The first public event of the Diabetes Africa Chamber on Telehealth took place on 20 August 2020, and was designed to explore practices and practical aspects of telemedicine in Nigeria. This event was supported by Codix Pharma.
113 participants joined the discussion and explored the practical aspects of telemedicine in Nigeria. Three diabetes and telehealth experts led the conversation: Prof. Olufemi Fasanmade, President of the Endocrine and Metabolism of Nigeria and head of the Endocrinology, Diabetes and Metabolism unit at the Lagos University Teaching Hospital, Dr. Afokoghene Isiavwe, Endocrinologist and Founding Partner of Rainbow Specialist Medical Center (Lagos) and Dr Ronald Kelechi Ikpe, general practitioner, and founder of MRI Medic Consulting, a healthcare consulting and creative digital firm . While all of them have practiced medicine remotely as part of the hospital or clinic, Dr Ikpe also holds virtual practices on Doctoora and Wellvis, two Nigerian telehealth platforms launched in 2017 and 2018 respectively.
What is telemedicine in Nigeria?
‘Telehealth’ and ‘telemedicine’ are often used interchangeably, but on this occasion, participants distinguished ‘telemedicine’ from ‘telehealth’, a term that encompasses a broad range of remote health-related education and services. Telemedicine is the part of telehealth that replaces face-to-face consultations and helps healthcare professionals connect to patients online or by telephone.
COVID-19 has forced many healthcare professionals to adapt their daily practice overnight and in Nigeria, this has taken the form of phone consultations, mobile phone messages and video consultations. In addition, many healthcare professionals have joined private telemedicine platforms where they can hold virtual clinics, taking advantage of the flexibility that these platforms offer and of the supplement in income. Of the healthcare professionals participating in the event who had done a remote consultation, a majority declared using telephone most often (see box 1).
Box 1. Remote diabetes consultation practices among event participants
Are you currently doing or have you ever done a remote diabetes consultation?**
* Poll conducted among 113 participants in a Diabetes Africa live event (20 August 2020). *79 respondents. **63 respondents.
If you do remote consultations which method do you use most often (one answer only)?
Having had to set restrictions to limit the number of patients on their grounds, hospitals have also looked at ways to set up telemedicine services, ranging from basic enquiries to virtual consultations.
“At the beginning of April, the Lagos University Teaching Hospital (LUTH) set up a platform that allowed patients to ask questions that would be redirected to the most relevant units, or request prescriptions renewals” Prof. Fasanmade explained.
In August, Tremendoc, a teleconsultation and health management app, announced a partnership with Lagos state to digitalise the 27 general hospitals in the state, allowing patients to chat with, and arrange video and audio calls with healthcare professionals through the same platform.
Why use telemedicine, and why not?
Dr Ikpe speaks with about 15-20 patients every week on average, using telemedicine apps. From his own account, about a third of them have diabetes. “Telemedicine is making it easier to follow patients with diabetes, especially those who just need a refill of their medications. If they don’t have any complaints, we can easily do an e-prescription” he explained during the event. “For the patients, it helps them avoid stress, waiting time or wasted time, as it is easy to get stuck in traffic around Lagos.”
For the patient and the physician, telemedicine offers an opportunity to take back control of their schedule. “It’s not uncommon to go to the hospital and wait for the whole day to see a doctor” Dr Ikpe explained. He noted that with telemedicine apps, the process was streamlined: “you schedule an appointment, in 10-15 minutes you are done, and you can go home happy” -or more often, stay home.
An important barrier to using telemedicine in Nigeria remains technical know-how, both for patients and healthcare professionals. “Telemedicine is used by young people mostly and professionals” Prof. Fasanmade observed, “but also by people who are caring for their parents: many of the elderly patients are not tech-savvy, and generally limit their interactions to SMS or telephone calls.”
Addressing the non-clinical challenges of a remote diabetes consultation
The lack of technological literacy compounds a general lack of literacy and knowledge of diabetes self-management among patients. Many are not able to, or do not understand the value of returning pre-consultation questionnaires that could provide precious information about their habits, the evolution of their weight or blood sugar levels. Both general practitioners and specialists must step in to deliver diabetes education, which in other places is delivered by nurses and trained educators. “Quite a number of patients are at the mercy of coming to see their doctors for basic advice, with virtually no skills in managing their own care.” Prof. Fasanmade observed regretfully. “This is a major area where progress is needed.”
Access to self-management tools and devices is also problematic. Healthcare professionals in the audience were asked to comment on this point: more than two thirds estimated that their patients had no glucometer or testing strips, or had issues replenishing their strips.
“In rural areas”, where glucometers are rare, Prof. Fasanmade explained, “the first port of call may be to check if the patient can provide the result of a urine test.”
What other types of challenges are there?
Understandably, reliability of network, lack of data and other technological issues came on top of the challenges faced by healthcare professionals practicing telemedicine, as another poll conducted during the event revealed.
The same poll revealed that a third or participants feared that their teleconsultations would not provide them with enough information to conduct a comprehensive assessment of patients.
Addressing the clinical challenges of a remote diabetes consultation
Teleconsultations are incomplete by nature and require attentiveness from healthcare professionals. Only one or two of the five senses can be mobilised during a teleconsultation, half of what would be used during an in-person consultation. Subtle changes in posture or intonation can also be picked up by healthcare professionals when they see patients face-to-face.
This is why experts recommend not to take a patient’s own examination at face value. “What a patient would describe as a ‘small wound’ is very relative” Dr Ikpe remarked. Dr Isiavwe concurred: “By and large, telemedicine is better for patients without complications.” In her view, one of the main purposes of a video consultation is to determine whether a face-to-face is required. “Essentially, we use the video consultation for screening” she explained. “For patients who have ulcers or acute conditions, we insist that they come to the hospital.”
On some occasions, a third party may be able to assist the healthcare professional with the examination: “I do see some patients who have a family member who is a nurse or a pharmacist.” Prof. Fasanmade added. “If they have some medical knowledge, this family member can be your eyes and your hands.”
Another challenge in establishing a diagnosis or following a patient remotely is the lack of access to electronic records. Many institutions do not provide remote access to a patient’s record, and remote consultations may have to take place without a record. “Medical records are important, but with or without records, I still conduct an independent history-taking from the patients themselves, to confirm what is available or identify new clues that may lead to an accurate diagnosis” Dr Isiavwe explained.
“Most times, I don’t hesitate to do a full diabetes work-up, including hypertension, so that we don’t leave anything unturned” Dr Ikpe added. Patients can be unreliable in their recollection or with their own record keeping. “‘Normal’ is not the answer I want to hear when I ask about the results of a cholesterol test” he added dryly.
Can remote diabetes consultations be improved?
Without access to telemedicine during the pandemic, many patients with diabetes may have been in danger of contracting COVID-19 or developing diabetes-related complications. Keeping a line of communication between patients and healthcare professionals has been invaluable, particularly with the challenges to healthcare access that exist in Nigeria.
COVID-19 looks set to shape daily activities for the foreseeable future. As patients gain greater access to and familiarity with remote consultation options, telemedicine can only grow in popularity. For this reason, ensuring up-to-date knowledge of diabetes and patient follow-up among all those practicing medicine remotely -specialists or not- is critical. In the same way, technical advice and good practices relating specifically to remote diabetes consultation, should be documented with the help of local stakeholders. Diabetes Africa is committed to help support this effort.
This article was written as part of a series of events on diabetes and telemedicine, organised by Diabetes Africa.