Mobile teledermatology for a prompter and more efficient dermatological care in rural Mongolia

DEAR EDITOR, Many developing countries suffer a scarcity of trained clinicians, who are usually concentrated in urban centres, leaving large rural populations essentially underserved. The adoption of technology could offer new opportunities for patient benefit in term of costs, better care and in turn, better outcomes. Telemedicine is a promising tool to ameliorate the widening healthcare supply and demand gap through which the reach of consultants can be digitally extended, allowing them to virtually cover larger or remote regions. Smartphone applications have been shown to be a simple, feasible and reliable method for performing store-and-forward teledermatology consultations in rural unpopulated areas. Our study aimed to estimate the distance, time and cost of travel saved by patients who received teledermatology service though a mobile phone platform in rural clinics in Mongolia, one of the least densely populated countries in the world. A cluster-randomized controlled trial was done for a period of 5 months from 1 September 2013 to 31 January 2014 at 20 rural health clinics in Mongolia. Three districts based on distance from Ulaanbaatar were selected: Khovd (2000 km), Khuvgul (1000 km) and Bulgan (350 km); and ten general practitioners (GPs) working in rural health clinics from each of these districts were invited to participate in the study. Twenty GPs attended a 2-day training session at the National Dermatology Centre in Ulaanbaatar to learn image-taking techniques and how to use the open-source electronic medical record system (OpenMRS) and Sana software on mobile phones. This is a mobile phone-based, open source software platform for telemedicine services that uses an Android-based system and supports multimedia, location-based data, and text. It is easy to use and highly customizable; doctors can build tailored questionnaires for healthcare workers and can create decision trees for diagnosis, triage and treatment to broaden the healthcare workers’ scope of practice. The questionnaires and web interface of OpenMRS and Sana were translated to Mongolian to mitigate the language barrier. With a computer-generated sequence, rural health clinics were randomly clustered either to the intervention group, in which all GPs received teledermatology consultation support through OpenMRS and the Sana system; or the control group, in which GPs referred patients to dermatologists at district hospitals or the National Dermatology Centre as per their usual standard of care. This randomization allowed for an equitable distribution of rural health clinics from the three districts into both groups. In the health clinics randomized to the intervention, GPs collected clinical data from patients through a step-by-step questionnaire on a smartphone. This data was uploaded to an OpenMRS with diagnosis-specific information and images (Fig. 1) in order to provide consultant dermatologists enough clinical information in an organized manner, and allowing them to give feedback and advice to the rural health clinic within 24 h. All GPs from both groups sent monthly reports of the number of hospital referrals done and information about the follow-up visits of the patients.