward telemedicine tools, such as TeleMedMail, as a routine, practical and acceptable method for medical and radiological consults from remote clinicians in South Africa. This study will focus on the KwaZulu-Natal province, with the hope that it will encourage similar studies in the rest of rural South Africa.

Owing to time constraints, two topics have been selected as the key focus of this project. User satisfaction with TeleMedMail and evaluating the need for such a system will be examined comprehensively, while some other areas will be dealt with in less detail.

With the intention of realizing this goal, TeleMedMail will be evaluated on elements chosen on the premise of their importance to the success of such a system, where success implies the establishment of a routine, sustainable service that caters for the needs of both clinician and patient.


1. Primary Focus:

1.1. Several sites without TeleMedMail have been identified as potential candidates for implementation. It is recognized that not all will be suited to this approach, which necessitates conducting a Needs Analysis before proceeding with implementation.
The Needs Analysis will attempt to determine the view of some potential users, thus determining the feasibility of such a system. This will enable decision-makers to decide on realistic objectives for the service and judge the degree of support for such a system. It is important to find and encourage enthusiasts as without this, minor problems in the early stages of implementation will set the project up for failure. According to Swanson, “The existence or absence of a ‘local champion’ to enthuse the project participants and ensure the project is carried to completion is one of the strongest predictors of success or failure.”
Demonstration of TeleMedMail to end users will give them an indication of the capabilities it has. It is the intention of the author to visit sites to assess remote clinicians’ attitude towards and the practicality of implementation. It is expected that discussion with them will highlight both perceived benefits and potential problems. A questionnaire will be used to gather basic core information while informal discussion will be employed to uncover issues not previously identified.

1.2. User satisfaction and acceptance following implementation will be assessed by developing an Action Research methodology that will include questionnaires and unstructured interviews aimed at determining practicality, usability and dependability of TeleMedMail as observed by users on the receiving and sending sides. Unstructured interview methods point out important variables that will help identify hypothesis for further investigation and the formulation of probing questions.

These tools would comprise a major part of the study and address issues such as:

• image quality, by comparing the routine method of reading radiological images to a teleradiological method. One hundred images have been collected and digitized with the intention of comparing the original with the quality of the digital photograph
• identifying possible hindrances and barriers to the wider use of store-and-forward telemedicine in rural or remote South Africa and making recommendations for improvement
• diagnostic outcome and management of cases in remote sites based on timeliness, accuracy and usefulness of replies
• user view of the sustainability of applications such as TeleMedMail as an enduring alternative to traditional referral methods
• use of the system for real-life situations

If practical, patients would also be interviewed to discover their views on such a system. This would probably comprise open-ended questions to obtain a general view pertaining to their acceptance of store and forward telemedicine as an alternative to traveling to the referral site.

2. Secondary Focus:

2.1. An initial Literature Review dealing with telemedicine evaluation issues and techniques will be conducted prior to the commencement of the project to provide the author with an overview of the various approaches to conduct a meaningful study.

2.2. Conducting a Technical Evaluation will illustrate the intended functionality of TeleMedMail. Telecommunication networks composition and capabilities will also be investigated to determine acceptable standards of performance. A systematic Heuristic Evaluation in line with Nielsen’s 10 Usability Criteria will be incorporated to assess the graphical user interface design for usability.

2.3. TeleMedMail will be compared to alternate referral and diagnostic verification procedures to determine the significance, if any, of using it as a method to obtain second opinions.

2.4. A simple Impact Analysis will be conducted at sites with TeleMedMail to determine the actual effect on clinician working practices and patient outcomes concerning the prevention of unnecessary transfers to district hospitals.

Time Plan

The research for this project will be carried out over a two month period from August 2003, in KwaZulu-Natal, South Africa. Data will be collated and analyzed throughout the lifetime of the project. The final effort will be presented to Dr Abdul Roudsari on or before the 31 December 2003.


Remote primary care clinicians in some parts of South Africa developed rudimentary store-and-forward mechanisms to address the lack of expert local opinion. Although effective, this proved cumbersome and did not provide basic confidentiality measures.

Setting up store-and-forward telemedicine tools, such as TeleMedMail, was driven by clinical need rather than technology push, giving it an advantage over solutions proposed without a perceived need. The likelihood of acceptance and successful use as an everyday tool is a good deal greater in this way.

The introduction of new technology is seldom trouble-free and TeleMedMail is no exception. It is hoped that this project will uncover difficulties and propose potential solutions that will contribute to the ultimate goal of determining if store-and-forward telemedicine will benefit remote South African clinicians and their patients.


Carnall, Douglas. (2000) Medical software's free future. BMJ, VOLUME 321, 976

Fraser, H et al. (No Date) TeleMedMail: free software to facilitate telemedicine in developing countries [online]. Available from:
[Accessed 11 July 2003].

Fraser, H. (No Date) TeleMedMail: Store and Forward Telemedicine System
[online]. Available from:
[Accessed 14 July 2003].

Fraser, H ( (July and August 2003). Telemedicine Project. Email to Hartley, E (

Friedman, Charles P and Wyatt, Jeremy C. (1997) Evaluation methods in Medical Informatics. 3rd edition. New York, Springer-Verlag.

Nielsen, J. (No Date) Heuristic Evaluation [online]. Available from:
[Accessed 1 August 2003].

Swanson, B. (1999) Introduction to Telehealth [online]. Available from: [Accessed 7 August 2003].

Wellman, J and Kruger, S (2002) Research Methodology. 2nd edition. Oxford university Press Southern Africa.

TeleMedMail Application available for download from:
Vienna university of Technology, Goodie Domain Service. Available from:
[Accessed 12 June 2003].

Surveys released for this project:
Store-and-forward Needs Analysis 41
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