Improved communication and collaboration.

ATCs enabled NPCs in Turkana to access clinical support from highly-qualified physicians/specialists. It also linked them to distant referral facilities with improved communication, teamwork, and continuity of care for patients recommended for referral. Whereas previously, NPCs in rural health facilities would have little-to-no communication with a physician, either for professional development or to discuss a case, ATCs provided a way for clear and directed communication to take place. Opportunities for collaboration, teamwork, and partnership within and between health systems also increased. Prior to engaging with ATCs, COs were afraid to approach MOs, and MOs were equally shy to approach specialists. Teleconsultations contributed to reducing social status barriers between healthcare providers, with health professionals of different cadres seeing themselves as part of a team delivering quality care to patients in Turkana.

“Even though I am alone, I feel that we are many; I am not alone.”–Nurse, Turkana County

NPCs and remote physicians alike addressed the platform’s ability to enhance a pre-existing perception of ‘brotherhood’ that existed among Kenyans working in remote locations. This closeness was further enhanced by a belief that healthcare professionals worked towards a common cause for the benefit of their people. From the perspective of remote physicians, the ability to speak directly to the NPC about a case, whether through the chat function on the platform or by phone, added greatly to their ability to provide sound feedback on case management.

Improved skills and confidence.

Both NPCs and remote physicians reported a direct link between using the ATC platform and growing technical skills and confidence in their clinical practice. For NPCs, uploading challenging cases and receiving feedback and support from physicians allowed them to learn and further develop clinical skills.

“I feel satisfied because when I enter the case, I get more knowledge because the doctors or the consultants will add more flesh to what I have, to my diagnosis, when they now send the feedback. I am able to see it and say, ‘Ok, I could have done this, I could have done that.’ So, it adds some more knowledge to me in my experience”–CO, Turkana County

NPCs also saw ATCs as a capacity-building mechanism, where they have direct access to technical advice and perhaps even longer-term mentorship from senior colleagues. These interactions assisted NPCs to better interpret patient signs and symptoms under the guidance of physicians. One NPC commented that knowledge acquired through one ATC had improved his ability to handle a similar case the next time without support.

Additionally, the ATC platform’s systematic approach to entering patient data using a “structured narrative” approach aligned with best practices in documenting patient history. NPCs improved their skills in case documentation through training and the structure of the platform. Both NPCs and remote physicians commented on the benefits of such organization of clinical information to improve consistency in documenting patient information by NPCs, and in aiding remote physician review of each case.

“It also makes me feel like now my records are well kept… Anything I need, especially for medical legal [purposes], I can get it from the platform.”–NPC, Turkana County

“… the [clinicians] who have been presenting materials in the platform have very good write ups on the history, particularly the previous history of what has gone on … from the information I have probably 80% of what I need to make a decision.”–Remote physician, Nairobi

The ATC platform’s capacity for uploading clinical and radiology images also added relevant details to a case review, increasing a remote physician’s ability to make an informed decision. Remote physicians also noted that the interaction with challenging and rare cases encouraged them to study and consult other physicians, building their own skills and strengthening profession networks in the process.

“I don’t want to pass on the wrong information, which may affect someone else’s life. It’s a huge responsibility…and motivates me to be more knowledgeable.”–Remote physician, Nairobi

“… as a professional I feel it’s giving me an opportunity to grow … it also helps keep building on medical knowledge especially considering where I work now, the range of cases we see are quite different, so for me it really helps me keep my mind sharp.”–Remote physician, Nairobi

Increased professional satisfaction.

NPCs and remote physicians expressed pride and satisfaction in their work as a result of the nREM project. Through ATCs, NPCs believed their patients could receive the highest quality of care possible, even in remote, low-resourced settings. The satisfaction of knowing they gave patients the best care possible generated a virtuous cycle, increasing patient confidence in their ability to deliver high-quality care.

“My patients see me as a professional. They always come back to my health facility because they say they’ve been helped.”–Nurse, Turkana County

Remote physicians also expressed professional satisfaction in their ability to review, study, and provide accurate feedback to a challenging case in rural Turkana, including feelings of usefulness and pride in serving fellow Kenyans.

Increased equity in access to care.

Increasing equity in healthcare access was particularly noteworthy in a vast county like Turkana where disparities in access to healthcare are wide [32]. Vast geography, poor infrastructure, a nomadic population, and a long history of marginalisation has resulted in a poorer healthcare services and health outcomes in Turkana compared to urban regions of Kenya [31]. Through ATCs, though, respondents expressed a great sense of enthusiasm about patients’ ability to access the same quality of care as someone living in Nairobi.

“Patients are getting great care from all this [access to teleconsultations].”–NPC, Turkana County

Quantitative data from the nREM project on age and sex distribution of physical referrals versus teleconsultations support the impact of ATCs on equity in access to physicians (Fig 4). ATCs tend to be more equally distributed between adult men and women, and children, when compared with physical referrals (across the county and not restricted to nREM sites) during the study period, which were dominated by adult men (difference not statistically significant).

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Fig 4. Distribution of referrals and ATCs between adult men, women and children.

Numbers of external referrals (from LCRH to facilities outside Turkana County) internal referrals (from PHCs in Turkana to LCRH), and teleconsultations/electronic referrals on the ATC platform between January 2017 and June 2018. External and internal referrals involved traditional patient movement (with or without ambulances), without electronic documentation on the ATC platform. Difference not statistically significant (χ² (4, n = 1,078) = 7.1703, p = .13).

https://doi.org/10.1371/journal.pone.0238806.g004

Increased efficiency of referral.

Access to ATCs made NPCs more likely to consider local management with remote support. Prior to the nREM project NPCs were more likely to refer challenging cases to referral hospitals. Multiple respondents spoke to the reduction in unnecessary referrals, and alleviating the pressure on referral facilities to accommodate patients who could be treated at primary level. When referrals were necessary, ATCs improved coordination of care between PHCs and the referral hospital.

“In the past I would have said, ‘Let’s just refer,’ but when someone senior tells you, ‘No, you know what? It’s malaria, let’s do this;’ or ‘It’s meningitis, let’s do this treatment;’ It helps.”–Nurse, Turkana County

“[ATCs] reduce patient influx, as in referral…patients who are occupying beds, you know, unnecessarily. So at least when we have patient referred to county referral centre, this is a patient who is worthy, who is really in need of that service, so we reduce the pressure in the referral facility, because we are able to do them wherever we are.”–CO, Turkana County

“Before the platform was introduced, you had to call Lodwar that you are bringing a patient with this and this condition, and sometimes you come with the patient, only to reach Lodwar and you become aware that they are not prepared to handle the case. But with the introduction of the platform, once you enter the case into the tablet, by the time the patient is referred…you come when they are already aware about the case of the patient and they have prepared. For those with minor surgical cases, they are attended to and patients are very happy. They come and say that this computer is actually helping us.”–CO, Turkana County

County Government officials spoke to the “millions of Kenyan shillings saved” through preventing unnecessary referrals (e.g. costs for ambulances, fuel, driver, accompanying clinicians, hospital expenses). While transportation cost savings from avoided referrals are relatively simple to calculate, savings from improvements in clinical care, patient outcomes and quality of life are harder to estimate, as are costs borne by patients and other actors outside the health system. These are however clearly articulated by clinicians and administrators in the county.

“[recording referrals on the nREM Platform] saves them a lot of things. One, they should write referral form. Two, they should look for an ambulance, in case they need an ambulance. Three, those ambulances…they need fuel, so they have to inquire about fuel. They inquire about allowances for the drivers. Then even the nurse who is accompanying the patient. So, it’s a big process when you are referring patients, rather than when you are using the platform, yes. I think it somehow you know reduces their works schedule.”–CHMT member, Turkana County

Increased data access and use.

Data collected through ATCs were available to county stakeholders for decision-making in health systems strengthening efforts. These data brought out trends in primary healthcare in remote areas, while also highlighting gaps in diagnostics, management, and personnel and equipment availability. Several county stakeholders chose to use ATC data from the nREM project for their own system-level reporting and decision-making. Availability of these data reportedly saved time that was previously used to search for information from each health facility. ATC data, available in electronic format, enabled health system managers to assess county achievements and set future milestones more easily. County stakeholders also valued the data availed through ATCs for purposes of developing health system strategies for the county, as well as advocating for the amendment and implementation of various health policies including those around facility and personnel development and the distribution of funds.

Improved patient management and quality of care.

By receiving remote support from MOs and specialists for managing cases locally, NPCs were able to offer improved clinical care to patients. While this is difficult to demonstrate quantitatively, responses from clinicians in interviews and FGDs suggest that patients received better services as a result of ATCs, at least partly due to improved clinical capacity and confidence in the NPCs. This was also reflected in a perception of increased patient confidence in their work and the system broadly.

“I feel connected to a wide range of information, so I’m confident about my care.”–Nurse, Turkana County

“Patients are also confident that the health care workers are working on him or her. And in case of anything, they have confidence that we will forward their case and we will get immediate feedback on how to give them better health management.”–CO, Turkana County

Increased social benefits to patients and communities.

The potential impact of illness on nomadic communities in Turkana County was starkly highlighted, as the entire community participates in caring for the family and livestock. Improved care processes and outcomes for patients in these nomadic communities, through ATCs, contributed to maintaining the social fabric of these societies.

“… with nomadic [communities] you know there [are] a lot insecurities involved and so the families tend to like to stay together … especially when you move men and they are the decision makers of the family, there will be a lot of things involved, there will be poor decision making, there is kind of feeling of insecurity because for them its men who provide security for the family.”–CHMT member, Turkana County

Avoiding unnecessary referrals has significant impact on the patient and the community at large. Averted referrals also reported as cost saving for the patient. Several respondents shared that members of nomadic communities sell livestock to cover the costs of sending a family member to a referral hospital for medical care. Patients often cannot afford the cost of transportation, accommodation, and workdays lost to either accompany a sick child to a referral hospital, or seek treatment him/herself. Therefore, treatment received at a PHC close to the patient contributed significantly to reducing the burden of sickness on communities.

“Referral here is hard. You may refer a patient who may never go to where you have told them to go…because of their condition; there is high poverty. Some may just not go to the hospital.”–CHMT member, Turkana County

“There is also a cost attached to clients. They have to pay, and even the people who take care of them, you see this is the cost sometimes it’s not seen, but it does cost a lot, people moving where they are to another place…The client himself and the caretaker, that person maybe has left some work, there is also cost related to that, skipping duties, maybe working, maybe doing a business, we count that time also a cost. If that decision can be arrived at where you are and you do the right thing from there you will have saved really a lot.”–CO, Turkana County

Improved health outcomes.

While this study did not aim to measure health outcomes at patient level, there are several cases where the clinicians using the ATC platform felt they had contributed to such outcomes, for example, by receiving instructions for managing the patient, or receiving patient information that improved referral.

“Usually, the protocol for obtaining blood from the blood bank is tedious and time consuming. In emergencies such as [patient name], having the prior information on the platform enabled us to save her life.”–MO, Turkana County