Experience with low-cost telemedicine in three different settings. Recommendations based on a proposed framework for network performance evaluation

Background: Telemedicine has been used for many years to support doctors in the developing world. Several networks provide services in different settings and in different ways. However, to draw conclusions about which telemedicine networks are successful requires a method of evaluating them. No general consensus or validated framework exists for this purpose. Objective: To define a basic method of performance measurement that can be used to improve and compare teleconsultation networks; to employ the proposed framework in an evaluation of three existing networks; to make recommendations about the future implementation and follow-up of such networks. Methods: Analysis based on the experience of three telemedicine networks (in operation for 7-10 years) that provide services to doctors in low-resource settings and which employ the same basic design. Findings: Although there are many possible indicators and metrics that might be relevant, five measures for each of the three user groups appear to be sufficient for the proposed framework. In addition, from the societal perspective, information about clinical-and cost-effectiveness is also required. The proposed performance measurement framework was applied to three mature telemedicine networks. Despite their differences in terms of activity, size and objectives, their performance in certain respects is very similar. For example, the time to first reply from an expert is about 24 hours for each network. Although all three networks had systems in place to collect data from the user perspective, none of them collected information about the coordinator's time required or about ease of system usage. They had only limited information about quality and cost. Conclusion: Measuring the performance of a telemedicine network is essential in understanding whether the network is working as intended and what effect it is having. Based on long-term field experience, the suggested framework is a practical tool that will permit organisations to assess the performance of their own networks and to improve them by comparison with others. All telemedicine systems should provide information about setup and running costs because cost-effectiveness is crucial for sustainability.