Applicability of smart phones in identification and transferring the static images of oral mucosal lesions by allied health workers- A feasibility study

Introduction

Health care system is moveable in nature, which involves various clinical work stations like clinics, in patient wards, outpatient services, emergency services, operation theatres, intensive care units and laboratories etc.^1-4 Work culture in health care delivery system involves high mobility among health care professionals, establishing communication and collaboration between their colleagues as well as patients. Earlier Pagers were used for communication among health care professionals before the advent of cell phone in 1990s.⁵

In recent years there has been a dramatic adoption of smart phones by health care professionals and public.^6-12 Smart phone is a device which uses satellite communication and computation which can be hand held and used at point of service delivery. Specifically areas of educating patients, self-management of diseases and monitoring and referral of patients has been made possible using Smartphone technology. The relative ease in carrying and user friendly technology coupled with an affordable cost drives a health care professional to them in a clinical setting for health care delivery.

Telemedicine is a novel way of using information technology and communication systems for delivery of health care services beyond boundaries.¹² It uses electronic information to communicate technologies to provide and support healthcare when distances separate the participants.¹³ Telemedicine is part of an extensive process or sequence of care. It can improve this chain and thus enhance the quality and efficiency of health care.¹⁴ Telemedicine nowadays has been used in academic medical centres, community hospitals, managed-care companies, rural hospitals, and is also being used internationally to link providers in developing countries to hospitals in developed countries. Advances in digital communication, telecommunication, and the Internet introduce an unprecedented opportunity to access remote medical care.¹⁵

The birth of teledentistry as a sub specialist field of telemedicine can be linked to 1994 and a military project of the United States Army (U.S. Army's Total Dental Access Project), aiming to improve patient care, dental education, and effectuation of the communication between dentists and dental laboratories. This military project demonstrated that teledentistry reduced total patient care costs, extending dental care to distant and rural areas and offering complete information required for deeper analyses.¹⁶ As technology has advanced, new opportunities for teledentistry have been created. Technologies currently available are beginning to change the dynamics of care delivery. Tele dentistry proposes newer prospects to improve level of patient care and reform existing commercial models.¹⁷

Tele dentistry has the capability to improve access and deliver oral healthcare as well as lower its costs.¹⁸ It also has innate capability to eliminate the disparities in oral healthcare between rural and urban communities.¹⁹ Tele dentistry might turn out to be cheapest, as well as fastest way to bridge the rural-urban health gap. Rural areas of Sullia Taluk of Dakshina Kannada District Karnataka are known for areca nut cultivation and consumption known risk factor for oral mucosal lesions. Further, remotely accessible areas and lack of sufficient awareness and health manpower complicate this serious public health problem.²⁰ The present study was planned and conducted with an aim of assessing the applicability of smartphones in identifying and transferring the static images of oral mucosal lesions captured by allied health workers in order to facilitate primary preventive procedures at the earliest.

Materials and methods

Study design: This pilot interventional project was designed and conducted amongst allied health workers in Sullia Taluk of Dakshina Kannada District for identification and transferring the static images of oral mucosal lesions by using smart phones for further diagnosis and follow-up.

Ethical clearance / informed consent: Ethical clearance was obtained by the institutional review board of K.V.G Dental College and hospital (SS15/15/ KVGMC). Permission to conduct this study was obtained from District Health Officer and respective medical officers of participating primary health centres. Informed consent was obtained from health workers as well as patients who participated in this project.

Inclusion criteria: All willing allied health workers (ASHA workers) from selected primary health centres who owned and continue to use a smart phone.

Sampling methodology: From a total of 10 Primary health centres spread across Sullia Taluk, six centres were randomly included using a random number table. Willing ASHA workers attached to the randomly included PHCs satisfying the inclusion criteria were included in this project.

Procedure: study included a total of 30 allied health workers from six different primary health centres. Prior permission was taken from the concerned medical officer for training of participants.The Principal investigator was trained and calibrated in providing the training to the ASHA workers. The investigator himself visited the respective centers with a prior permission and trained the ASHA workers for one hour in each centre for identifying the patients with mucosal lesions, photographing, coding and transferring the static images of mucosal lesions by using smart phone application. At the end of each day they were asked to forward the images to a particular contact number (chief investigator) given to them.

The static images of oral mucosal lesions that were received by the chief investigator over a period of 2 month were forwarded to a staff (Associate Professor) in the department of oral medicine radiology and diagnosis of K.V.G. Dental College and Hospital on daily basis for an expert opinion. The Staff was trained in the Department for interpretation. The interpretation of staff was coded into 4 categories like 1) No abnormality detected 2) Benign lesion 3) Potentially-Malignant lesions and 4) Malignant lesions. Repeat opininons from the staff were obtained for one third of the images every day and calibrated for accuracy. Kappa statistics was calculated to assess intra examiner reliability. It was found to be 0.7 suggesting a very good reliability. Necessary action was taken further according to a standard protocol of management. Data was entered in a specially designed proforma which included four parameters;

1. Socio-demographic characteristics of the allied health workers.

2. Coding of the static images including patient’s details

3. Diagnosis of the images transferred from allied health workers through various smart phone apps

4. Standard follow-up protocol

Statistical analysis: Basic descriptive statistic was performed and expressed in numbers and percentages. R command software was used to perform the analysis.

Results

Between May and June 2016, 38 allied health workers from six primary health centres’ who fulfilled inclusion criteria of this study were invited to participate in pilot project. Of the consenting participants, eight were excluded from the final analysis because of failure to comply with inclusion criteria. As a result, 30 allied health workers were included in this study. Frequency distribution of participant’s shows 80% participants were female, 53% of participants belonged to 24-35 age group, 47% were staff nurse and most of them used Samsung cell phone (60%) with WhatsApp (80) for the transfer of images as shown intable No-1. A total of 160 oral images of 80 patients (2 images of each patient) were obtained from 30 allied health workers participants using the various Smartphone Apps. A total 32 images were discarded because of poor quality thus a total of 128 images, (64 pairs) were amenable for further analysis.

All received images were stored in a database in an uncompressed JPEG format; the average file size was 900 KB. The number of pictures collected from different participants, their designation and diagnosis done in the department of oral medicine radiology and diagnosis as mentioned in Table No-2 further communication/ referral and treatment was undertaken according to the protocol as mentioned in Table No-3.

It took approximately one minute to register a patient (entering personal details) and five minutes to take pictures. The quality of images obtained was assessed by the chief investigator himself to ensure that they were complete, colour-balanced, focused and clear. Image analysis revealed no abnormality detection in 66 images (33 patients) and benign lesions in 14 images (7 patients) potentially-malignant lesions in 34 images (17 patients) and malignant lesions in 14 images (7 patients).

Discussion

Smartphones can access medical applications; evidence based resources as well as mobile communications at the point of healthcare delivery. Their flexibility allows clinicians to use them in a medical scenario for patient care.²¹ Tele dentistry is ‘not’ a novel specialty. It is, in reality, an alternative method to deliver the existing dental services.

The utility of telemedicine in distant, remote areas cannot be emphasized enough. Its application is of utmost importance and great value in rural and urban areas where there is unavailability of specialist consultation.

Thus this study assessed Smartphone-based health care application in identification and transferring the static images of oral mucosal lesions by allied health workers. There are many advantages of using smartphone based healthcare applications in medical practice. For example, they allow for advanced mobile clinical communications using multimedia functions and provide access to various clinical resources at the point of care.

In addition, they can provide secure remote access to real-time patient monitoring system for better patient care. Smartphone-based patient oriented applications deliver healthcare services for patients with chronic conditions, which is the purpose of mobile health or mHealth.^22-23 The mHealth component of eHealth delivers medical and healthcare services through mobile devices.²⁴ The World Health Organization (WHO) has recently defined mHealth as “medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices.”²⁵ The wide adoption of high-functionality smartphones by the general public highlights the increased demand for better mHealth services through smartphones.²⁶

Studies show wide adoption of smartphones by healthcare professionals during recent years6 Smartphones are getting popular for clinical use among clinicians, and medical and nursing students.^27-29

Tele dentistry could be a new aspect of overall patient care that's quickly increasing in quality and price.³⁰ It'll turn out rattling blessings for the patients of a medical care doctor UN agency partake of the large experience obtainable through teleconsultation.³¹

Information exchange leads to improved patient care, and the ability to consult more efficiently with colleague’s leads to greater understanding of the treatment objectives and better treatment outcomes.³² Teleconsultation over teledentistry may happen in following ways – “Real-Time Consultation” and “Store-and Forward Method”.³³ Real-Time Consultation involves videoconferencing among dentists and patients located remotely.³⁴ Store-andForward Method involves exchange of clinical information and static images collected and stored by a dentist, who forwards them for consultation and treatment planning.³⁵ The patient need not be present during the “consultation.” As a pilot study 30 allied health workers were involved in this project for identification, photographing and transferring the static images of oral mucosal lesions to a health care facility. Among 128 photographs selected for the analysis, 51% of them found to have no abnormality, 12% of them were having benign lesions, and 27% were diagnosed with premalignant lesions and 10% with malignant lesions and the Smartphone camera used in this study produces images of 10 megapixels and above and is considered adequate for producing good-quality images.

However, in some cases there was concern about the loss of valuable clinical data due to the poor quality of images. Our findings recommend a blend of a Smartphone camera and store-and-forward technology for oral health screening can be adequate for screening purposes and offers a reliable alternative to traditional oral examinations. This pilot project showed that at the level of proof-of-concept that there was a good concordance between teledental and faceto-face oral assessments.

Considering the principle of primary and secondary level of prevention the early detection and treatment of various mucosal lesions can be an effective way of  health intervention for the underserved and people leaving in remote areas.

The use of available economical network infrastructure can reduce overall practice expenses and consultation fees. Integration of teledentistry into practice has the potential to address certain aspects of routine dental practice such as reducing consultation times and practice expenses, as well as improving practice management, referrals and patient satisfaction.

This trial demonstrated the effectiveness of teledentistry in providing dental care to people living in a remote space and also the viability of remote specialty consultations

Conclusion

This trial shows that teledental screening has prospective of utilization as a valid and reliable screening tool to identify high-risk individuals with decay and can allow onsite practitioners to triage referrals in a timely manner and treat more patients. However, this study was only a proof-of-concept trial and a full study is needed to confirm the accuracy and reliability of the teledentistry system.

Recommendations

Smart phone application in diagnosis and referral may be recommended to combat various health issues at least in rural areas.