The initial phase of data analysis involved the transcription of the recorded data to written data by the researchers. The researchers elected not to use computer aided software to assist with the transcription as, although it is faster, the researchers wanted to become immersed in the data and get a sense of the whole interview prior to commencing the initial search for themes [57,55]. An inductive thematic analysis was applied to the transcribed data as it enabled the researchers to identify and develop themes via iterative readings of the transcripts [58,59].
Three main themes, associated with image quality, emerged from the analysis of the transcripts. These themes were:
- The infrastructure and connectivity within countries affected the image quality.
- Images taken by tele-health professionals are superior to those taken by the patients on hand-held devices.
- Transmission of images between health-care to health-care professionals can result in degradation of the quality of the image.
Infrastructure and Connectivity
Two different themes, both associated with ICT, emerged from the data collected. The participants situated in Pakistan identified that that main issue with image quality was the inconsistency in the infrastructure between institutions. As there is no standard infrastructure used between telehealth facilities, the quality of the image can be affected. Participant P1 identified:
The first thing is the infrastructure. The infrastructure should be there in all the institutions you want to involve patients and others for this purpose.
This was supported by participant P2:
You can have very good internet facility in your center but the same sort of facility has to be available to the remote areas, only then you can deliver the services.
Within India the problem with image quality is the consistency in the connectivity of the broadband throughout the country. Participant I1 stated:
Basic connectivity should be more robust. Instead of tower and cable based, satellite based broadband is required for much better service. The bandwidth needs increasing so there is an uninterrupted supply; a robust and steady bandwidth.
Further evidence of the issues associated with connectivity in India came from participant I3:
The platform has to improve. In future it may be good for communication. Now it’s not up to the mark, there is lots of scope for improvement. In our country we have to sit in a place where we can connect, we can’t afford to walk and talk to a client.
Participant I7 said:
The one-to-one connection in the virtual window needs to be improved. We also need to work on the platform. The challenges in the virtual platform are the ease of use and the network problems.
In another example, participant I6 said:
First of all connectivity, it is not always seamless particularly in terms of voice connectivity as lot of people are using the same bandwidth. The quality of voice is poor and it getting worse, there is no point of having a good telephone and a bad line.
The connectivity specifically affects the use of digital equipment and the associated recorded image. Participant I1 said: “Configuring the digital instruments are a challenge due to the disruptions in connectivity”.
As evident from the above excerpts, two related factors affecting the quality of images is the different infrastructures used by different telehealth set-ups and the connectivity in rural and remote locations, specifically in India. In Pakistan the telemedicine hubs located in urban hospitals have adequate broadband and ICT infrastructure. Similarly, the urban ICT infrastructure in India is robust, however, the connectivity in rural areas is inconsistent.
Expertise of person taking images
From analyzing the data, the second theme that emerged was the difference in the quality of the image depending upon who took the image. If the image was taken in an organized telemedicine set-up and handled by a trained technician, it was evident that the quality was first class which made for easier diagnosis by doctors and other health professionals.
Participant P1 said:
There are conditions in which you can directly see the problem of the patient, you can ask to focus the camera on the problem, you can see problem, you can take the picture, you can get the reports online, and then you can tell the patients something about the treatment.
Participant P2 said:
Our technical people they can make a very good audio-visual connection, so the image and audio-visual is very clear. We can watch everything on our screen, look at the CT scan images and ask questions which they can answer. They make a very good audio-visual connection.
Participant I2 agreed:
If the health workers facilitates the interaction between the doctors and patient and sets up connected devices like digital stethoscope, patient examining camera and other things to measure blood pressure, hypertension, diabetes, random blood sugar fasting, oral cancer detection, the doctor can clearly see the issues, give advice and prescribe a treatment.
However, it appeared that in both countries there were consistent challenges associated with patients taking images of their health issues:
In Pakistan, participant P1 suggested that:
There are so many challenges, which are related to knowledge of IT. The thing which is important is the availability of the gadgets, every second person is holding a smart phone, they can easily connect to many things, but these things need to be organised at higher levels so people at the lower levels can get the benefit. General education and knowledge is important.
The lack of education in using smart phone technology and transmitting images using different apps was evident in the responses of participant P3:
A few of the patients, they are educated and we can give them the services. Using WhatsApp via the internet only a few people get the benefits as many of our patients cannot afford these services now. Only the educated patients can understand and know how to use them.
Participant P4 thought that the main issue when using smart phone technology was language based: ‘Some of the people in remote areas they can write in English with Urdu knowledge, but they can’t read English’.
In contrast, participant I4 thought:
I think the majority of the people are illiterate, but they know how to use headphones, how to use mobiles, it would not be difficult to train these persons regarding using them for telehealth.
Participant I6 also agreed that training would assist in the use of smart phone technology for telehealth imaging; “I think training is useful, very useful, but that has to go with good quality technology as well”.
The issues associated with the patient using a smart device to take images appears to be the lack of knowledge regarding the use of different apps both to take the image and to transmit it to health-care professionals. Additionally, it is not evident that there is any consistency in the type of app that is preferred by health-care professionals for image transmission. Connectivity and the ease of use by the patient are the two main criteria by which apps are selected. Participant I5 said:
Skype has some sound issues. I use Appear.in which has good connectivity and no sound issues. Patients do not have to log in which is an advantage for the non tech-savvy patients. It has a virtual video room where the doctor-patient can interact and images can be observed.
The selection of app to use for best interaction between the client and health-care professional was supported by participant I7:
We need to have video conferencing, they have a much better connectivity and feel when compared to the small apps such as video chat. Using video conferencing systems such as Zoom we get better connectivity.
The importance of the quality of the image received by the health-care professional was highlighted by participant I3 who said:
We are judging by pictures only. The picture quality matters as on-line consultations are only in 2D whereas in physical/face-to-face consultations you can see everything in 3D.
Participant I2 mentioned that the transmission of images was:
A lifestyle changer, not only for medicine, but pictorials, multimedia, films can be sent over the internet and seen on the computer. The challenge is that human resources are required to run this technology effectively and efficiently with focus and institutional interest.
The findings indicate that high quality images are important when diagnosing conditions. Images taken and transmitted are of higher quality than those taken by patients using handheld devices. The lower quality images taken by patients appear to be the result of clients being uneducated in using apps on handheld devices and the inconsistency in the apps used by different healthcare set-ups. All healthcare professionals interviewed agreed that the quality of the image was extremely important in determining the issue and diagnosing treatments.
Health-care to health-care transmission of images
The third theme evident from the analysis of transcript interviews was the transmission of digital images to other doctors and specialists to get a second or expert opinion. If the initial image quality is poor, it is difficult for specialists and doctors to make an evidence-based decision or determine appropriate treatment.
Participant P1 talked about the convenience of using digital images to get a second opinion:
I have a patient over there, this happens to me every day or every other day. I see that patient and I seek another opinion. I need the opinion of some other person, so I will take the picture and send it on WhatsApp to the other person. I will then call him, give him the history of the patient, what my findings are and ask him to give me their opinion.
Participant P2 said:
We use them as experts, calling them and sending them data to look at and give their expert opinion. Even during operations, the surgeons need consultation. I used to call my professor and share my findings for expert opinion. If I can take a picture and send it through WhatsApp then the professor can advise me of the next steps after watching the pictures.
As most of the healthcare professionals work in an organized telehealth set-up the transmission of images between them for expert opinion depends upon the organizational ICT infrastructure. Images are frequently transmitted for expert opinions and any degradation in the image, through compression of photos, distortion from device-to-device or unreliable infrastructure can affect the quality of the image.