title: An investigation into the use of 3G mobile communications to provide telehealth services in rural KwaZulu-Natal.
abstract: BACKGROUND
  We investigated the use of third-generation (3G) mobile communications to provide telehealth services in remote health clinics in rural KwaZulu-Natal, South Africa.
  
  
  METHODS
  We specified a minimal set of services as our use case that would be representative of typical activity and to provide a baseline for analysis of network performance. Services included database access to manage chronic disease, local support and management of patients (to reduce unnecessary travel to the hospital), emergency care (up to 8 h for an ambulance to arrive), e-mail, access to up-to-date information (Web), and teleclinics. We made site measurements at a representative set of health clinics to determine the type of coverage (general packet radio service [GPRS]/3G), its capabilities to support videoconferencing (H323 and Skype™ [Microsoft, Redmond, WA]) and audio (Skype), and throughput for transmission control protocol (TCP) to gain a measure of application performance.
  
  
  RESULTS
  We found that none of the remote health clinics had 3G service. The GPRS service provided typical upload speed of 44 kilobits per second (Kbps) and download speed of 64 Kbps. This was not sufficient to support any form of videoconferencing. We also observed that GPRS had significant round trip time (RTT), in some cases in excess of 750 ms, and this led to slow start-up for TCP applications.
  
  
  CONCLUSIONS
  We found audio was always so broken as to be unusable and further observed that many applications such as Web access would fail under conditions of very high RTT. We found some health clinics were so remote that they had no mobile service. 3G, where available, had measured upload speed of 331 Kbps and download speed of 446 Kbps and supported videoconferencing and audio at all sites, but we frequently experienced 3G changing to GPRS. We conclude that mobile communications currently provide insufficient coverage and capability to provide reliable clinical services and would advocate dedicated wireless services where reliable communication is essential and use of store and forward for mobile applications.
authors.affiliation: 1 School of Information Systems, Computing, and Mathematics, Brunel University , Uxbridge, United Kingdom .
authors.forename: Malcolm
authors.initials: M
authors.lastname: Clarke
authors.forename: Maurice
authors.initials: M
authors.lastname: Mars
mesh_terms: D005240:Feasibility Studies; D006297:Health Services Accessibility / Q000191:economics / Q000592:standards*; D006801:Humans; D063731:Mobile Applications / Q000191:economics / Q000592:standards / Q000600:supply & distribution*; D019982:Organizational Case Studies; D019035:Rural Health Services / Q000191:economics / Q000458:organization & administration / Q000600:supply & distribution*; D000068997:Smartphone / Q000191:economics / Q000295:instrumentation / Q000600:supply & distribution; D013019:South Africa; D013685:Telecommunications / Q000191:economics / Q000295:instrumentation / Q000600:supply & distribution; D017216:Telemedicine / Q000191:economics / Q000295:instrumentation / Q000379:methods*
keywords: e-health; mobile health; telecommunications; telehealth; telemedicine