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Telehealth in the Developing = World

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Telehealth in the Developing World

Edited by

Richard Wootton

Scottish Centre for Telehealth, Aberdeen, = UK;
University of Queensland, Brisbane, Australia

Nivritti G Patil

University of Hong Kong, Hong Kong,=20 China

Richard E Scott

University of Calgary, Calgary,=20 Canada

Kendall Ho

University of British Columbia, = Vancouver,=20 Canada

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=A9 2009 Royal Society of Medicine Press Ltd

Co-published by
Royal Society of Medicine Press = Ltd
1=20 Wimpole Street, London W1G 0AE, UK
Tel: +44 (0)20 7290 2921
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Email: publishing@rsm.ac.uk
Website: http://www.rsmpress.co.uk/=

International Development Research Centre
PO Box = 8500,=20 Ottawa, ON K1G 3H9, Canada
Email: info@idrc.ca
Website: http://www.idrc.ca/

Apart from any fair dealing for the purposes of = research or=20 private study, criticism or review, as permitted under the UK Copyright, = Designs=20 and Patents Act, 1988, no part of this publication may be reproduced, = stored or=20 transmitted, in any form or by any means, without the prior permission = in=20 writing of the publishers or in the case of reprographic reproduction in = accordance with the terms of licences issued by the Copyright Licensing = Agency=20 in the UK, or in accordance with the terms of licences issued by the = appropriate=20 Reproduction Rights Organization outside the UK. Enquiries concerning=20 reproduction outside the terms stated here should be sent to the = publishers at=20 the UK address printed on this page.

The rights of Richard Wootton, Nivritti G Patil, = Richard E=20 Scott and Kendall Ho to be identified as Editors of this work have been = asserted=20 by them in accordance with the Copyright, Designs and Patents Act, = 1988.

This publication has been generously supported by a = grant=20 from the International Development Research Centre, Canada; with = additional=20 contributions from HiiTeC and the Faculty of Medicine, University of = Hong=20 Kong.

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A catalogue record for this book is available from the = British=20 Library

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Contributors	ix=
Foreword	xiii
Preface	xv=
SECTION 1: = BACKGROUND
1. Introduction	3
Richard Wootton, Kendall Ho, = Nivritti G Patil=20 and Richard E Scott
SECTION 2: = POLICY
2. Bridging the digital = divide:=20 Linking health and ICT policy	9
Joan Dzenowagis
3. Telemedicine in = developing=20 countries: Perspectives from the Philippines	27
Alvin B Marcelo
4. Information = technology for=20 primary health care in Brazil	34
Elaine Tomasi, Luiz A Facchini, = Elaine Thum=E9,=20 Maria FS Maia and Alessander Osorio
5. Community-based = health workers=20 in developing countries and the role of m-health	43
Adesina Iluyemi
6. Global e-health = policy: From=20 concept to strategy	55
Richard E Scott
7. Experiences and = lessons learnt=20 from telemedicine projects supported by the IDRC	68
Laurent Elder and Michael=20 Clarke
8. Strategies to promote = e-health=20 and telemedicine activities in developing countries	79
Sisira Edirippulige, Rohana B = Marasinghe,=20 Vajira H W Dissanayake, Palitha Abeykoon and Richard=20 Wootton
SECTION 3: = EDUCATIONAL
9. Telemedicine in = low-resource=20 settings: Experience with a telemedicine service for HIV/AIDS = care	91
Maria Zolfo, Verena Renggli, Olivier = Koole and=20 Lut Lynen
10. Medical Missions for = Children:=20 A global telemedicine and teaching network	101
Philip O Ozuah and Marina=20 Reznik
11. Telementoring in = India:=20 Experience with endocrine surgery	109
Saroj K Mishra, Puthen V Pradeep = and Anjali=20 Mishra
SECTION 4: = CLINICAL
12. Teledermatology in = developing=20 countries	121
Steven Kaddu, Carrie Kovarik, = Gerald Gabler=20 and H Peter Soyer
13. Cross-cultural = telemedicine=20 via email: Experience in Cambodia and the USA	135
Paul Heinzelmann, Rithy Chau, = Daniel Liu and=20 Joseph Kvedar
14. Telepathology and = telecytology=20 in developing countries	149
Sangeeta Desai
15. Internet-based=20 store-and-forward telemedicine for subspecialty consultations in = the=20 Pacific region	156
C Becket Mahnke, Charles W Callahan = and=20 Donald A Person
16. Telehealth support = for a=20 global network of Italian hospitals	170
Gianfranco Costanzo and Paola=20 Monari
17. Telemedicine in = Nepal	182
Mohan R Pradhan
18. Telemedical support = for=20 surgeons in Ecuador	193
Stephen Cone, Edgar J Rodas and = Ronald C=20 Merrell
19. A low-cost = international=20 e-referral network	203
Richard Wootton, Pat Swinfen, Roger = Swinfen=20 and Peter Brooks
20. Telehealth in China: = Opportunities and challenges	212
Jie Chen and Zhiyuan = Xia
21. Telemedicine in = South=20 Africa	222
Maurice Mars
22. Telemedicine in = sub-Saharan=20 Africa	232
Maurice Mars
23. Telehealth for = mountainous and=20 remote areas of northern Pakistan	242
Hameed A Khan and Irfan = Hayee
24. Teleneurology: Past, = present=20 and future	252
Usha K Misra and Jayantee=20 Kalita
25. Telepaediatric = support for a=20 field hospital in Chechnya	262
Boris A Kobrinskiy and Vladimir I=20 Petlakh
26. Web-based paediatric = oncology=20 information and registries: An international perspective	273
Andr=E9 Nebel de = Mello
27. E-health in = international=20 networks: New opportunities for collaboration	287
Shariq Khoja and Azra = Naseem
SECTION 5: THE = FUTURE
28. The future use of = telehealth=20 in the developing world	299
Richard Wootton
Index	309

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Contributors

Palitha Abeykoon Ministry of = Health, Colombo,=20 Sri Lanka

Peter Brooks Faculty of Health = Sciences,=20 University of Queensland, Brisbane, Australia

Charles W Callahan De Witt Army = Community=20 Hospital, Ft Belvoir, Virginia, USA

Rithy Chau Sihanouk Hospital Center = for HOPE,=20 Phnom Penh, Cambodia

Jie Chen Key Laboratory of Health = Technology=20 Assessment, Ministry of Health; School of Public Health, Fudan = University,=20 Shanghai, China

Michael Clarke International = Development=20 Research Centre, Ottawa, Canada

Stephen Cone Virginia Commonwealth = University=20 Medical Center, Richmond, Virginia, USA

Gianfranco Costanzo Ministry of = Labour,=20 Health and Social Policies, Alliance of the Italian Hospitals Worldwide = =96=20 Secretariat for Technical Assistance, Rome, Italy

Sangeeta Desai Department of = Pathology, Tata=20 Memorial Hospital, Mumbai, India

Vajira H W Dissanayake Human = Genetics Unit,=20 Faculty of Medicine, University of Colombo, Colombo, Sri Lanka

Joan Dzenowagis World Health = Organization,=20 Geneva, Switzerland

Sisira Edirippulige Centre for = Online Health,=20 University of Queensland, Brisbane, Australia

Laurent Elder International = Development=20 Research Centre, Ottawa, Canada

Luiz A Facchini Department of = Social=20 Medicine, University Federal of Pelotas, Pelotas, Brazil

Gerald Gabler Department of IT and=20 Telecommunications, Graz University Clinics and General Hospital, Graz,=20 Austria

Irfan Hayee COMSATS Headquarters, = Islamabad,=20 Pakistan

Paul Heinzelmann Center for = Connected Health,=20 Partners HealthCare; Department of Medicine, Massachusetts General = Hospital,=20 Harvard Medical School, Boston, Massachusetts, USA

Kendall Ho Faculty of Medicine, = University of=20 British Columbia, Vancouver, Canada

Adesina Iluyemi Centre for = Healthcare=20 Modelling and Informatics, School of Computing, University of = Portsmouth, UK

Steven Kaddu Department of = Dermatology,=20 Medical University of Graz, Graz, Austria

Jayantee Kalita Department of = Neurology,=20 Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, = India

Hameed A Khan Pakistan Atomic = Energy=20 Commission, Islamabad, Pakistan

Shariq Khoja Faculty of Health = Sciences, Aga=20 Khan University, Karachi, Pakistan

Boris A Kobrinskiy Moscow Research = Institute=20 of Paediatrics and Children=92s Surgery, Moscow, Russia

Olivier Koole Institute of Tropical = Medicine,=20 Department of Clinical Sciences, Antwerp, Belgium

Carrie Kovarik Department of = Dermatology,=20 Dermatopathology, and Infectious Diseases, University of Pennsylvania,=20 Philadelphia, USA

Joseph Kvedar Center for Connected = Health,=20 Partners HealthCare; Department of Dermatology, Massachusetts General = Hospital,=20 Harvard Medical School, Boston, Massachusetts, USA

Daniel Liu Sihanouk Hospital Center = for HOPE,=20 Phnom Penh, Cambodia

Lut Lynen Institute of Tropical = Medicine,=20 Department of Clinical Sciences, Antwerp, Belgium

C Becket Mahnke Tripler Army = Medical Center,=20 Honolulu, USA

Maria F S Maia University Federal = of Pelotas,=20 Pelotas, Brazil

Rohana B Marasinghe Centre for = Online Health,=20 University of Queensland, Brisbane, Australia

Alvin B Marcelo National Telehealth = Center,=20 University of the Philippines, Philippines

Maurice Mars Nelson R Mandela = School of=20 Medicine, University of KwaZulu-Natal, South Africa

Ronald C Merrell Virginia = Commonwealth=20 University Medical Center, Richmond, Virginia, USA

Anjali Mishra Sanjay Gandhi = Postgraduate=20 Institute of Medical Sciences, Lucknow, India

Saroj K Mishra Sanjay Gandhi = Postgraduate=20 Institute of Medical Sciences, Lucknow, India

Usha K Misra Department of = Neurology, Sanjay=20 Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

Paola Monari Alliance of the = Italian=20 Hospitals Worldwide =96 Secretariat for Technical Assistance, Rome, = Italy

Azra Naseem Institute of = Educational=20 Development, Aga Khan University, Karachi, Pakistan

Andre Nebel de Mello Laboratorio de = Sistemas=20 Integraveis da Escola Polictecnica da Universidade de S=E3o Paulo, S=E3o = Paulo,=20 Brazil

Alessander Osorio University = Federal of=20 Pelotas, Pelotas, Brazil

Philip O Ozuah Children=92s = Hospital at=20 Montefiore, Albert Einstein College of Medicine, New York, USA

Nivritti G Patil University of Hong = Kong,=20 Hong Kong, China

Donald A Person Tripler Army = Medical Center,=20 Honolulu, USA

Vladimir I Petlakh Moscow Research = Institute=20 of Paediatrics and Children=92s Surgery, Moscow, Russia

Puthen V Pradeep Sanjay Gandhi = Postgraduate=20 Institute of Medical Sciences, Lucknow, India

Mohan R Pradhan Health Net, = Kathmandhu,=20 Nepal

Verena Renggli Institute of = Tropical=20 Medicine, Department of Clinical Sciences, Antwerp, Belgium

Marina Reznik Children=92s Hospital = at=20 Montefiore, Albert Einstein College of Medicine, New York, USA

Edgar J Rodas University of Azuay, = Cuenca,=20 Ecuador

Richard E Scott Health Innovation = and=20 Information Technology Centre (HiiTeC), University of Calgary, Calgary,=20 Canada

H Peter Soyer Dermatology Group, = School of=20 Medicine, University of Queensland, Brisbane, Australia

Pat Swinfen Swinfen Charitable = Trust,=20 Canterbury, UK

Roger Swinfen Swinfen Charitable = Trust,=20 Canterbury, UK

Elaine Thum=E9 Department of = Nursing,=20 University Federal of Pelotas, Pelotas, Brazil

Elaine Tomasi Department of = Psychology,=20 University Catholic of Pelotas, Pelotas, Brazil

Richard Wootton Scottish Centre for = Telehealth, Aberdeen, UK; University of Queensland, Brisbane, = Australia

Zhiyuan Xia Telemedicine Centre, = Fudan=20 University, Shanghai, China

Maria Zolfo Institute of Tropical = Medicine,=20 Department of Clinical Sciences, Antwerp, Belgium

Foreword

Telehealth in the Developing World is a = very=20 wide-ranging book, rich in practical experience, which will be of = interest both=20 to those who want to learn about the developing world and to those who = want to=20 learn from developing countries. It is full of real-life stories. = Telemedicine,=20 rightly in my view, is seen as central to the improvement of health and = life in=20 developing countries. Much has been said and written about telemedicine = and its=20 potential to transform life, but these are still early days. A great = deal of=20 what has been written and said has been theoretical. This book reflects = the=20 reality.

All the projects described here have been driven by = people of=20 vision and passion. All have had to confront the problems of the real = world,=20 whether these have been the realities of desperate poverty or the, = equally real,=20 obstacles of clinical, technical and governmental politics. All the = pioneers=20 have been on journeys of discovery, working out how to be effective in = the=20 particular environment where they are operating. Who can fail to be = impressed by=20 the Swinfen Charitable Trust and its journey? It has pioneered the use = of the=20 simplest of modern electronic technology to ensure that people working = in=20 isolation in poor countries can benefit from the opinions of specialists = in the=20 richest countries.

Other impressive pioneering work in particular = specialities =96=20 such as teledermatology, telepaediatrics, telepathology, telepsychiatry = and=20 e-mental health =96 is described here. There are also descriptions of = progress in=20 developing countries, such as China, Pakistan, Chechnya and Ecuador, as = well as=20 accounts of linking with Italian expatriates and cross-cultural = experiences=20 between the USA and Cambodia.

Importantly, these accounts show how telemedicine = enables=20 professionals to be put in touch with other professionals. Individual = clinicians=20 in remote areas are able to tap into advice from their peers and, very=20 motivationally, to feel part of their profession and of an international = group=20 of colleagues. This by-product of telemedicine must not be = underestimated. It=20 has sustained human beings when other resources have failed.

Underpinning all this are accounts of public and = technical=20 policy that attempt to answer the question of how the enthusiasm of the = pioneers=20 can be turned into sustainable mainstream activity. This is, of course, = the=20 vital question.

Health care, as we know, is primarily about = people-to-people=20 interactions. It is about understanding, diagnosis, physical contact,=20 communication and, ultimately, providing care. All of this is = facilitated by the=20 technical processes of imaging, pathological testing, information = gathering,=20 research and so forth. The task for every health care system is how to = maximize=20 the personal contact at the same time as maximizing the=20 technical input, while all the time operating within a sustainable = financial=20 framework.

People working in developing countries have had to = think about=20 this task with even more urgency than those of us working in richer = countries.=20 They have had to think about how to obtain an expert opinion in remote = places,=20 how to support local clinicians who may not have all the skills they = need, how=20 to make sure technical information is interpreted wisely in very = difficult=20 circumstances and how best to use very scarce resources. Telemedicine = offers=20 help in meeting these conflicting needs by improving access to data and = to=20 individuals, while driving down the costs of doing so.

We in the developed world have large and = industrialized health=20 systems that grow costlier by the day as we absorb new technologies. At = some=20 point, as costs and demand both rise, we too will need to learn some of = the=20 lessons that our colleagues are learning in Africa, South America and = Asia. The=20 pioneers in this book are learning lessons for developing countries. = They are=20 learning lessons for us all.

LORD CRISP
Honorary Professor at the London School = of=20 Hygiene and Tropical Medicine

Preface

This is the ninth book in the Royal Society of = Medicine=92s=20 series of multi-author books on telemedicine topics. The series aims to = provide=20 examples of best practice. This book=92s predecessors are:

The = Legal and=20 Ethical Aspects of Telemedicine, BA Stanberry, 1998

= Introduction to=20 Telemedicine, R Wootton and J Craig (eds), 1999

=20 Teledermatology, R Wootton and AMM Oakley (eds), 2002

= Telepsychiatry=20 and e-Mental Health, R Wootton, P Yellowlees and P McLaren (eds), = 2003

= Telepediatrics:=20 Telemedicine and Child Health, R Wootton and J Batch (eds), = 2004

=20 Teleneurology, R Wootton and V Patterson (eds), 2005

= Introduction to=20 Telemedicine, 2nd edition, R Wootton, J Craig and V Patterson = (eds),=20 2006

Home = Telehealth:=20 Connecting Care Within the Community, R Wootton, SL Dimmick and JC = Kvedar=20 (eds), 2006

Much has been written about the potential use of = telemedicine=20 in developing countries, but equally much of it has been criticized as = little=20 more than wishful thinking. While it is sometimes said that there are = relatively=20 few cost-effective and sustainable telemedicine projects in the = industrialized=20 world, there are even fewer in developing countries. The present volume=20 therefore aims to summarize the experience of starting and sustaining = telehealth=20 projects in the developing world. It represents a description of how=20 telemedicine in the broadest sense can be applied to improve the = delivery of=20 health care in developing countries.

The book=92s contributors have substantial practical = experience=20 across a wide range of application areas, and most have published = previous=20 reports of their work in the peer-reviewed literature.

It is a pleasure to acknowledge the support of = Canada=92s=20 International Research and Development Centre, the Li Ka Shing Faculty = of=20 Medicine at the University of Hong Kong, the Health Innovation and = Information=20 Technology Centre (HiiTeC) of the University of Calgary, and the U21 = Health=20 Sciences Group in the production of the book. We have divided the = material into=20 sections:

background = and=20 introductory material

a section = on policy=20 matters

a section = describing=20 educational applications

a section = about=20 clinical applications

a view of = the=20 future.

We hope that within the broad spectrum of ideas = expressed in=20 this book everyone will find something of relevance. We also hope that = you enjoy=20 reading it.

RICHARD WOOTTON
Edinburgh, UK

KENDALL HO
Vancouver, Canada

NIVRITTI G PATIL
Hong Kong, China

RICHARD E SCOTT
Calgary, Canada

SECTION 1
BACKGROUND

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1 Introduction

Richard Wootton, Kendall Ho, Nivritti G Patil = and=20 Richard E Scott

What is telemedicine?

There is no generally accepted definition of = telemedicine. The=20 literal meaning is =91health[care] at a distance=92. Thus, telemedicine = may=20 represent health care practised in real time, using a video link for = example, or=20 asynchronously, perhaps by email. The type of health care interaction is = perfectly general, and may encompass diagnosis and management, education = =96 of=20 staff, patients and the general population =96 and administrative = meetings.

The history of telemedicine has been bedevilled by = loose=20 terminology, which, some observers feel, has not assisted its = cause.1 What = began=20 originally as =91telemedicine=92 has become successively = =91telehealth=92, =91online=20 health=92, =91e-health=92, =91connected health=92, etc. In this book, = different=20 contributors use slightly different terms to describe their telemedicine = experience, depending on their local environment. While the editors have = tried=20 to reduce the number of terms used, we have deliberately not enforced a = uniform=20 terminology throughout, in recognition of these local differences.

Scope of the problem

Telemedicine is one aspect of the use of information = and=20 communication technology (ICT) in health care. It is widely believed = that ICT=20 generally has the potential to improve clinical care and public health. = In=20 addition to facilitating medical education, administration and research, = appropriate use of ICT may:

improve = access to=20 health care;

enhance = the quality=20 of service delivery;

improve = the=20 effectiveness of public health and primary care interventions;

improve = the global=20 shortage of health professionals through collaboration and training.

However, many questions remain about the potential = value to=20 people in resource-constrained settings such as the developing = world.

There are major problems of inequity of access to = health care in=20 developing countries, to which telemedicine offers a potential solution. = It may=20 be valuable in other ways as well.

Crisp report

In 2007, Lord Crisp reported about how UK experience = and=20 expertise in health could best be used to help improve health in = developing=20 countries.2 He = concluded=20 that sufficient progress towards the United Nations=92 Millennium = Development=20 Goals (e.g. in reducing child and maternal deaths, and tackling = HIV/AIDS,=20 tuberculosis and malaria) would not occur unless:

developing = countries=20 are able to take the lead and own the solutions =96 and are supported by = international, national and local partnerships based on mutual = respect;

the UK and = other=20 industrialized countries grasp the opportunity =96 and see themselves as = having a=20 responsibility as global employers =96 to support a massive scaling-up = of=20 training, education and employment of health workers in developing=20 countries;

there is = much more=20 rigorous research and evaluation of what works, systematic spreading of = good=20 practice, greater use of new information, communication and biomedical=20 technologies, closer links with economic development, and an = accompanying=20 reduction in wasted effort.

Clearly, telemedicine could play a major part in = facilitating=20 all of these activities. Furthermore, one can imagine the consequences = if every=20 hospital in the richer countries were to be linked up on a formal basis = with a=20 small group of hospitals or health centres in developing countries. = Through=20 mutual learning and collaboration in health service provision, such = health=20 partnerships could ultimately change health-care delivery at the = national level;=20 they might also change how the industrialized nations perceive the = world.=20 Telemedicine and ICT would be essential to maximizing the potential of = these=20 health partnerships.

Aim of the book

Any discussion of telemedicine in the developing = world raises=20 difficult questions about resource use, sustainability and global equity = in=20 access to health care. Despite the large number of published articles on = the=20 concept of telemedicine in the developing world, there are = remarkably=20 few examples of successful implementation.3 In = this book,=20 we have attempted to assemble a representative cross-section of the very = wide=20 range of work that has been carried out to date. Thus, the book offers a = state-of-the-art review of telemedicine in the developing world, and = should also=20 provide the basis for a high-level operations manual. It could be = considered=20 unethical, after all, not to learn from the experience of others and to = squander=20 scarce resources on an idea that may have already been proved to be=20 unfeasible.

The major sections of the book cover policy, clinical = and=20 educational matters. We hope that you enjoy reading it.

References

1=20 Wootton R. Telemedicine and isolated communities: a UK perspective. = J=20 Telemed Telecare 1999; 5(Suppl 2): 27=9634.

2=20 Crisp N. Global Health Partnerships. The UK Contribution to Health = in=20 Developing Countries. London: COI, 2007. Available at:=20 www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolic= y-AndGuidance/DH_065374.

3=20 Wootton R. Telemedicine support for the developing world. J Telemed=20 Telecare 2008; 14: 109=9614.

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SECTION 2
POLICY

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2 Bridging the digital divide: Linking health and = ICT=20 policy

Joan Dzenowagis

Introduction

The past decade has seen a remarkable growth in the = diffusion=20 of information and communication technology (ICT) across the world. This = growth=20 has been fuelled by technological advances, economic investment, and = social and=20 cultural changes that have facilitated the integration of ICT into = everyday=20 life. The general public =96 consumers =96 as well as a range of new = stakeholders=20 have had a significant impact on shaping this growth, for example by = demanding=20 better products, services and value for money. As these technologies = enter the=20 mainstream of business and cultural life, there is also a greater = awareness of=20 their potential as economic and social tools and, with it, new social = and=20 political pressure to re-frame ICT as a public good to be made = accessible and=20 available to all. This shift has had important ramifications in = countries and at=20 the international level as well.

Despite this encouraging progress, however, the uptake = of ICT=20 globally continues at an uneven pace, and the =91digital divide=92 = remains a=20 significant obstacle to achieving global development goals. The digital = divide=20 is understood broadly to be the gap between those with access to ICT and = its=20 benefits and those without. It is specifically acknowledged in the = United=20 Nations Millennium Development Goals (MDGs). Goal 8, Target 18 of the = MDGs=20 proposes =91a global partnership for development to make available the = benefits of=20 new technologies, especially information and communication = technologies=92.1

Recent events such as the G8 Summits and the World = Summit on the=20 Information Society2 have = continued=20 to promote this target and to highlight the striking gaps in access to = ICT=20 worldwide. In some countries, both urban and rural regions remain = isolated from=20 the knowledge society: infrastructure is non-existent, costs for basic = services=20 are beyond average income levels and well-intentioned ICT pilot projects = end=20 without ever scaling-up. While this can be disastrous for national = economies=20 competing in a global environment, it is also a tragedy for the health = sector,=20 where ICT is essential to improve health and help alleviate = inequalities.

ICT in the health sector

In the health sector, ICT is a cornerstone of = efficient and=20 effective services. In many countries, use of ICT within the sector = continues to=20 grow, and the Internet in particular is driving significant change. For = example,=20 in middle- and high-income countries, the Internet is dramatically = changing the=20 way in which consumers interact with health services, including access = to health=20 information and the ability to purchase pharmaceuticals and other health = products. The Internet also plays a key role in expanding the reach of = health=20 services to remote areas. The spread of broadband networks and the = development=20 of new e-health applications, defined as the use of ICT for health, have = a=20 mutually stimulating effect on further developments. However, it is = clear that,=20 despite the numerous creative and sometimes quite costly efforts to = improve the=20 situation, access to these developments is not universal, and many = countries do=20 not benefit as they might from advances in ICT in health.

For policy makers committed to improving national = health=20 systems, working with ICT policy makers and participating in the = national=20 policy-making process is essential to ensure that national ICT policy, = when=20 implemented, will meet the interests of the health sector in the years = to=20 come.

Measuring the digital divide

It has only been within the past few years that = meaningful=20 measures of the digital divide have been developed. The potential choice = of=20 indicators is enormous and the continuing evolution of technology = shortens the=20 useful lifespan of established indicators, creating the need for their = regular=20 revision. However, whether measured by ICT diffusion, technology = investment or=20 other related measures, the digital divide is manifest within and = between=20 countries in a variety of ways.

The digital divide is evident in low-income countries, = where=20 technology is unaffordable for private enterprise as well as for = individuals,=20 and where government policies and regulations do not encourage or = support ICT=20 business development. It is evident in the contrast between urban and = rural=20 areas, where investment in basic ICT infrastructure and services is = chronically=20 inadequate. It is also evident in communities and households, where = literacy=20 rates, educational levels and incomes are low and where content imported = from=20 abroad does not suit local needs or transmit in local languages. Most of = these=20 aspects are captured by the ICT Diffusion Index,3 which = takes=20 into account the complex dimensions of access, connectivity and policy = in=20 countries. The index results in a composite score between 0 and 1, = giving a=20 picture of ICT status in general but not addressing ICT diffusion by = sector. The=20 link between ICT, health and development is clear in Figure 2.1, = showing=20 country ICT diffusion and mortality strata, by WHO region.4,5

Following the World Summit on the Information Society = in 2003=20 and 2005, many countries undertook the development of national = strategies that=20 aimed to increase the use of ICT. Such strategies sought to increase = investment=20 and stimulate innovation, particularly in small and medium enterprises = in the=20 private sector, and to improve

3DImage=20

Figure 2.1 ICT diffusion and = mortality.=20 (Stratum 1 =3D very high adult and very high child mortality; stratum 5 = =3D low=20 adult and low child mortality.)

efficiency and effectiveness in the public sector = (e.g. in=20 government and education). For both the public and private sectors, the = use of=20 ICT in health, or e-health, is considered to represent a key instrument = for=20 health care delivery and public health action,6 and a = number of=20 governments have supported specific investments and policy instruments = towards=20 this end.

In high- and low-income countries, e-health has = already=20 demonstrated its value, particularly in containing cross-border threats = to=20 health and safety. However despite the documented value of ICT in terms = of=20 improving quality, cost and access to health care, the picture globally = remains=20 mixed. In particular, the ability to plan and implement e-health on a = large=20 scale, while adapting it to local health problems, presents a huge = challenge for=20 countries and institutions.

Despite the difficulties, there have been major ICT = investments,=20 particularly in countries such as those in Eastern Europe. These = economies are=20 growing rapidly, and large-scale infrastructure investments supported by = the=20 European Union include ICT for health institutions and universities. In=20 higher-income countries, there is spending in the areas of information = systems,=20 electronic health records, e-prescribing systems, diagnostic tools and = medical=20 imaging. In developing countries, ICT pilot projects are being funded by = international donors, leading to uncoordinated deployment of ICT in = health=20 service delivery and incompatible systems at many levels. In addition,=20 investments are being made in applications that support =91vertical=92 = health=20 programmes such as disease surveillance, management = of drug=20 supply, and planning and monitoring human resources for health.

Driving forces for ICT in health

Challenges in global public = health

Despite significant progress in public health over = the past 50=20 years, the fundamental conditions for health have not been achieved in = many=20 countries. Most of the burden of premature death and illness among the = poor is=20 due to problems for which solutions are known and prevention is = possible, yet=20 the health of populations in developing countries continues to be at = risk.=20 Today, the gap in health between the wealthy and the poor, both within = and=20 between countries, continues to grow.

The health divide is evident especially in low-income = countries,=20 which face a high burden of endemic and epidemic-prone infectious = diseases,=20 unacceptably high levels of child and maternal mortality, a continuing = HIV/AIDS=20 pandemic and the rapid spread of chronic conditions accelerated by = poverty. In=20 many countries, there is a deepening crisis in access to basic health = services,=20 linked to a shortage of essential health workers.7 In = the face of=20 these and numerous other challenges, governments are attempting to build = and=20 sustain their health systems.

Over the last decade, the need to develop and organize = new ways=20 of providing health services has been accompanied by major advances in = ICT,=20 enabling better support for health services and systems, and improving = global=20 awareness of health issues. These technologies hold great promise for = the health=20 sector in both low- and high-income countries, and some countries are = realizing=20 the benefits today. This is true not only for the delivery of health = services,=20 but also for health-related markets more generally. As the use of ICT = grows, it=20 is vital that the health sector participates in key international forums = and=20 helps to shape national policy to ensure that ICT improves outcomes for = health,=20 particularly for the most vulnerable populations.

Forces for change

In all countries, including developing countries, = forces from=20 health care and the ICT industry are spurring the growth of e-health. = These=20 forces include industry developments in wireless and satellite systems, = the=20 spread of broadband communications, better access to applications and = services,=20 and increasing digital processing power and storage capacity. This = growth has=20 led to significant regulatory change, advances in consumer protection, = greater=20 patient mobility, and new opportunities for trade and cross-border = services in=20 health.8 In = the health=20 sector, driving forces for adoption of ICT include such factors as = government=20 pressures to control costs, chronic and ever-increasing health work = force=20 shortages, greater expectations by consumers for higher quality and = safer care,=20 and changing models of health care delivery.

From the micro-level to the macro-level, from basic = human=20 genetics research to the provision of humanitarian aid and disaster = relief to=20 populations at risk, ICT supports the health sector in addressing a vast = range=20 of immediate and long-term challenges to human life and health, through = the=20 functions outlined in Table = 2.1.

Table 2.1 Examples of the use = of ICT in=20 health systems and services
Broad area	Examples
Access to information and knowledge	1. Improved access to health information, = research,=20 literature and training materials, such as access to biomedical = and social=20 sciences research. This supports the health research enterprise = and=20 enables comprehensive, evidence-based management of acute and = chronic=20 conditions
	2. Improved access to resources on prevention, = awareness=20 and education, for the general public as well as for health = professionals,=20 researchers and policy makers
Networking and collaboration	1. Collaboration for the management and = coordination of=20 care across different health providers, community health services = and=20 health institutions
	2. Better exchange of knowledge among policy = makers,=20 practitioners and advocacy groups
	3. Rapid and coordinated response to disasters = and=20 disease events
Information for policy and action: measuring = progress,=20 tracking quality and trend analysis	1. ICT for collecting, organizing and = disseminating=20 public health evidence and information for advocacy, practice and=20 policy
	2. Improved ability to describe, model, analyze = and=20 monitor trends on health status, income, employment and service = coverage,=20 and disaggregate by gender
	3. Support for research on policy = effectiveness
Health education and training	1. Direct support to education and training for = health=20 professionals and workers, including both pre-service education = and=20 in-service training and resources
	2. Improved efficiency and effectiveness of = education=20 delivery through strategic application of ICT and ICT-enabled = skill=20 development
	3. Improved availability of quality educational = resources=20 through ICT
	4. Outreach to special populations (girls and = women)=20 using appropriate technologies
	5. Enhanced delivery of basic and in-service=20 education
Public accountability through greater flow of=20 information	1. Greater transparency, accountability and = accessibility=20 in delivery of public services
	2. Improved enforcement of regulations and = performance=20 monitoring of decentralized services
Delivery of health services	1. Prevention of disease, health education and = promotion,=20 and support for diagnosis and treatment
	2. Establishment of health registries and = health=20 information systems
	3. Extension of care to rural and remote areas = through=20 telemedicine applications; increased access of rural health = workers to=20 specialist support and consultation

A number of these uses of ICT promise particular = benefits for=20 developing countries. For example, decreasing the isolation of the = health=20 community is seen as a major benefit, and is thus a driver for adoption. = ICT is=20 increasingly well integrated in educational settings in middle- and = high-income=20 countries, where communication, collaboration and access to information = are at=20 the core of research and teaching. Universities in the developing world = need to=20 connect on an equal footing with their counterparts. This access will = play an=20 important role in advancing locally relevant research, and will improve = capacity=20 by enabling participation in the peer-review process required for = publishing and=20 participation in research conferences.

Improved access to care is an important benefit of = ICT,=20 particularly for countries tackling the challenge of providing health = care to=20 people over a broad geographical area. One of the main drivers behind = public=20 investment in e-health systems is the expectation that ICT will improve = access=20 to services and reduce the inequities experienced by people in remote = locations.=20 This is a serious matter in countries that have chronic shortages of = physicians,=20 nurses and health technicians. The problem of shortages is often coupled = with=20 public concern over access and demographic shifts with concomitant major = health=20 resource implications, such as ageing populations and rapid population = growth in=20 native or aboriginal communities.9 In = contexts=20 such as these, the goal of access to health care has driven the adoption = of ICT=20 for remote diagnosis, monitoring and consultation.

Quality of care is another important driver for ICT = adoption.=20 Health service providers are not only attempting to deliver more = effective care,=20 they are also attempting to deliver care that is safe. Both goals = require the=20 use of ICT to measure, monitor and report on quality improvement = initiatives, as=20 well as the use of information systems =96 such as pharmaceutical = ordering systems=20 =96 that are proven to reduce errors.10 = Developments=20 such as e-prescription and computer-assisted imaging are part of this. = With=20 respect to technology-assisted care, it is critical to ensure that the = care and=20 information provided through e-health meet appropriate standards, = relating to=20 the quality of information transmitted as well as to the overall = reliability of=20 the system and the satisfaction of users, both professionals and = patients.

To date, e-health has mainly been used to improve = productivity=20 in delivery systems focused on patients and hospitals. In the future, it = can be=20 expected that ICT will be used to facilitate personalized and = home-centred care.=20 To this end, there has been significant investment in research and = development,=20 such as in the European Union (EU) Framework Programmes, which have = invested=20 over 500 million euros in establishing a European health area, e-health=20 conferences and an e-health action plan.11

The concept of citizen-centred care has become the = basis of=20 programmes designed to empower consumers in part by improving the health = information environment. Many observers expect that the Internet and the = web=20 will become the place to obtain health advice for citizens. In 2007, the = worldwide Internet population was estimated at 15.8 users per 100 = inhabitants,=20 up from 5.3 users per 100 in 1999.4 = Health is=20 consistently among the most sought-after types of Internet = information.12 = Some=20 governments, worried that the volume and quality of health information = on the=20 Internet might pose a risk to citizens, have responded by creating or = sponsoring=20 health information portals. Others have provided guidelines for website = quality=20 and promoted consumer education as a protection against the growing = problem of=20 Internet fraud and spam.

Economy and efficiency of care is another important = driver for=20 the adoption of ICT in health. Key areas aimed at controlling costs over = the=20 long term include hospital information systems, regional networks, = secure=20 reimbursement and procurement systems, and patient =91smart cards=92 = carrying=20 personal medical data. The electronic health record is central to the = ability to=20 improve quality, access and economy of care. It is also fundamental to = realizing=20 the concept of an expanded, digitized health care network that enables = more=20 effective public health services.

Just as ICT is at the core of much of the improvement = in=20 national health systems, global health security is = also=20 critically dependent on ICT. Reliable and secure ICT systems enable = tracking of=20 diseases and monitoring of populations at risk, and provide the basis = for global=20 defence against bioterrorism as well as early response to natural and = man-made=20 disasters. For example, the best way to prevent international spread of = diseases=20 is by detecting public health risks early and mounting an effective = response=20 while the problem is still localized. Rapid reporting, enabled and = validated=20 through global electronic communication, was a critical factor in the=20 containment of the SARS epidemic in 2003 and is a key aspect of = preparedness for=20 pandemics such as that anticipated with avian influenza. Fortunately, = steady=20 improvements in satellite technology, and particularly its more = widespread use,=20 have enabled a faster, more coordinated response globally and nationally = to=20 disease events and natural disasters.13

An overview of ICT policy

It is important for health policy makers to have an = overview=20 of the forces and policies that shape the availability and cost of ICT, = and to=20 understand potential points of influence. This will ensure that the = health=20 sector benefits from ICT to the greatest extent possible. Globally, the = ICT=20 policy picture is complex and changing, and is not easily governed by=20 traditional forms of national and international public authority. Beyond = this,=20 the Internet in particular has given rise to new patterns of = international=20 cooperation. Whereas the technical management of the Internet is = dominated by=20 companies working in industry forums to devise private systems of rules, = in=20 parallel governments and firms are collaborating to devise shared rules = on=20 communications behaviour and global electronic commerce conducted over = that=20 infrastructure.14 = This is not a=20 trivial matter for the health sector, as decisions made in this unwieldy = international system will have a direct effect on the future development = of=20 e-health, such as patient mobility and the viability of cross-border = services in=20 health.

Interested parties

In addition to governments, other major stakeholders = in the=20 ICT policy-making process include a wide range of organizations and = firms, such=20 as international organizations (e.g. the United Nations, the = International=20 Telecommunication Union and the World Trade Organization), consumer = rights=20 organizations (e.g. Consumers International), regional Internet = registries,=20 private businesses (e.g. ICT systems and equipment vendors, = telecommunications=20 operators, Internet service providers, and financial and certification=20 companies), business forums (e.g. the International Chamber of Commerce) = and=20 civil society organizations (e.g. Privacy International and the = Association for=20 Progressive Communications). A wide variety of civil society = organizations are=20 increasingly engaged in ICT forums in order to have their perspective = reflected=20 in ICT debates.

Pivotal role of = governments

While the above groups are active in seeking = influence at the=20 international level, government policy at the national level can have a = dramatic=20 effect on the diffusion of ICT.15 It = is=20 governments that create the policy environment that will foster = technology use=20 and encourage national and international investment in ICT = infrastructure,=20 development and a skilled workforce. Government action is also important = in=20 extending the benefits of technology to all social groups, as = governments have=20 the power and mandate to balance the needs of their citizens for = long-term=20 economic growth and social prosperity. Ultimately, how and what users = have=20 access to depend on specific legal, economic, political and social = conditions.=20 Not least, national systems of innovation strongly influence the = diffusion=20 process in a country.16

Linking health goals to ICT = policy

ICT represents not a single innovation but rather a = cluster of=20 related technologies that must be present together to support adoption = by users,=20 such as servers, communication links, software and user devices. In the = simple=20 model shown in Figure=20 2.2 there are three levels. At the bottom, is the connectivity level = or=20 underlying telecommunications and network infrastructure level, without = which=20 there can be no ICT. In the middle, a services level consists of = organizations=20 providing ICT applications and services, reflecting the extent to which = ICT=20 services are available in a country. At the top, is the individual and=20 organizational user level, where ICT adoption is typically measured by = the=20 overall number of users in a country.17

Policy implemented at each level affects meaningful = access to=20 ICT in a country and therefore in the health sector. Policies on the=20 infrastructure level provide the basis for expanding physical = infrastructure=20 such as satellite, wireless and broadband by shaping market conditions = and=20 competition. Providing access to technology is critical, but more than = physical=20 access is necessary. Networks and services are insufficient if ICT

3DImage=20

Figure 2.2 A simple framework for=20 understanding ICT policy. (Adapted from Wolcott et al.17)

is not used because it is not affordable, people = cannot=20 understand how to use it or the local economy cannot sustain its use. = Policies=20 at the services level therefore shape the legal and regulatory framework = that=20 creates conditions for a viable, secure online environment, promotes = diffusion=20 and uptake of services, and supports minimum levels of consumer = protection. At=20 the user level, a wide range of government and organizational policies = affect=20 user adoption and conditions of use. For example, a United Nations group = has=20 developed an index of ICT diffusion.18 = This=20 considers the indicators for Internet access in a country as including = Internet=20 users per 1000 inhabitants, adult literacy rate, cost of a 3-minute = fixed-line=20 telephone call and gross domestic product (GDP) per capita. Seen from = this broad=20 perspective, government investment and policies to boost literacy =96 as = much as=20 direct involvement in ICT policy =96 are important in ensuring that all = citizens=20 can benefit from ICT.

Health policy makers in the process of developing or=20 implementing national e-health strategies need to be able to work = effectively=20 with ICT policy makers. However, there are few precedents for = cooperation=20 between the sectors and little experience to draw on to align policy=20 interests.

Linking health and ICT policy

The potential points of influence, or entry points, = in a=20 complex environment such as ICT policy are not necessarily obvious. At a = minimum, national health policy makers need to know the basics of ICT = policy=20 objectives and approaches in order to be effective advocates for = improving=20 infrastructure, access and affordability, or for obtaining concessions = or aid=20 for the health sector. While every country is unique, national policies=20 generally set out goals and objectives for the development of the ICT = industry,=20 development of the economy and support for key sectors of the economy. = The list=20 below highlights core elements included in national ICT policy.

Core content of ICT policy

The core content of any ICT policy must include five = factors:

1. Infrastructure development. These policies = promote=20 the development, expansion, operation and increased efficiency of ICT = networks=20 at the infrastructure level. This is an area of great interest to the = health=20 sector, but not traditionally one where the sector has much influence. = Those=20 involved include governments (ministries of information technology and=20 telecommunications), the private sector (multinational corporations),=20 independent bodies (regulators) and international organizations = (International=20 Telecommunication Union).

2. Universal and equitable access to ICT = services.=20 These policies, implemented primarily at the infrastructure and services = level,=20 aim to improve the availability and affordability of ICT services. They = are=20 designed to facilitate access to ICT networks and services for all = citizens, as=20 well as for under-served groups such as the disabled and women. This = area is of=20 vital interest to the health sector, and is becoming = more open=20 to influence as policy-makers strive for more transparent and inclusive=20 policy-making processes.

3. Promotion of market competition. Policies = in this=20 area aim to stimulate ICT development and adoption by creating an = environment=20 for fair competition between providers of infrastructure and services,=20 corresponding to the infrastructure and service levels of the model. = Outcomes=20 are of great interest to the health sector, but this is not typically an = area of=20 direct influence.

4. ICT as a means of achieving national social and = economic=20 goals. These policies are designed to exploit ICT in achieving = national=20 social and economic goals, such as health, education and economic = development.=20 Policies in this area correspond to the service and user levels of the = model.=20 This is a natural and realistic entry point for the health sector in = policy=20 discussions.

5. Encouraging private sector investment. = Policies aim=20 to promote private enterprise development of ICT infrastructure and = services.=20 Policies in this area correspond to the infrastructure and services = levels of=20 the model, and are also related to overall government policies for = transparency,=20 accountability, anti-corruption and so on. Robust and sustainable = private sector=20 investment in ICT benefits the health sector, and this policy area is=20 increasingly open to sectoral advocacy and influence. There are = significant=20 variations in telecommunications investment across the world.4

Countries place different emphasis on the above = elements,=20 depending on factors such as their level of economic development, the = strength=20 and maturity of the private sector, the orientation of development = partners and=20 existing policy capacity. For example, one country may see a need for = stronger=20 emphasis on competition in services rather than on expansion of ICT=20 infrastructure. Examples of ICT policy and potential impact on the = health sector=20 are highlighted in Table=20 2.2.

Factors affecting ICT use in the health=20 sector

There are several factors that affect the use of ICT = in the=20 health sector. These include costs, access speed, education and = collaboration=20 between stakeholders.

Costs for ICT

These influence uptake in all sectors. They are = normally=20 reflected at the service level, and incorporate the costs passed on to = the user=20 from the infrastructure level. In general, two basic disparities exist = in the=20 affordability of ICT: in the basic cost of the technology and in the = cost=20 relative to per capita income. Access costs such as high Internet = service=20 provider and telephone call fees can be two to four times as high in = developing=20 countries as in developed market economies.19 = When the=20 monthly cost for Internet access exceeds the monthly income of a = significant=20 proportion of the population, its level of use will remain low.

Access speed

This directly affects cost. In nearly all = countries,=20 telephone calls are charged on a per-minute basis for telephone = mainlines, with=20 an additional access charge. Where Internet access is through a dial-up=20 connection, download times are long, and costs therefore

Table 2.2 Policy areas = related to=20 ICT
Level	Description	Examples
Infrastructure	Telecommunications and related systems	Policies that affect basic ICT = infrastructure:
		1. Telecommunications licensing = system
		2. Telecommunications operator privatization = and market=20 liberalization
		3. Spectrum allocation
		4. Internet domain management
		5. Banking and financial sector = regulation
		6. Standard setting
		7. Customs standardization
		8. Rules on taxation, tariffs, foreign = ownership of ICT=20 infrastructure
Services level	Trust and security =96 transactions that affect = use of=20 services and applications	Policies that affect business, government and = consumer=20 trust towards ICT and others online, including:
		1. Electronic signatures
		2. Data security
		3. Cybercrime, fraud and spam
		4. Privacy
		5. Intellectual property
		6. Regulation of content and freedom of = speech
		7. Consumer protection
Service level	Technology diffusion	Service and access fees, universal service = provisions,=20 and private sector and civil society access
User level	Capacity building	Policies that build the capacity to use ICT, = including=20 curriculum and materials, and technical education. For the general = public,=20 this also includes policies to ensure basic literacy, without = gender=20 difference
Overall environment	General government environment	Government structure (transparency, = independence of=20 judiciary and regulatory authorities), discrimination=20 policy

increase. The trend to using large web pages and = files is not=20 an obstacle in countries where bandwidth is increasing, but in = low-income=20 countries the long download time further increases the cost. Although=20 telemedicine can be successfully practised via low-bandwidth = connections, lack=20 of affordable broadband infrastructure significantly hampers the ability = to=20 conduct telemedicine applications where transfer of high-resolution = images is=20 required (see Chapter 13=20 and 19).

Education

This clearly affects ICT use, and international = disparities=20 are evident at the user level. The degree of technical capacity at this = level is=20 a result of long-standing government investment or under-investment in = education=20 and training, not only through initiatives such as staff development = programmes=20 and technical training in schools, but also including investment in = secondary=20 and tertiary education.

Collaboration between stakeholders

At the infrastructure and service levels, = regulations such as=20 those for importation of telecommunications equipment in emergency = situations=20 show the need for cross-border collaboration in ICT and health. Clearly, = ICT is=20 central to an effective health sector response in disaster situations, = whether=20 natural disasters or man-made (e.g. armed conflict). In the absence of = formally=20 established procedures covering disasters and emergencies, customs = clearance and=20 type-approval procedures for telecommunications equipment, allocation of = radiofrequencies and authorization for radio communications can delay=20 installation of urgently needed communications systems. For example, = regulations=20 on telecommunications equipment importation and type approval delayed = help when=20 a non-governmental organization arrived to install radio communications = in Bam,=20 Iran after a major earthquake in 2004. Lengthy national and local = customs and=20 telecommunications regulatory clearance resulted in an unnecessary and = costly=20 delay before the equipment could be installed where needed.

Legal framework, skills and protections for = a
network=20 economy

Trends in the uptake of advanced applications of ICT = such as=20 e-commerce show even greater disparities than trends in basic access to=20 computers. Many countries still lack the infrastructure, capacity and = resources=20 to develop and manage health applications, including those emerging from = e-commerce and e-government. Without these prerequisites, ICT in health = will not=20 grow significantly in developing countries. Furthermore, countries must = have the=20 skills of a networked society in order to deal with common challenges = and=20 threats. For example, security threats are growing and are becoming more = malicious, damaging and widespread, with serious implications for = countries.=20 Threats to a networked economy include spam and security violations. = These are=20 increasingly propagated from developing countries with weak laws, weak = policies=20 and inadequate security. The consequences can be severe for developing=20 countries, where awareness, protection tools, legislation and = enforcement are=20 still underdeveloped.20 = Basic=20 measures are required to ensure that security threats emanating from = developing=20 countries do not pose a threat to the Internet. Collaboration is = essential in=20 this respect, to ensure that technology resources are not diverted from = the=20 health area to deal with these security concerns.

ICT policy orientation in middle- and = high-income=20 countries

At the policy level, most high-income countries = maintain a=20 separation between government ministries in charge of telecommunications = and=20 information technology.21 = However,=20 telecommunications policy makers and regulators are increasingly = attempting to=20 incorporate the entire range of ICT in their policy domains. While = health is=20 often mentioned in the list of general benefits of ICT to society, the = specific=20 benefits of ICT for the health sector are rarely mentioned in ICT policy = statements. It is also rare to find specific actions or commitments by = ICT=20 policy makers to improve health, which is often = viewed as a=20 sector that would benefit from the latest developments in ICT. In this = context,=20 health applications often appear in policy programmes mainly to justify = the=20 importance of broadband technologies.

While the interests of the health and ICT sectors = appear to be=20 shared at conceptual levels, they are not in practice implemented to the = extent=20 that might be desired. For example, policy makers may view the health = sector as=20 a test bed for the application of high-speed telecommunications systems. = The=20 health sector would certainly benefit from the network technologies that = enable=20 transmission of the images used in medical diagnosis. It is = questionable,=20 however, whether ICT policy makers recognize these benefits and = subsequently=20 afford high priority to the health community.

Private sector ICT vendors naturally have = technology-centred=20 views and are concerned with health as a business. They are interested = in=20 digital opportunity, rather than the digital divide. They explore = business=20 opportunities to sell ICT equipment and systems. The lack of = telecommunications=20 infrastructure in rural areas may be perceived as a business opportunity = for a=20 vendor to prove the benefits of wireless broadband systems, but unless = this can=20 be profitable, it will not be sustained or implemented on a large = scale.

ICT policy orientation in low- and = middle-income=20 countries

Lack of reliable infrastructure is a severe = constraint for=20 low- and middle-income countries. The lack of adequate infrastructure to = support=20 high-quality, high-speed Internet connections is a major obstacle for = economic=20 and social development, and lack of bandwidth excludes countries from = taking=20 part in the global information society. A fundamental challenge is the = cost of=20 bandwidth, which, because of policy, regulation and technology = challenges, can=20 be up to 50 times as high as the cost of bandwidth in industrialized=20 countries.19 = Operational=20 costs on this scale put ICT out of reach for the health sector, and = represent a=20 difficult trade-off for government decision makers when considering how = best to=20 allocate health and social welfare budgets.

Provision of basic ICT services to the general public = is=20 becoming a high priority as donor-financed initiatives are beginning to = stress=20 core policy reform, incentives for private sector investment towards = providing=20 access to rural and underserved areas, development of national backbone = links,=20 and deployment of broadband and government networks.22 = This=20 long-term perspective represents a significant shift from the previous = decade of=20 project-based ICT development initiatives such as tele-centres, where = the=20 benefits to the health sector were often mentioned in the rationale for = their=20 construction but where in reality the benefits were rarely realized.

Opportunities presented by policy reform=20 processes

Policy reform processes in countries can provide an=20 opportunity for the health sector to participate in consultations when = ICT=20 policy is being developed or revised. Countries trying to improve policy = making=20 may also require training or guidelines for the public sector policy = process=20 that specifically mandate broad consultation with stakeholder groups. = For=20 example, it is evident that ICT policy makers would benefit from = understanding=20 how policy affects the technology users in all sectors. This can be achieved by means of evaluation, consultation = mechanisms or a=20 combination of the two. A government mandate for input, dialogue and = better=20 information flow provides a good starting point. At the least, the = sectors can=20 acknowledge each other=92s interests and responsibilities, although they = may not=20 share the same perspective or priorities.

Policy adjustment to meet local=20 needs

It would seem obvious that policy directions must = reflect and=20 be adapted to the local context, but this is not always the case in ICT = policy.=20 Often, basic ICT policy principles are agreed at the international = level, or=20 policies of high-income countries are simply transferred to low- and=20 middle-income countries. However, the local context =96 in terms of = local needs,=20 skills and political issues =96 has a significant effect on whether = generally=20 accepted policy reforms are adopted and put into practice. Even national = governments with the political will to drive change often face = challenges in=20 putting policies into effect, particularly where the necessary legal = framework=20 and human resources are lacking.

Opportunities for action

There is much that the health sector can achieve by = becoming=20 actively involved in ICT policy making, particularly in the long term. = But the=20 health sector may first need to build its own capacity to use evidence = and=20 information for policy and planning. A country=92s level of ICT = diffusion and=20 general policy-making capacity will show the potential areas for focus = and=20 action. The following are some examples.

A holistic approach to ICT = development

ICT is an enabler, not an end in itself, and = national ICT=20 strategy should be =91outward looking=92 and designed to ensure = effective fulfilment=20 of national development activities. ICT strategy should ensure that = there is=20 compatibility across government sectors (e.g. access and security = protocols, and=20 user interfaces). Resources should be provided for initiatives that = produce=20 significant cost savings and improve services to users.

A growing number of countries are seeking assistance = to develop=20 sector-based ICT programmes, including e-education, e-health and = e-government.=20 However, without an overall coordination mechanism at the country level, = these=20 ICT programmes may lead to sector-specific ICT infrastructure owned and = operated=20 by the relevant ministry, thereby duplicating private sector or other=20 infrastructure. A holistic approach is required, with governments = ensuring that=20 investment in ICT is coherent and sufficient to meet common needs across = the=20 sectors. The health sector may need to lobby for a more active role in = policy=20 formulation. This is possible by highlighting existing policies that = show their=20 investment and commitment to benefiting from ICT. For example, a = coordinated=20 framework may have been developed for the integration of ICT services in = district health settings. There may already be arrangements for = improving=20 managerial and technical competence to oversee e-health projects. Or = projects=20 may already be planned and funded, thereby ensuring that the health = sector will=20 obtain a substantial benefit when ICT becomes more readily available. = Not least,=20 health policy makers should be aware of the relevant policy trends in = other=20 countries and build on documented experience.

Making the case for health

ICT infrastructure, costs, human resources and=20 telecommunications regulations are four major factors that shape the = development=20 and uptake of ICT. Health policy makers must work to ensure that = policies in=20 these four areas align with health interests wherever possible. Policy = makers=20 should therefore anticipate their needs and requirements for = infrastructure and=20 bandwidth. They should propose benchmark targets for access to basic = services,=20 cost of basic services and establishment of new services for the sector. = This=20 requires more than awareness: it requires understanding and planning for = what=20 ICT can bring on a medium- to long-term basis. Policy makers should be = able to=20 articulate the drivers for access to ICT, and the potential effects of = ICT=20 policy change. High-level need and justification are important factors = in ICT=20 allocation and policy change.

Health policy makers should have an understanding of = ICT=20 solutions that can potentially be provided at low cost to meet the = sector=92s=20 needs. They must also be aware of new solutions (e.g. low-cost voice=20 communication over the Internet) that may be prohibited by = telecommunications=20 regulations in some countries. Such knowledge will provide health policy = makers=20 with alternatives in the choice of appropriate ICT policy = mechanisms.

The costs of ICT services can be expected to be an = important=20 factor for some time to come. To improve rates and services, health = policy=20 makers must be able to indicate at what level they would consider = operating=20 costs to be reasonable and sustainable. This should be based on the = funding=20 model and resources of the health sector. Across a country or set of = countries,=20 it should be possible to calculate what percentage of gross income of = the=20 subsectors could be reasonably spent on ICT services and systems and = what=20 potential funding mechanisms might be considered.

Participation in a networked economy requires = expertise and=20 resources for dealing with global technical security threats, including = viruses=20 and email spam. The sector must be able to show adequate capacity to = respond to=20 threats in a networked environment, not only to protect the sector but = also so=20 as not to pose a threat to others. Where ICT is relatively new, planning = is=20 required to develop the necessary human resources capacity, and in this = the=20 health sector must be proactive. Gaps in skills should be identified and = a plan=20 developed for training and long-term staff development and = retention.

Outlook for the future

Developing countries must boost their capacity in = ICT and=20 policy making. Basic ICT access indicators cannot demonstrate the full = extent of=20 ICT divides. Countries that are crippled by poverty, disease, foreign = debt and=20 corruption may not have the resources or the political will to invest in = ICT or=20 be considered good markets for foreign ICT investment. Countries must = boost=20 their policy-making capacity in order to ensure that their ICT policy = addresses=20 the concerns of multiple stakeholders. Even as the use of basic ICT = increases,=20 the control of advanced technology will require an environment based on = a=20 comprehensive ICT policy that reflects domestic as well as international = interests.

Table 2.3 Examples of ICT = trends and=20 their application to health
Technology trends	Applications to = health	ICT policy = issues
Broadband Internet	Distance delivery of health care services: = consultations,=20 transmission of prescription and purchase of medicines, using = text, still=20 and mobile pictures, and voice	= Technology=20 standards
		= Privacy=20 protection
		=20 Costs
		= Geographical=20 availability of broadband Internet
Digitization	Video and pictures	= Technology=20 standards
	Electronic databases and memory chips as = patient record=20 archive	= Privacy=20 protection
Wireless communications technologies	Mobile communications: health anywhere from=20 everywhere	=20 Costs
		= Geographical=20 availability of wireless = communication

For the future, international and domestic divisions = in ICT use=20 will be shaped by a number of factors that have the potential to widen = or close=20 the gap. These include the following:

new = technology=20 solutions, such as automatic translation services and inexpensive = wireless=20 phone-based Internet;

increasing = global=20 coverage of satellite systems and lower costs for access;

concerted = action to=20 diffuse ICT and help people use it effectively;

broad = economic and=20 trade policies that will spur integration of ICT into the global economy = as a=20 key engine for growth;

improved = governance=20 and standards setting and the need for evolving models to improve = inclusion and=20 representation of stakeholders.

Boosting government awareness and capacity is = central to=20 achieving equitable, affordable ICT for the health sector in all = countries. The=20 health sector has an important role. Those involved can take concrete = action as=20 follows:

actively = participate=20 in the ICT policy debate to improve awareness and understanding of the = needs of=20 the sector;

emphasize = that=20 benefits to the health community also benefit the public at large;

educate = ICT vendors=20 to develop equipment and systems that meet the needs of developing = countries,=20 i.e. low cost, durable and easy maintenance;

work with=20 non-governmental organizations and civil society, who have an interest = in=20 improving ICT access for the public;

learn from = each=20 other, in order to improve input and participation in ICT policy debate = on such=20 issues as costs, infrastructure development, access to the Internet, = content in=20 local languages and privacy protection.

Conclusion

ICT is fundamental to providing effective and = efficient health=20 services and systems. These technologies can improve workforce and = workplace=20 efficiency and boost quality of care by reducing medical errors, = reducing costs=20 and improving safety. They provide networks and tools for learning, = research and=20 practice. They enable access to information, products and advice for = disease=20 prevention and management, and will be essential to the move to = personalized=20 health and care in the future.

There are many opportunities for health policy makers = to=20 influence the ICT policy process. Their chances of success will be = improved by=20 understanding how ICT can benefit health. Health policy makers must be = effective=20 advocates for health concerns and must be able to enumerate the effects = of ICT=20 policies on health. For policy makers committed to improving national = health=20 systems, participating in the national ICT policy-making process is = essential to=20 ensure that national ICT policy, when implemented, will meet the = interests of=20 the health sector.

Acknowledgements

I thank Ms Yoshiko Kurisaki, SITA, Geneva, = Switzerland for=20 preliminary discussions and Mr Shubhabrata Roy, Microsoft, UK, for his=20 assistance with data and graphics.

References

1.=20 United Nations Statistical Division. Millennium Development Goals = and=20 Targets. Available at: = unstats.un.org/unsd/mi/pdf/mdglist.pdf.

2.=20 International Telecommunication Union. World Summit on the = Information=20 Society Tunis Commitment. Available at:=20 www.itu.int/wsis/docs2/tunis/off/7.html.

3.=20 United Nations Conference on Trade and Development. The Digital = Divide: ICT=20 Development Indices 2004. Available at:=20 www.unctad.org/en/docs/iteipc20054_en.pdf.

4.=20 International Telecommunication Union. World Telecommunication = Indicators=20 Database 2006. Available at: = www.itu.int/publ/D-IND-WTID-2006/en.

5.=20 World Health Organization. The World Health Report 2004 =96 = Changing=20 History. Available at: www.who.int/whr/2004/en/index.html.

6.=20 Council of the European Union. Legislative Acts and Other = Instruments.=20 Council Resolution on the Implementation of the eEurope 2005 Action = Plan=20 (Document 5197/03). Brussels: European Union, 2003.

7.=20 World Health Organization. The World Health Report 2006 =96 Working = Together=20 for Health. Available at: www.who.int/whr/2006/en/index.html.

8.=20 European Commission, Information Society and Media. The Networked = Future:=20 Living in a World of Converging Information and Communication = Technologies.=20 Luxembourg: European Communities, 2005.

9.=20 Picot J. MBTelemedicine Evaluation Final Report. Volume 1: = Information and=20 Findings. Report to the Canadian Health Infostructure Partnership = Program,=20 Government of Canada, 2003.

10. Ball MJ, = Garets DE,=20 Handler TJ. Leveraging IT to improve patient safety. In: Yearbook of = Medical=20 Informatics 2003. Stuttgart: International Medical Informatics=20 Association/Schattauer, 2003: 1=966.

11. = Commission of the=20 European Communities. Communication from the Commission to the = Council, the=20 European Parliament, the European Economic and Social Committee and the=20 Committee of the Regions, June 2005. Brussels, European Union, = 2005

12. Fox S. = Health=20 Information Online. Available at:=20 www.pewInternet.org/pdfs/PIP_Healthtopics_May05.pdf.

13. World = Health=20 Organization. World Health Report 2007 =96 A Safer Future: Global = Public=20 Health Security in the 21st Century. Available at:=20 www.who.int/whr/2007/en/index.html.

14. Kamal A. = The=20 Law of Cyber-space. Geneva: United Nations Institute of Training = and=20 Research, 2005.

15. Dzidonu = CK. Demand=20 and supply for access and connectivity: the case of Ghana. In: Low = Cost=20 Access and Connectivity: Local Solutions. New York: United Nations = ICT Task=20 Force, 2003: 1=9620.

16. United = Nations=20 Economic and Social Council, Economic Commission for Africa. National = knowledge=20 systems and the status of information access policies in Africa=20 (E/ECA/CODI/4/50). Paper presented at the Fourth Meeting of the = Committee on=20 Development Information, Addis Ababa, Ethiopia, April 2005.

17. Wolcott = P, Press L,=20 McHenry W et al. A framework for assessing the global diffusion of the = Internet.=20 J Assoc Inform Syst 2001; 2: 1=9650.

18. United = Nations=20 Conference on Trade and Development. The Digital Divide: ICT = Development=20 Indices 2004. New York: United Nations, 2005.

19. Jensen M. = Interconnection Costs. Available at:=20 www.apc.org/en/pubs/issue/accessibility/all/interconnection-costs.

20. = International=20 Telecommunication Union. ITU Activities Related to = Cybersecurity.=20 Available at: www.itu.int/cybersecurity.

21. = Organisation for=20 Economic Co-operation and Development. Regulatory Reform as a Tool = for=20 Bridging the Digital Divide. Paris: OECD, 2004.

22. Hamilton = P.=20 Identifying Key Regulatory and Policy Issues to Ensure Open Access = to=20 Regional Backbone Infrastructure Initiatives in Africa. Washington, = DC:=20 World Bank, 2004.

3 Telemedicine in developing countries: = Perspectives from=20 the Philippines

Alvin B Marcelo

Introduction

The University of the Philippines Manila National = Telemedicine=20 Center was established in 1998 to investigate the use of information and = communications technology (ICT) to improve health care delivery for all=20 Filipinos. The Center is based at the Philippine General Hospital. It = manages=20 referrals from more than 40 doctors in remote areas around the country,=20 connecting them to more than 600 experts at the Philippine General = Hospital. In=20 implementing e-health and telemedicine, the National Telemedicine Center = chose=20 an approach based on community involvement as well as technology. Three=20 different case studies are described below that demonstrate different = aspects of=20 this strategy. The case studies are CHITS, the E-Learning for Health = Project and=20 the SMS Telemedicine Project.

The approach to implementation consisted of three = distinct=20 steps:

1. The human experience: start from where the people = are.

2. The technological opportunity: identify = appropriate,=20 available, accessible and culturally acceptable technologies.

3. The sustenance factor: embed the technology into = the local=20 fabric.

The human experience

Although technology offers benefits in terms of = applying new=20 processes and approaches to problem-solving, the fact is that most = health=20 interventions are only as effective as their ability to become embedded = in=20 routine activity. This means that if e-health implementations are = approached=20 from a purely technical standpoint it will invariably fail to realize = their full=20 potential.

The essence of the human experience is communication = and=20 interaction. The National Telemedicine Center has observed that the = benefits for=20 communities of e-health and telemedicine occur when the technology = presents=20 itself (a) as an enhancement to existing human relationships that have = been=20 established through conventional routes or (b) as a = solution=20 to a long-felt community need. In either case, the Center=92s experience = has shown=20 that technology has higher chances of sustaining itself in areas where = mature=20 human relationships and interactions already exist.

My experience with the Community Health Information = Tracking=20 System1 = (CHITS) has=20 allowed me to observe a highly technical training programme evolving = into one=20 that is less technology based and more community oriented and = dialectical.=20 During the initial CHITS training, much time was wasted in teaching = elderly=20 health workers how to use a mouse and to type on a keyboard. At the end = of the=20 training sessions, participants still appeared to be afraid of = accidentally=20 damaging the computer. Post-training interviews revealed that the health = workers=20 never became comfortable with the technologies that were being = introduced (the=20 PC and the electronic medical record application).

Community Health Information Tracking=20 System

CHITS was funded in 2004 by the International = Development=20 Research Centre of Canada and subsequently by the United Nations = Development=20 Programme (UNDP). The aim was to develop an integrated disease = surveillance=20 system. CHITS was developed in close consultation with village health = workers to=20 best identify their needs. The result was an open-source application for = the=20 village health centre that combined the features of an electronic health = record=20 and clinic appointment system while also integrating modules for = national health=20 programmes.

CHITS was a starting point for the integration of = information=20 systems. Through CHITS, community-based health information was made = available=20 not only to public health agencies requiring community level information = but=20 also to the community that generated the information. It enabled the = community=20 to use this information for local decision-making.

Currently, CHITS is in use in 12 health centres in two = cities=20 and two provinces in the Philippines. It has made the work of village = health=20 workers easier, since information is entered only once during a patient=20 consultation and can then be used to generate the different reports that = need to=20 be submitted to the Department of Health. Since data are stored = electronically,=20 it is now easier to access and consolidate information, and there is = less risk=20 of data loss. More timely reports allow community leaders to make better = decisions for their people.

There are approximately 100 000 transaction records = from the 12=20 health centres presently using CHITS. The information is stored in = databases=20 using simple data elements patterned after the Department of Health. = Access is=20 limited to authorized personnel, who undergo a two-day electronic health = record=20 training prior to using the system. In this training programme, the = ethics of=20 health information management are taught with special attention to the=20 responsibility and security required for digital data. All data are = owned by the=20 relevant health centre, which also controls access. The data can be = extracted=20 using open-source software tools.

In the light of early experience, revisions in the = training=20 programme were made. Foremost among the changes was the shift from a = highly=20 structured training programme on how to use the keyboard and mouse to a = less=20 strict, more fun approach to using the interfaces by allowing the health = workers=20 to play games on the computer. The trainers = discovered that=20 health workers were often afraid of the new =91formal=92 skills that = they needed to=20 acquire, but were more relaxed (albeit sometimes fiercely competitive) = when=20 asked to beat each other in a game of solitaire. So, instead of coercing = the=20 participants into a strict regimen of clicking and copy-pasting, they = are given=20 time to develop confidence in the use of the keyboard and the mouse = through=20 simple games. The game orientation removes the fear that they have to = perform=20 well in a short period of time. This is what is meant by starting from = where the=20 people are. A recognition of the cultural aspects of community life is = important=20 in starting them off into a new direction such as computerization and=20 automation.

In 2006, CHITS was chosen as one of the key = e-government=20 projects by the APEC Digital Opportunity Center in Taiwan.2 It = was also a=20 finalist in the 2006 Stockholm Challenge.3

The technological opportunity

The process of understanding local cultures and = processes,=20 respecting the local experts, and analyzing their thought processes can = often be=20 frustrating. However, it is essential if external technology is to be = embedded=20 into the community=92s way of life. Once the community has been = understood, the=20 technologies that are available and appropriate can be determined. The = National=20 Telemedicine Center=92s experience with its E-Learning for Health = Project has=20 demonstrated the importance of this step.

E-Learning for Health = Project

The migration of health professionals from rural = areas in the=20 Philippines has progressed to the point that many municipalities are = unable to=20 provide regular training to community health care volunteers. Many of = these=20 under-served communities are also in hard-to-reach, remote areas, and = travel=20 costs can be high. With support from USAID, the National Telemedicine = Center=20 developed four video modules about common topics relevant to the = management of=20 disease in the community:

community = management=20 of accidental childhood poisoning

community = management=20 of stroke

community = management=20 of tuberculosis

community=20 introduction to the avian influenza threat.

These video modules last 7=9610 minutes each and are = narrated in=20 the vernacular with English subtitles. The audiences are community = health care=20 volunteers in remote communities. After the video showing, an = interactive=20 question and answer session is established between the expert in Manila = and the=20 volunteers using the best available technology (ranging from = videoconferencing=20 to mobile phone calls). Various telecommunication media have been = employed for=20 the educational sessions which are held in various locations (Figure = 3.1):

childhood = poisoning=20 between Manila and Basak Pardo, Cebu, using broadband Internet (Figure = 3.2)

3DImage=20

Figure 3.1 Locations of educational=20 sessions

3DImage=20

Figure 3.2 An expert participating = in a health=20 worker=92s meeting via videoconferencing

stroke = between=20 Manila and Nueva Vizcaya, using cellphones

avian = influenza and=20 tuberculosis between Manila and Roxas City and Tapaz, Capiz Province, = using=20 Internet videoconferencing.

One reason for the success of this teaching model = was the=20 familiarity of the audience with the lecture format. We were able to = elicit=20 participation from the audience by providing them with access to an = expert in=20 Manila. There were several benefits. First, there were cost and time = savings=20 from travel by not having to transport the expert to a remote area. = Second, the=20 expert could serve several communities in a single session. The audience = were=20 able to receive updates using a novel method that did not require them = to=20 establish new skills. In all cases, the local participants were given = the=20 opportunity to participate and ask questions directly of the expert = using the=20 vernacular.

In the Philippines, massive migration of doctors and = nurses has=20 resulted in a lack of trainers in the public health sector. Even where = there are=20 many community health volunteers, there are not enough trainers and = leaders to=20 provide them with the requisite knowledge.

Visiting the under-served communities has made the = staff of the=20 Center aware of what technologies are available. Televisions and video = CD=20 players can be found in almost all communities. In populated areas, = there is=20 invariably mobile phone coverage, so that voice calls and/or a = short-message=20 service (SMS) are also available.

The E-Learning for Health Project has shown that, by = using=20 locally available technology and the best available bandwidth, it is = possible to=20 establish interaction between a group of health care volunteers (in a = remote=20 community) and an expert (in an urban area). Voice calls were found to = be most=20 effective, although participants also appreciated videoconferencing. The = community members were keen to accept the new modality, because it = employed=20 technologies that were already familiar to them. Pretests and post-tests = given=20 to participants revealed that they were able to gain knowledge from the=20 e-learning activity.

The sustenance factor

Stand-alone, intermittent, expert-driven events = (such as the=20 E-Learning for Health Project and CHITS) are easy to implement, but are = they=20 sustainable? In order to achieve permanence, e-health and telemedicine=20 applications must be embedded into the local fabric of the = community.

How, then, do we overlay the technologies (step 2) = over the=20 local issues (step 1) to ensure that the technical solution finds a home = in the=20 heart of the community? E-health should be considered as another = community=20 activity that will need to involve discussions, arguments and = deliberations.=20 E-health should thus become the vehicle for more rapid and more = structured=20 community development through enhanced communications and process = documentation.=20 This becomes more apparent with the use of mobile phones for = health-related=20 concerns such as announcements for community meetings, reminders for=20 vaccinations and prenatal check-ups. It also involves gathering the = health=20 volunteers and workers regularly to attend e-learning sessions on = community=20 health development.

In one high-profile government-funded project, the = BuddyWorks=20 Community Partnership in Delivering Telemedicine Services, remote sites = were=20 provided with workstations and broadband Internet connections to allow = them to=20 refer difficult cases to experts in a central facility. A total of 10 = facilities=20 in four provinces was involved. However, despite the substantial = investment,=20 referrals from the remote sites did not occur. Analysis revealed a = workflow that=20 prevented the users from assimilating desktop Internet technologies for=20 communicating clinical dilemmas. In the proposed system, the remote = physician=20 needed to log on to a computer with Internet access, go to the agreed = website=20 portal, enter the relevant clinical data and wait for the response of an = expert=20 =96 who would probably be busy with his or her own patients at the time. = The=20 process had so many steps that the risk of a failed transaction was very = high.

SMS Telemedicine Project

In response, the workflow was revised to allow the = doctors to=20 communicate via SMS. Most doctors already owned a mobile phone. Using = SMS, they=20 were able to communicate more effectively. It was then decided to = supplement the=20 existing network by providing modest prepaid SMS allowances to the = doctors and=20 offering them free conference call services for voice-based referrals. = This=20 system has proved to be sustainable and effective. During a 6-month = period, over=20 300 referrals were received from 44 doctors in remote areas.

Conclusion

It is widely accepted that all societies, especially = those of=20 developing countries, can build more cohesive communities through the = primary=20 health care approach. Telemedicine and e-health have a great potential = to=20 facilitate service delivery in primary care. For example, rural health = workers=20 commonly suffer from inefficient, paper-based recording systems. CHITS, = based on=20 free and/or open source software and SMS, provided a more effective=20 alternative.

At the core of any telemedicine service is an = electronic health=20 record. This is how CHITS plays a role in telemedicine =96 by providing = a=20 consistent view of the patient=92s records. The current telemedicine = services in=20 the Philippines are simple enhancements to existing trust structures. By = using=20 SMS and mobile phones, the National Telemedicine Center is able to = provide=20 access to experts for patients who would not otherwise have been able to = consult=20 them. The use of SMS technology has increased the area of coverage of = the=20 Center.

The challenges that plague the Philippine system are = the=20 continuing loss of health professionals from internal and external = migration. As=20 more and more health workers seek work in other countries and rural = physicians=20 move from rural to urban practices, the number of municipalities without = doctors=20 will increase. Establishment of an efficient and effective referral = network,=20 based on mobile phone technology, is a key component in mitigating the = effects=20 of this migration. The faster the trust relationships between the remote = doctors=20 and physicians are established, the quicker telemedicine services can = take hold=20 in the relevant communities.

References

1.=20 Tolentino H, Marcelo A, Marcelo P, Maramba I. Linking primary care = information=20 systems and public health information networks: lessons from the = Philippines.=20 Stud Health Technol Inform 2005; 116: = 955=9660.

2.=20 APEC Digital Opportunity Center. Available at: www.apecdoc.org.

3.=20 Stockholm Challenge. Available at: www.stockholmchallenge.se.

4 Information technology for primary health care = in=20 Brazil

Elaine Tomasi, Luiz A Facchini, Elaine = Thum=E9, Maria FS=20 Maia and Alessander Osorio

Introduction

Decision making in public health depends on the = availability=20 of reliable information, which is generated, analyzed and disseminated = by=20 information systems.1,2 = However, most=20 national health information systems lack the information needed to = address=20 health inequities, namely, reliable, longitudinal data that links = measures of=20 health with measures of social status at the individual or small-area = level.

At all levels of health care, particularly in primary = care,=20 there is a consensus concerning the usefulness of information = technology,=20 especially for promoting greater efficiency in management = processes.3,4 = Although=20 studies evaluating the impact of such technologies on health are still=20 rare,5,6 most = authors=20 agree that there are positive effects from these systems and that they = can be=20 improved further through regular monitoring.

Low levels of computerization in primary health care = are very=20 common. Furthermore, many papers stress the need for continued = motivation and=20 training for all team members as a prerequisite for the success of any=20 initiative in this area.7,8 It = may be=20 pertinent here to quote the reflections by Branco9 on = the=20 significance of training, that is, the amplification of knowledge:

=85 knowledge of the logic behind health = information=20 production and flux must be provided to all persons involved, and should = include=20 an understanding of the goals of the systems to which they have access, = and of=20 the possibilities for use of the information produced =85

Martinez et al10 = analyzed=20 communication and information needs in primary health care in rural = areas from=20 Peru and Nicaragua. They found three main factors related to the = inefficiency of=20 the health systems: poor infrastructure, a lack of information systems = and=20 deficiencies in the training of health professionals. Other authors have = emphasized the need to incorporate good-quality health care data from = local=20 levels into national databases.11=9614 = Similarly,=20 Gething et al15 = stated that=20 the value of information systems in health is to = point out the=20 needs and priorities at both national and local levels, but the process = of=20 feeding data into the systems often fails.

Another source of problems is the contrast between the = availability of information technology (IT) at the central level of = health=20 system management and its shortage elsewhere, particularly in primary = care.=20 There is often pressure for new data, increasing the time required for=20 collection, with no assurance about its analysis, dissemination and = usefulness=20 in decision making. The great quantity of data about each patient, = recorded by=20 health professionals, seems to have little meaning in their daily=20 activities.16 We = believe=20 that all of these factors contribute to the current situation =96 but = especially=20 the lack of motivation of most health care staff and the poor = integration=20 between health care and IT professionals.

Establishing IT in the health services, especially in = primary=20 care, is a challenge for the advance of information systems, not only in = the=20 smaller and poorer towns. In bigger cities, the central levels of the = health=20 system generally have good access to IT resources, but the recording of = the=20 actions of the major part of the health services is still performed=20 manually.16

There are few reports in the literature about the = experience=20 with the development and use of computerized systems in primary care. = Herman et=20 al17 = described the=20 Community Health Information Tracking System (CHITS) in the Philippines, = which=20 has the objective of integrating local and national level information = and=20 pointing out =91islands=92 in the information systems and a great amount = of repeated=20 work in the management of such systems (see also Chapter 3). = Aspects related=20 to access to data from different information systems, and their use and = control,=20 should be considered, including their creation, implementation, = monitoring and=20 evaluation.18

IT in primary care in Brazil

Two recent initiatives from the Brazilian government = are the=20 National Information Policy on Informatics in Health (NIPIH/PNIIS)19 and = the=20 National Telemedicine Programme in 2006.20 The = NIPIH=20 focuses on health work, on the user and on the electronic health record. = The=20 proposals are underpinned by standards to represent and share health=20 information, the connectivity structure, the training of human resources = in the=20 information systems in health, and, above all, the guarantee of privacy = and=20 confidentiality of the information.

National Telemedicine = Programme

Telemedicine activity currently involves about 30 = universities=20 and research institutes in 9 of the 27 Brazilian states. The pilot = project in=20 telemedicine for primary care involves the installation of 900 PCs, = mainly for=20 decision support. These PCs are connected to a wide area network, and = can also=20 be used for videoconferencing. They have an electronic medical record, = which can=20 be shared with other units. Priority is being given to cities where = there is a=20 family health programme, a population of less than 100 000 and = geographical=20 barriers to health care. The Ministry of Health, together with=20 the Ministry of Education, has been investing in distance learning for = training=20 and continuing education of health professionals.

National information = systems

The information systems available in Brazil consist = of large=20 databases of statistics. These include births, deaths and a disease = surveillance=20 system. There are also tools for the management of outpatient and = hospital=20 services.

The only computerized health information system used = in family=20 health centres is the Primary Care Information System. This is the = source of=20 information, and provides most of the tools and the forms completed by = the=20 primary care team. Most health professionals recognize it as a tool for=20 improving the epidemiological profile, but it is underutilized. = According to the=20 staff concerned, this underutilization is due to various limitations of = the=20 system, to a lack of knowledge and lack of preparation for exploring its = full=20 capacity, to a lack of training and to a lack of incentive to use it for = data=20 analysis. The system has weaknesses, but some professionals also have=20 difficulties in manipulating it both regarding the input of data and in=20 producing reports.

Data collection is fragmented, with no connection with = health=20 policies to facilitate the planning and decision making. The data = collection and=20 transfer mechanisms generate repeated work and reduce efficiency in the=20 management of information.19 The = system=20 does not allow integration with other systems, and cannot identify users = and=20 show their links to health services. For this, a National Health Card is = being=20 implemented. However, because of the magnitude of the investment = required,=20 progress has been slow.

The proliferation of information systems should be = highlighted.=20 For each need, sector, disease or event, new software is created, = implying high=20 costs for development and maintenance, and a lack of standardization and = interoperability. According to Cohn et al,12 = there is=20 little use of information from the large databases in Brazil, especially = in=20 small towns. The full potential of the information has yet to be = realized.12,21

Telemedicine

Separate from the National Telemedicine Programme, = the BH=20 Telemedicine Project was implemented in 2003. The aim was to promote the = continuing education of health workers in primary care units, as well as = contributing to the modernization of the public health system. The BH=20 Telemedicine network connects primary care centres to the Federal = University of=20 Minas Gerais teaching units, with activities in the fields of medicine, = nursing=20 and dentistry. The network uses videoconferences for continuing = education, and=20 teleconsulting between specialists and staff at the primary care centres = for=20 second opinions and for discussion of clinical cases. The = videoconferencing=20 network operates at 128 kbit/s.

The telemedicine network has been implemented in 121 = primary=20 care centres. About 1500 teleconsultations per year occur between = specialists=20 and staff at the primary care centres. In 2006, there were 75 = educational=20 videoconferences, including medical, nursing and dentistry areas, = involving more=20 than 5000 participants. The activities have resulted in more effective=20 participation of the oral health group, followed by nurses and finally = by the=20 physicians.

The project has been evaluated by two groups. The = results showed=20 better outcomes for the cases discussed, with about 70% of patients = staying in=20 basic units, with no need for referral to a specialist. There was also a = reduction of 71% in the number of patients who needed to travel to the = Clinics=20 Hospital of Belo Horizonte to be seen.

Computerized tools

In 2005, a survey was conducted to characterize = primary care=20 and evaluate differences in the effectiveness of services according to = the model=20 of care =96 family health or traditional.16 = Under the=20 Family Health Programmes (FHP), teams are composed of a doctor, a nurse, = a nurse=20 technician and about five community health agents. These teams are = responsible=20 for supervising a set number of families (about 1000) living in a = particular=20 area. The teams undertake work involving health promotion, prevention, = recovery=20 and rehabilitation. In the traditional model, teams do not include = community=20 health agents and do not have their activities focused on health = promotion and=20 disease prevention.

The survey enrolled 41 municipalities of more than 100 = 000=20 inhabitants in the south and north-east regions of Brazil, which = represented=20 approximately 20% of these size municipalities in the country. There = were=20 systematic differences between the demographic and socioeconomic = indicators from=20 the south and north-east of the country. In the south, the average human = development index (HDI), life expectancy, number of literate people and = homes=20 with tap water supply were higher than in the north-east. North-east=20 municipalities showed a higher proportion of poor people (41% vs 17%), = while the=20 southern municipalities showed a higher proportion of elderly citizens = (9% vs=20 7%).

Information about the 236 primary care centres was = obtained by=20 questionnaire: 4749 health workers were studied. Among these, 11% were=20 physicians, 7% nurses, 8% professionals with another college degree, 18% = nursing=20 assistants, 23% other professionals with a high school degree and 33% = community=20 health agents. One-third of the primary care centres had a computer = (35%): 40%=20 in the south and 29% in the north-east. Considering the care model, 39% = of the=20 family health services had a computer, as opposed to only 25% of the = traditional=20 services (Table = 4.1).=20 Only 11% of the primary care centres had Internet access: 17% in the = south=20 region and 5% in the northeast region. The traditional services had more = Internet access (14%) than the family health services (9%) (Table = 4.2).

About 20% of the health workers mentioned their use of = computers=20 for professional activities. This use was almost 50% among physicians, = nurses=20 and other professionals with a college degree, and a little more than = 10% among=20 nursing technicians, community health agents and other members of the = teams who=20 had a high school education. The use of computers in the primary care = centres=20 was even less frequent, being mentioned only by 8% of the professionals = (Table = 4.3).

Depending upon the region, the use of computers in = health=20 centres was 14% in the south and 5% in the north-east. Depending upon = the care=20 model, it was 10% in family health services and 6% in the traditional = centres=20 (Table = 4.4).

Table 4.1 Microcomputers in = primary=20 care services according to the model of health care and = geographical=20 region (n =3D 236)
	South (%)	North-east (%)	Total (%)
Family health	46	33	39
Traditional	30	16	25
Total	40	29	35

Table 4.2 Access to the = Internet in=20 primary care services according to the model of health care and=20 geographical region (n =3D 236)
	South (%)	North-east (%)	Total (%)
Family health	16	4	9
Traditional	17	10	14
Total	17	5	11

Table 4.3 IT use by primary = care=20 workers according to location of access (n =3D = 4749)
	In home or primary health care unit=20 (%)	Only in primary health care unit=20 (%)
Community health agents	3	6
Other assistants	4	10
Nurse assistants	6	7
Nurses	34	16
Other professionals	35	11
Doctors	47	8
All	14	8

Table 4.4 Use of computers by = primary=20 care health workers according to model of health care and = geographical=20 region (n =3D 4749)
	South (%)	North-east (%)	Total (%)
Family health	15	6	10
Traditional	12	3	6
Total	14	5	8

PACOTAPS

PACOTAPS is a tool for decision making. The = objective of the=20 PACOTAPS software is to assist health managers and teams with = information about=20 population characteristics and health demands.22 The = software=20 provides a structure to receive data about the contacts and procedures = performed=20 at primary care centres. The origin document is the = Outpatient=20 Contact Form, which is completed by the health team and signed by the = user. Once=20 the form has been completed, the data are typed in using a module called = users contact with the services.

PACOTAPS includes lists of professionals, groups and = procedures=20 that are standardized by the Outpatient Information System. For the=20 identification of the diagnosis, PACOTAPS provides the application = PESQCID,23 = which allows=20 a guided consultancy to the International Classification of Diseases = (ICD-10).24 = Thus, using=20 the system it is possible to find out, for a certain period of time, the = distribution of patients by age and gender, the main diagnosis and the=20 proportion of referrals.

Training

About 400 primary care workers from the 41 cities = under study=20 were trained in monitoring and evaluation through practice exercises in = a=20 computer laboratory, in two regional workshops. The participants could = install,=20 become familiar with and use PACOTAPS, with emphasis on the module = users=20 contact with the services. Thus, they were able to understand its=20 usefulness for the daily activities of primary care centres, and in = municipal=20 health management. The simplified data entry and the immediate = availability of=20 reports were very attractive, as these are requirements often mentioned = by=20 health workers. The training aims to make health workers aware of the = need to=20 produce accurate and valid information. At the end of training, each=20 municipality received a CD for installation of the software and the = application=20 manual.

Survey results

In the PROESF study, all the 26 019 user contacts = with the=20 primary care centres were recorded in PACOTAPS. Information was = collected about=20 the users=92 profiles (age, gender and health problems), the procedures = performed=20 and the referrals. One-third of the contacts (35%) were for women = between 15 and=20 49 years old, i.e. of reproductive age. The second largest group was for = people=20 60 years of age or older (19%) and the third largest group was children = below 5=20 years old (15%).

Every user can receive one or more procedures at each = contact.=20 For example, a child may receive an immunization and also have a medical = consultation for diarrhoea; an elderly person may have his or her blood = pressure=20 checked, have a medical consultation for back pain and receive his or = her=20 medication; a pregnant woman may have her weight checked, have a medical = consultation for urinary infection and be attended to by the social = worker for=20 receiving a benefit. Therefore, the number of procedures is usually = higher than=20 the number of people attended to. In this sample, more than 37 000 = procedures=20 were analysed.

Although nurses and nurses=92 assistants comprised 25% = of the=20 teams, they performed more than half of the procedures (53%). The = physicians,=20 who represented 11% of the professionals, accounted for 26% of the = procedures.=20 Almost 70% of the procedures were related to factors that influenced the = health=20 status and the contact with the services, such as prenatal care and = paediatrics,=20 immunization and screening tests. After this, health problems related to = the=20 digestive system (7%), circulatory system (4%) and respiratory system = (4%) were=20 observed more frequently.

Although 23% of the records did not have information = about=20 referrals, it was observed that in 70% of the contacts there was no need = to=20 refer the user to other care levels or to request diagnostic tests.

Conclusions

Primary care plays a major role in producing better = health=20 care for all people, particularly in developing countries. Efforts are = now being=20 directed towards the improvement of different models of care. As in = other=20 places, in Brazil, family health care is becoming a successful equity = promotion=20 effort, because it is more widely present in poorer regions with a more=20 vulnerable population. Despite limitations that are common to primary = care, the=20 family health programme does more for whoever needs more.

The experience of the BH Telemedicine implementation = provides=20 guidance for the future:

potential = for=20 innovation in the public network

standards = governing=20 the interaction between teaching and the assisting practice of the = health=20 services

= improvements in the=20 assisting structure, with possibilities of reduced costs and better = structuring=20 of a multidisciplinary project of telemedicine.

The main challenges regarding IT for primary care = are:

1. To improve IT in primary care centres, rather than = at the=20 central levels of health system management.

2. To estimate standardization and compatibility = between=20 national health information systems, especially through web-based tools = rather=20 than the production of local software or information systems.

3. To promote a wide professional training in IT as a = strategy=20 to facilitate its use in decision making for clinical practice, and to = monitor=20 and evaluate health programmes, focusing on people rather than on=20 technology.

Overall, this will require greater investment in IT = and=20 telecommunications directed towards the basic health units. This = investment=20 should be made by municipalities, but currently there are other = priorities in=20 the country=92s public health system, and resources are scarce.

References

1.=20 AbouZahr C, Boerma T. Health information systems: the foundations of = public=20 health. Bull World Health Organ 2005; 83:=20 578=9683.

2.=20 Magruder C, Burke M, Hann NE, Ludovic JA. Using information technology = to=20 improve the public health system. J Public Health Manag Pract = 2005;=20 11: 123=9630.

3.=20 Kukafka R. Public health informatics: the nature of the field and its = relevance=20 to health promotion practice. Health Promot Pract 2005;=20 6: 23=968.

4.=20 OPS (Organizaci=F3n Panamericana de la Salud). Sistemas de = informaci=F3n y=20 tecnologia de informaci=F3n en salud: desafios y soluciones para = Am=E9rica Latina y=20 el Caribe. [Information Systems and Information Technology in = Health:=20 Challenges and Solutions for Latin America and the Caribbean.] = Washington,=20 DC: OPS, 1998.

5.=20 Macinko J, Guanais FC. Selected Annotated Bibliography on Primary = Health=20 Care in the Americas. Pan American Health Organization=92s Primary = Health=20 Care Working Group, 2004. Available at:=20 www.opas.org.br/servico/arquivos/Sala5520.pdf.

6.=20 Mitchell E, Sullivan F. A descriptive feast but an evaluative famine: = systematic=20 review of published articles on primary care computing during 1980=9697. = BMJ 2001; 322: 279=9682.

7.=20 Magalh=E3es CAS. An=E1lise da resist=EAncia m=E9dica =E0 = implanta=E7=E3o de sistemas de=20 registro eletr=F4nico de sa=FAde. [Analysis of Medical = Resistance to the=20 Introduction of Systems for Electronic Health Records]. Rio de = Janeiro:=20 Funda=E7=E3o Get=FAlio Vragas, 2006.

8.=20 Nobel J. Changes in health care: challenges for information system = design.=20 Int J Biomed Comput 1995; 39: 35=9640.

9.=20 Branco MAF. Informa=E7=E3o e tecnologia: desafios para a implanta=E7=E3o = da Rede=20 Nacional de Informa=E7=F5es em Sa=FAde. [Information and technology: = challenges to=20 developing a national health information network.] Physis: Rev Saude = Coletiva 1998; 8: 95=96123.

10. Martinez = A,=20 Villarroel V, Seoane J, del Pozo F. Analysis of information and = communication=20 needs in rural primary health care in developing countries. IEEE = Trans Inf=20 Technol Biomed 2005; 9: 66=9672.

11. Ali M, = Park JK, von=20 Seidlein L et al. Organizational aspects and implementation of data = systems in=20 large-scale epidemiological studies in less developed countries. BMC = Public=20 Health 2006; 6: 86.

12. Cohn A, = Westphal=20 MF, Elias PE. Data and the process of formulating health policies. = Rev Saude=20 Publica 2005; 39: 114=9621.

13. Gladwin J, Dixon RA, Wilson TD. Implementing a = new health=20 management information system in Uganda. Health Policy Plan = 2003;=20 18: 214=9624.

14. Viacava = F, Dachs=20 JNW, Travassos C. Os inqu=E9ritos domiciliares e o Sistema Nacional de = Informa=E7=F5es=20 em Sa=FAde. [Household surveys and the National Health Information = System.]=20 Cienc Sa=FAde Coletiva 2006; 11: = 863=969.

15. Gething = PW, Noor=20 AM, Gikandi PW et al. Improving imperfect data from health management=20 information systems in Africa using space=96time geostatistics. PLoS = Med=20 2006; 3: e271.

16. Facchini = LA,=20 Piccini RX, Tomasi E et al. Monitoramento e avalia=E7=E3o do Projeto de = Expans=E3o e=20 Consolida=E7=E3o da Sa=FAde da Fam=EDlia: relat=F3rio final. Pelotas: = UFPel, 2006.=20 Available at: www.epidemio-ufpel.org.br/proesf/index.htm.

17. Herman T, = Marcelo=20 A, Marcelo P, Maramba I. Linking primary care information systems and = public=20 health vertical programs in the Philippines: an open-source experience. = AMIA=20 Annu Symp Proc 2005: 311=9615.

18. McGrail = KM, Black=20 C. Access to data in health information systems. Bull World Health=20 Organ 2005; 83: 563.

19. Brasil, = Minist=E9rio=20 da Sa=FAde. PNIIS =96 Pol=EDtica Nacional de Informa=E7=E3o e = Inform=E1tica em Sa=FAde;=20 proposta vers=E3o 2.0; inclui delibera=E7=F5es da 12a=20 Conferencia Nacional de Sa=FAde. Bras=EDlia: MS, 2004. Available at:=20 www.datasus.gov.br.

20. Brasil, = Minist=E9rio=20 da Sa=FAde. Portaria n=B0 35 de 4 de janeiro de 2007 que institui, no = =E2mbito do=20 Minist=E9rio da Sa=FAde, o Programa Nacional de Telessa=FAde. = Bras=EDlia: MS, 2007.=20 Available at:=20 dtr2004.saude.gov.br/dab/docs/legislacao/portaria35_04_01_07.pdf.

21. Barbosa = AK, de A=20 Novaes M, de Vasconcelos AM. A web application to support telemedicine = services=20 in Brazil. AMIA Annu Symp Proc 2003: 56=9660.

22. Tomasi E, = Facchini=20 LA, Osorio A, Fassa AG. Aplicativo para sistematizar informa=E7=F5es no = planejamento=20 de a=E7=F5es de sa=FAde p=FAblica. [Software program to systematize data = for planning=20 public health actions.] Rev Sa=FAde Publica 2003; = 37:=20 800=966.

23. MS = (Minist=E9rio da=20 Sa=FAde). DATASUS: informa=E7=F5es em sa=FAde Bras=EDlia: MS, 2002. = Available at:=20 www.datasus.gov.br.

24. OMS = (Organiza=E7=E3o=20 Mundial da Sa=FAde). CID 10. [International Classification = of=20 Diseases, 10th revision.] S=E3o Paulo: EDUSP, 1996.

5 Community-based health workers in developing = countries=20 and the role of m-health

Adesina Iluyemi

Introduction

The World Health Organization (WHO) has proposed the = use of=20 low-cost information and communication technology (ICT) to improve the = quality=20 of service delivery and to build up health workers=92 capacity = especially at the=20 primary health care (PHC) level.1 This=20 application of ICT in health care has been termed e-health.2 = Mobile=20 e-health, or m-health, involves using wireless technologies such as = Bluetooth,=20 GSM/GPRS/3G, WiFi, WiMAX, on to transmit e-health data and facilitate = services.=20 Usually, these are accessed by the health worker through devices such as = mobile=20 phones, Smartphones, personal digital assistants (PDAs), laptops or = tablet PCs.=20 Health data stored on devices such as USB memory sticks and memory = storage cards=20 (SDs) can also be regarded as m-health tools.

The International Telecommunication Union (ITU) has = been=20 piloting m-health for health system and workers development in = developing=20 countries since 2002, especially at the PHC level.3 Most = e-health=20 development has been aimed at employing mobile/wireless ICT for PHC = service=20 development in developing countries. However, this is often not grounded = within=20 local practices in these countries. Attempts to develop new applications = without=20 taking account of local sensibilities have been known to fail.4 How = can=20 m-health be made sustainable for health workers and for PHC delivery in=20 developing countries? To answer this question, case studies on the use = of=20 m-health applications by community-based health workers (CBHWs) from = four=20 developing countries in three continents are presented in this = chapter.

Opportunities in m-health for addressing = global
health=20 problems

Health systems in developing countries face the = double burden=20 of chronic and infectious diseases. Scarce financial resources, coupled = with the=20 brain drain, have led to the loss of mostly high- and medium-level = health=20 workers. The Millennium Development Goals (MDGs) set = out by=20 the United Nations in 2000 provide targets for tackling the disease = burdens in=20 developing countries.5 The=20 health-related MDGs are to:

reduce = child=20 mortality from childhood diseases

improve = maternal=20 health

combat = HIV/AIDS,=20 tuberculosis and malaria.

These diseases have affected the fabric of society. = Timely=20 achievements of the health-related goals of MDGs in developing countries = according to WHO can be attained by adopting the principles of the Alma = Ata=20 Declaration on Primary Health Care.6 This = implies=20 that the PHC service model could be the best approach to the management = of the=20 health-related MDGs in developing countries. However, the shortage of = human=20 resources is a major impediment to achieving the MDGs. Recently, there = have been=20 calls to focus strategies on the development of =91substitute health = workers=92 for=20 providing health services in developing countries.7,8 CBHWs = are=20 long-standing providers of primary health care in many developing = countries, and=20 can be considered as =91substitute health workers=92 in this = context.

These factors all provide a rationale for introducing = m-health=20 for CBHWs and making policy changes to produce health system reforms in=20 developing countries.

Primary health care

PHC is operationalized through the district health = system=20 (DHS). The DHS is a hierarchical organizational structure for PHC = service=20 delivery, and is made up of four or five integrated levels of health = service=20 delivery configuration. PHC forms the first level of contact of = individuals, the=20 family and community with the national health system. Essential health = services=20 are provided through the PHC system using community outreach programmes = and=20 facilities. CBHWs are regarded as the lowest cadre within the PHC = system.

CBHWs are a variety of health workers who are = selected, trained=20 and work within communities. They normally have a shorter education than = professional workers. In developing countries, they are usually located = in rural=20 and semi-urban settings, but may also operate in urban areas. CBHWs are = either=20 paid staff or volunteers, and are trained within the local community in = which=20 they are expected to operate. They also perform specialist functions = such as=20 providing reproductive health and family planning, nutrition education, = and=20 community rehabilitation for convalescing and disabled patients. As well = as=20 delivering essential health services, CBHWs are also agents for health = promotion=20 in the community in which they live and work. They also act as advocates = for=20 socioeconomic development and community empowerment.

Five case studies that illustrate aspects of = implementing=20 m-health innovations with CBHWs in developing countries are presented=20 below.

Case study 1

Background

The Ca:sh (Community Access to Sustainable = Health)=20 programme was instituted in India in 2001. Large quantities of = health data=20 are generated by the PHC system in India. This is used for = treatment=20 planning, resource allocation, disease surveillance and = management. Moving=20 this information from the lower level to the district level of the = PHC=20 system in a timely and accurate manner was difficult because of = the size=20 of India=92s health system. The Ca:sh programme was conceived to = provide a=20 cost-effective method of managing and accessing these large = volumes of=20 health data. The CBHWs (usually auxiliary nurses or midwives) = provide=20 community, maternal and childhood care. The m-health application = was=20 developed to support the CBHWs in rural communities where most of = the=20 population live.

Case description

The m-health application was piloted in 2001 in = a rural=20 community with a population of 70 000. The Ca:sh programme was = implemented=20 by local staff in conjunction with the international developers. = There was=20 a two-stage implementation process involving a participatory = approach in=20 order to engage with the CBHWs. The first stage lasted for five = months,=20 and problems that were identified were incorporated into the = design=20 process. The second stage lasted for nine months, and culminated = in a=20 programme evaluation exercise. During this process, technical = support and=20 training for the CBHWs were provided by the local implementers. = The=20 training for the CBHWs also followed the two phases of the design=20 process.

The m-health application enables the CBHWs to = collect=20 household, demographic, antenatal and prenatal, and childhood = immunization=20 data at the point of care in the patients=92 homes. The data = collected by=20 the CBHWs are then transferred at regular intervals to a central=20 repository located at a district health centre. Unfortunately, = despite a=20 successful demonstration phase, the project was discontinued owing = to lack=20 of support by the national government.9

Case study 2

Background

The Hispano-American Health Link (EHAS) = programme was=20 instituted in Peru in early 2000. Maternal and childhood diseases = such as=20 respiratory and gastrointestinal infections are common in Peru, = especially=20 in rural areas. Rural villages have health posts that are usually = staffed=20 by CBHWs, who provide PHC services. Usually, CBHWs depend on the = bigger=20 health centres for second opinions, case referrals, pharmaceutical = deliveries and service administration. However, the execution of = these=20 activities was very difficult because of poor communications. = Often, the=20 CBHWs spent hours or even days travelling to the health posts. The = EHAS=20 m-health system was designed to tackle this problem.

Case description

The EHAS programme commenced with a pilot = project=20 involving the deployment of 39 sets of m-health equipment to the = health=20 posts and centres within a district health system. This was = preceded by a=20 comprehensive assessment of the ICT needs of CBHWs in the region. = This=20 indicated that lack of communication facilities hampered the = coordination=20 of the CBHWs=92 activities, sharing and exchange of information, = and their=20 education. The contents of the m-health application included = e-learning=20 materials such as journals, evidence-based guidelines and local = health=20 news, mostly for managing childhood and maternal health care. An online e-learning test and assessment system = was also=20 provided. Access to experts=92 or second opinions was also = provided through=20 a store-and-forward teleconsultation system.

The implementation involved the participation = of local=20 authorities and host communities in the development and = installation of=20 the m-health equipment. Training was provided for the local = implementers,=20 who in turn trained the CBHWs. The training included material on = computer=20 literacy, the operation of the m-health communication system and = simple=20 maintenance procedures. Two local technicians from the district = hospital=20 were trained in equipment maintenance and repair procedures. In = addition,=20 training was also provided for the managers at the district = hospital on=20 how to configure the m-health application to their local=20 requirements.

At the completion of the nine-month pilot = implementation,=20 an evaluation was carried out to measure the impact of m-health on = the=20 community, on the CBHWs and on health service delivery. This was = compared=20 with the baseline study conducted at the start of the project. = Findings=20 from the evaluation were then employed to further improve and = develop the=20 m-health application. In the last seven years, the programme has = provided=20 valuable lessons on using high-bandwidth wireless ICT for rural = m-health.=20 Similar programmes in Columbia and Cuba have been inspired by this = success.10,11

<= /TD>

Case study 3

Background

Cell-Life is a project in South Africa focusing = on the=20 management of the HIV/AIDS epidemic. South Africa has one of the = highest=20 rates of HIV/AIDS rate in the world. In 2004, there were = approximately 3.8=20 million people infected with the HIV/AIDS virus. In response, the = South=20 African government commenced a nationwide programme of = antiretroviral=20 (ARV) therapy for people living with HIV/AIDS (PLWHA). PLWHA are = usually=20 managed by state and community-based organizations. However, these = often=20 lack resources. Most PLWHA are resident in rural areas where there = is a=20 lack of basic amenities, and often the supply of ARV drugs to = these=20 centres is unreliable, thereby predisposing these patients to = secondary=20 infections such as tuberculosis. The South African government also = recognized the importance of up-to-date information and access to=20 communication facilities for the support and empowerment of=20 PLWHA.

Case description

Initially, Cell-Life started as a community = home-based=20 care system for the direct management of HIV/AIDS patients known = as=20 =91Aftercare=92. However, it has since been expanded to cover = other aspects of=20 the HIV/AIDS management process, such as pharmacy stock control, = voluntary=20 counselling and testing. The Aftercare module was designed for = volunteer=20 CBHWs known as therapeutic counsellors for the management of = PLWHA.=20 Therapeutic counsellors are PLWHA who are also undergoing ARV = therapy=20 themselves, but are more in control of their health situation. = This=20 represents a kind of peer-to-peer homecare management model. Each = CBHW is=20 usually allocated to 15=9620 PLHWA. This involves the CBHWs = providing care=20 and support to their fellow PLHWA in their homes, and ensuring = their=20 compliance with ART treatment regimens. The m-health system = supports these=20 CBHWs in their health volunteer activities.

The first pilot was implemented in 2002 at a = rural HIV=20 research centre. Training and continuous supervision were provided = by a=20 doctor from the local university hospital. The mobile devices were = provided for the CBHWs by the clinic for their professional and = personal=20 use. The clinic is also responsible for maintenance of the mobile=20 devices.

Basically, the m-health innovation is used by = the CBHWs=20 for accessing real-time health and ART records of their fellow = PLHWA=20 during home visits. Information collected includes drug=20 dosage and side effects, and relevant socioeconomic indicators. = This=20 information is transmitted via a public wireless network to a = central=20 database for analysis by a care manager; feedback is then provided = for the=20 CBHWs as required. Real-time communication between the care = manager and=20 CBHWs is usually by voice communication. The care manager also = employs the=20 data for monitoring the CBHWs=92 activities.

In 2002, there were 6 CBHWs and 250 patients. = At present,=20 there are about 46 CBHWs in 4 rural and peri-urban sites, managing = about=20 3500 PLWHA. Recent indications are that the programme may not be = sustained=20 because of financial constraints.

Case study 4

Background

In India, traditional health practices serve as = alternatives to formal health services, and meet the health needs = of the=20 mostly rural and poor population. Ayurveda, a 5000-year-old = practice, is=20 an example. Ayurveda uses medicinal plants to create low-cost = drugs for=20 managing chronic and acute diseases. These services are delivered = by=20 traditional CBHWs, who provide home consultation to clients in = rural=20 areas. In 2001, Jiva Health, an Ayurvedic health care provider, = decided to=20 develop an m-health system known as Jiva TeleDoc for supporting = the=20 homecare activities of its CBHWs. The aim was to develop a = sustainable=20 solution that was appropriate for the primary health needs of = villagers in=20 India.

Case description

The aim of the Teledoc innovation was to = identify health=20 care priorities. The design and development were carried out in = India. The=20 first pilot was a feasibility assessment study that lasted for a = month in=20 a selected village. This was to determine the contextual = sustainability=20 factors for the m-health innovation within the village = environment. After=20 a successful pilot study, the m-health programme was then extended = to=20 another 15 villages, where further piloting was conducted for = another=20 three months.

The m-health application enables CBHWs to = update and view=20 medical records in their clients=92 homes, away from the health = centre. A=20 store-and-forward teleconsultation can be carried out by the CBHWs = with=20 the urban health centre. At the urban health centres, an Ayuverdic = doctor=20 interprets the received data and then prescribes drugs, which are = then=20 delivered to the clients by CBHWs. In the pilot trial, CBHWs = conducted 800=20 home visits with the m-health application. The project was then = extended=20 to another 30 villages in 2003. By 2006, the m-health application = had been=20 employed for the management of nine million homecare visits in = about 10=20 000 villages.12 The = CHITS programme in the Philippines13 = (see=20 also Chapter = 3)=20 also began as an m-health project.

Case study 5

Background

In Uganda, the Ministry of Health recognized = that the=20 ability to collect and analyze reliable information was vital for=20 providing effective health care to the population. Therefore, a = functional=20 health management information system was required. An = international=20 coalition led by a university-based organization developed the = Uganda=20 Health Information Network (UHIN), an m-health application. The = network=20 used low-cost mobile ICT in a computerized health management = information=20 system and also provided access to e-health learning materials for = all=20 health workers, including CBHWs.

Case description

The m-health work started as a pilot project in = two=20 health districts in Uganda in 2003. Pre-implementation planning = was=20 carried out through awareness-raising workshops at the pilot = sites.=20 Experience from previous m-health projects involving mobile = devices=20 without wireless connectivity in other parts of Africa also = provided=20 insights. The implementation was carried out by Ugandan workers = from local=20 and national health organizations and coordinated by a = university-based=20 research and development institution. The information content was=20 developed through a participatory approach with the local health = workers=20 who were going to be the eventual users. This process involved the = digitization of the existing paper-based health data forms, = decision=20 support guidelines and educational materials.

Technical support and training were provided = continuously=20 throughout the early phase of the implementation process. = Basically, the=20 innovation consisted of two main applications, namely the health=20 management information system and the e-learning contents. The = e-learning=20 contents included locally developed and WHO guidelines for = managing=20 health-related MDGs.

In 2003, 200 PDAs were distributed to 386 = health workers=20 in two health districts. By 2006, 350 mobile devices were in use. = A large=20 proportion of these health workers were CBHWs. As there were too = few=20 mobile devices to go round, up to six CBHWs in health posts or = centres=20 were observed to be sharing one device for their daily PHC=20 activities.14

<= /TD>

Case study summary

The development and implementation of the m-health=20 applications in the above case studies involved mostly international and = not-for-profit academic and research organiz ations working with local=20 collaborators. These are listed in Table = 5.1.

Table 5.1 Stakeholders = involved in=20 m-health project development and implementation
	International = implementers	Local = implementers
Ca:sh 1.	Dimagi USA	1. Media Lab India
	2. Massachusetts Massachussets Institute of = Technology=20 (MIT), USA	2. All India Institute of Medical Sciences = (AIIMS),=20 India
		3. State Ministry of Health of Haryana, = India
EHAS	1. Biomedical Engineering and Telemedicine = Group of the=20 Technical University of Madrid (GBT=96UPM), Spain	1. Catholic University of Peru = (PUCP)
		2. Cayetano Heredia University of Peru = (UPCH)
	2. Engineering Without Frontiers (ISF), = Spain
		3. Ministry of Health of Peru = (MINSA)
Cell-Life	None	1. Cell-Life
		2. University of Cape Town (UCF), South = Africa
		3. Cape Peninsular University of Technology, = South=20 Africa
		4. Desmond Tutu Institute
Jiva TeleDoc	1. Media Lab MIT	1. Jiva Health, Jiva Institute, = India
		2. Media Lab India
		3. Indian Institute of Technology
UHIN	1. AED/Satellife	1. Uganda Chartered HealthNet (UCH), = Uganda
		2. Makerere University Medical School, = Uganda
		3. District Health Authorities,=20 Uganda

Table 5.2 M-health = technology
Case	Technology
Ca:sh	1. PDAs
	2. Compact storage card (SD)
EHAS	1. VHF wireless networks and = transceivers
	2. WiFi wireless networks and = transceivers
	3. WiFi cards and routers
	4. Laptops
	5. Solar panels
	6. Email
Cell-Life	1. Smartphones and mobile phones
	2. SIM cards
	3. SMS/GSM/GPRS/3G
	4. Mobile web
Jiva TeleDoc	1. Smartphones
	2. GSM/GPRS
	3. Mobile web
UHIN	1. PDAs
	2. Portable wireless servers
	3. GSM/GPRS
	4. Solar panels
	5. Mobile email

Table 5.3 M-health project = funding=20 sources
Case	Funding = organizations
Ca:sh	1. Media Lab India
	2. Ministry of Information Technology, = Government of=20 India
	3. Fogarty International Centre, National = Institutes of=20 Health (NIH), USA
	4. Media Lab, Massachusetts Institute of = Technology,=20 USA
EHAS	1. Spanish Agency for International Cooperation = (AECI)
	2. Spanish Interministerial Commission for = Science and=20 Technology (CICYT)
	3. Latin American Program for Science and = Technology for=20 Development (CYTED)
	4. Supervisory Organization for Private = Investments in=20 Telecommunication in Peru (OSIPTEL)
	5. World Bank InfoDev program
	6. Committee for Solidarity and Development of = the UPM,=20 the Council of Madrid
	7. Spanish Association of Engineers of the ICAI = and the=20 Official Association of Industrial Engineers of Spain = (COIIM)
Cell-Life	1. Vodacom Foundation
	2. National Research Foundation of South = Africa
UHIN	1. Connectivity Africa: International = Development=20 Research Centre (IDRC), Canada
Jiva TeleDoc	1. George Soros Foundation
	2. Flora Family Foundation
	3. Media Lab = Asia

Different low-cost technologies were employed in the = m-health=20 work described in the case studies (Table 5.2). = The source=20 of funding for these m-health programmes was mostly international = not-for-profit=20 organizations (Table=20 5.3).

The effects of the m-health projects can be considered = under=20 four headings: technology interfaces, social, finance, and = government.

Technology interfaces

The m-health projects described above were generally = employed=20 to extend essential PHC services to mostly rural communities previously = without=20 services. Different types of CBHWs were involved. For example, in the = Ca:sh=20 project, they performed specialist functions in maternal and = childcare.

The importance of engaging users in the development = process was=20 a common factor in most of the cases. The participatory design = approach15,16 = adopted in=20 the Ca:sh17 and = EHAS18 = projects=20 should be more widely employed, even though it did not result in = sustainability=20 for the Ca:sh project. Participatory action research19 was = employed=20 in the design and implementation process of the TeleDoc and EHAS = projects. Here,=20 community members, the users of the m-health services, were engaged in = the=20 development work. An iterative design approach was employed in all the = projects,=20 but most notably in the Ca:sh17 and = EHAS20 = projects.

User interface design was also important. The users = were=20 involved in the mobile devices interface design process, especially in = the Ca:sh=20 project. Of particular importance is engaging users in the adaptation = process of=20 fitting paper-based content to device screens. User engagement in = interface=20 design has a role to play in successful mobile device usability and = eventual=20 adoption.15 = However, this=20 cannot be carried out in isolation. In a failed innovation, CBHWs = abandoned=20 their devices, despite an intensive long-term action, research-oriented = design=20 process, because other contextual factors were not appropriated into the = planning process.21

The prior exposure of the CBHWs to mobile devices in = the=20 Cell-Life project and their exposure to desktop computers in the Ca:sh = project=20 were reported as being important to rapid adoption. Another factor was = the=20 training provided to the CBHWs. Training for users has been identified = as=20 important to the successful adoption of e-health in developing = countries.22 In = the=20 Cell-Life project, there was an increased health care workload on the=20 CBHWs.23 = However, the=20 health care competence of the CBHWs was observed to be enhanced by = m-health in=20 both the Cell-Life and UHIN projects.14,23

Social

Personal security concerns may be a barrier to the = adoption of=20 m-health. In the Cell-Life project, some CBHWs were observed to leave = their=20 mobile devices at home because of fear of armed robbery while working in = the=20 community.23 = There were=20 also social effects of m-health on the work of the CBHWs. Some CBHWs = complained=20 about intrusion into their private lives in the Cell-Life project.23 = This=20 perceived intrusion was identified as a limiting factor in the adoption = of=20 m-health.

A positive social effect observed in the Cell-Life = project was=20 that the CBHWs=92 status within their working and professional community = was=20 enhanced by the m-health work.23 = Another=20 social effect, albeit a negative one, was observed in the UHIN project = as an=20 outcome of the CBHWs=92 team-working. As a consequence of the shortage = of mobile=20 devices, the CBHWs had to share them.14 = Sharing a=20 mobile device is common in many developing countries.24 = This should=20 not, however, be the case with CBHWs, because of their health care role. = Each=20 health worker deserves to have a personal device in order to manage and = secure=20 their patients=92 data, access email and use the device at any time for=20 educational purposes.

Finance

Sustaining m-health projects in developing countries = should be=20 important to health policy makers. Most of the cases described above = started as=20 pilots, and most have since been expanded beyond their sites of origin. = Thus,=20 valuable lessons can be gained from their experiences.

The funding sources for these m-health projects are = summarized=20 in Table = 5.3. Most=20 were funded from outside the countries of implementation, with the = exception of=20 Cell-Life and Jiva TeleDoc. Most of the financiers were non-governmental = organizations. It is known that developing countries are replete with = abandoned=20 health projects caused by the short-term focus of international=20 implementers.4,25 = This=20 observation is also supported by empirical work on the sustainability of = PHC=20 innovations in developing countries.26 = Sustainable=20 PHC innovations were dependent on the degree of integration of local and = contextual organizational factors in their planning. Financial = sustainability of=20 PHC innovations was observed to be important to local stakeholders.27

The financial basis of some of these cases is = therefore worth=20 considering. For instance, both the Jiva TeleDoc and Cell-Life = innovations were=20 run as social enterprises. Social enterprises are organizations that = develop new=20 solutions to social problems.28 = They can be=20 run as a business or as a not-for-profit operation. However, the common = goal is=20 to ensure financial sustainability while solving societal issues. They = are also=20 known to provide an alternative to inefficient public services.28 The = m-health=20 projects were social enterprises that filled the gap created by = underperforming=20 public health services. In future, perhaps, health policy makers should = adopt=20 this approach to meet the health-related MDGs of developing = countries.

However, taking the social enterprise approach is not = without=20 its own problems.29 = Both the=20 TeleDoc and Cell-Life applications were developed with seed funding from = their=20 sponsors, but achieving financial sustainability was difficult. The = Cell-Life=20 m-health work started as a donor-funded research project in response to=20 government policy on HIV/AIDs care.30 = However, it=20 has since mutated to an =91academic research-based=92 social = enterprise.

Other m-health applications have also struggled to = achieve=20 financial sustainability. In the case of the now defunct Ca:sh = innovation,=20 long-term sustainability could not be attained owing to withdrawal of = funding by=20 its main sponsor, the Indian government.9 Indeed, the long-term viability of private funding for = m-health=20 innovations in developing countries has been questioned. In an analysis = of the=20 financial constraints encountered in scaling up the TeleDoc application, = Singh31 = argued for=20 complementary government funding.

Government

Despite some impressive results in the UHIN project, = including=20 scaling up from two to five health districts,14=20 institutionalization into the national health system has not yet been = achieved.=20 The UHIN project started as a commitment made by government leaders on = MDGs at=20 the G8 meeting in 2002. It was funded initially by the Canadian = government.=20 Substantial buy-in has been achieved with governments at the district = level.=20 However, this has not occurred at the national government level. This = may=20 jeopardize its future financial security.32

Despite these financial concerns, the UHIN project = managed to=20 attain international visibility. It has been transferred to neighbouring = Mozambique and planning is under way in Rwanda. Information from the = Mozambique=20 project indicates that early involvement of the government has = contributed=20 immensely to its diffusion.32

From the above, it can therefore be surmised that = direct or=20 indirect government support affects the financial sustainability of = m-health=20 applications in developing countries. Governments at local/district, = national=20 and even international levels have a significant role to play.

International governmental and non-governmental = financial=20 support is also important. Funding from the Spanish government enabled = the=20 implementation of the EHAS project. Non-governmental international = financiers=20 may, however, have a different outlook. Engineering professionals,=20 telecommunication companies and international development organizations = all=20 contributed to the EHAS project.

Conclusion

Frequent misalignment between international = development=20 strategies and local realities in developing countries has been observed = as a=20 major cause of failure of initiatives and of wasted resources.4 There = has often=20 been a lack of coherence between micro-level practices and strategic or=20 macro-level policies.33 The = outcomes=20 of the m-health case studies are the results of micro-level practices = within the=20 health systems of developing countries. National and international = policy=20 initiatives, especially within the sphere of global health, are typical = of=20 macro-level practices. National and international grants, and social=20 philanthropy, are important for sustainable m-health. So is = institutional=20 support from both national and international organizations. = Institutional and=20 financial support from national and district governments is required for = long-term, successful m-health.

References

1.=20 World Health Organization. WHA58.28 e-health. Geneva: WHO, = 2005.

2.=20 World Health Organization. Strategy 2004=962007. E-health for Health = Care=20 Delivery. Geneva:, WHO, 2004

3.=20 Tomioka Y, Androuchko V, Nakajima I et al. An aspect of the ITU-D = activities=20 from a viewpoint of ehealth and human resource development. In: = Proceedings=20 of 8th International Conference on e-Health Networking, Applications and = Services, 2006: 283=966.

4.=20 Heeks R. Information systems and developing countries: failure, success, = and=20 local improvisations. Inf Soc 2002; 18: = 101=9612.

5.=20 United Nations. Millennium Development Goals. Available at:=20 www.un.org/millenniumgoals/.

6.=20 Kekki P. Primary health care and the Millennium Development Goals: = issues=20 for discussion. Geneva: WHO, 2004.

7.=20 Dovlo D. Using mid-level cadres as substitutes for internationally = mobile health=20 professionals in Africa. A desk review. Hum Resour Health 2004; = 2: 7.

8.=20 Hongoro C, McPake B. How to bridge the gap in human resources for = health.=20 Lancet 2004; 364: 1451=966.

9.=20 Keim B. Vikram Kumar. Nat Med 2007; 13: = 113.

10. = Mart=EDnez A,=20 Villarroel V, Puig-Junoy J et al. An economic analysis of the EHAS = telemedicine=20 system in Alto Amazonas. J Telemed Telecare 2007; = 13:=20 7=9614

11. = Mart=EDnez A, L=F3pez=20 DM, S=E1ez A et al. Improving epidemiologic surveillance and health = promoter=20 training in rural Latin America through information and communication=20 technologies. Telemed J E Health 2005; 11:=20 468=9676.

12. = Bhattacharyya A.=20 Distance Doc. GPs with GPRS. BusinessToday India 2004; = 1128=9630.

13. Tolentino = H,=20 Marcelo A, Marcelo P, Maramba I. Linking primary care information = systems and=20 public health information networks: lessons from the Philippines. = Stud=20 Health Technol Inform 2005; 116: 955=9660.

14. = SatelLife.=20 Uganda Health Information Network Phase II. Ottawa: IDRC, = 2006.

15. Graves M, = Grisedale=20 S, Gr=FCnsteidl A. Unfamiliar ground: designing technology to support = rural=20 health-care workers in India. ACM SIGCHI Bull 1998;=20 30: 134=9643.

16. Graves M, = Reddy NK.=20 Electronic support for rural health-care workers. In: Bhatnagar S, = Schware R,=20 eds. Information and Communication Technology in Development: Cases = from=20 India. New Delhi: Sage Publications, 2000: 35=9649.

17. = Anantraman V,=20 Mikkelsen T, Khilnani R et al. Handheld computers for rural healthcare,=20 experiences in a large scale implementation. In: Proceedings of the = 2nd=20 Development by Design Workshop (DYD02), 2002.

18. = Mart=EDnez A,=20 Villarroel V, Seoane J, del Pozo F. Analysis of information and = communication=20 needs in rural primary health care in developing countries. IEEE = Trans Inf=20 Technol Biomed 2005; 9: 66=9672.

19. Byrne E, = Gregory J.=20 Co-constructing local meanings for child health indicators in = community-based=20 information systems: the UThukela District Child Survival Project in=20 KwaZulu=96Natal. Int J Med Inform 2007; = 76(Suppl 1):=20 78=9688.

20. Martinez = A,=20 Villarroel V, Seoane J, Pozo FD. Rural telemedicine for primary = healthcare in=20 developing countries. IEEE Technol Soc Mag 2004; = 23:=20 13=9622.

21. Ranjini = CR, Sahay=20 S. Computer-based health information systems =96 projects for = computerization or=20 health management? Empirical experience from India. In: Tan J, ed. = Medical=20 Informatics: Concepts, Methodologies, Tools, and Applications. = Hershey:=20 Medical Information Science Reference, 2008.

22. Kimaro = HC.=20 Strategies for developing human resource capacity to support = sustainability of=20 ICT based health information systems: a case study from Tanzania. = Electron J=20 Inf Syst Dev Countries 2006; 26: 1=9623.

23. Skinner = D, Rivette=20 U, Bloomberg C. Evaluation of use of cellphones to aid compliance with = drug=20 therapy for HIV patients. AIDS Care 2007; 19:=20 605=967.

24. Donner J. = The use=20 of mobile phones by microentrepreneurs in Kigali, Rwanda: changes to = social and=20 business networks. Inf Technol Int Dev 2007; = 3:=20 3=9619.

25. Heeks R, = Mundy D,=20 Salazar A. Why Health Care Information Systems Succeed or Fail. = Manchester: Institute for Development Policy and Management, 1999.

26. Sarriot = EG, Winch=20 PJ, Ryan LJ et al. Qualitative research to make practical sense of=20 sustainability in primary health care projects implemented by = non-governmental=20 organizations. Int J Health Plann Manage 2004; = 19:=20 3=9622.

27. Sarriot = EG, Winch=20 PJ, Ryan LJ et al. A methodological approach and framework for = sustainability=20 assessment in NGO-implemented primary health care programs. Int J = Health=20 Plann Manage 2004; 19: 23=9641.

28. Harding = R. Social=20 enterprise: the new economic engine? Business Strategy Review = 2004;=20 15: 39=9643.

29. Dees JG, = Elias J.=20 The challenges of combining social and commercial enterprise. = Business=20 Ethics Quarterly 1998; 8: 165=9678.

30. Wessels = X.=20 Improving the efficiency of monitoring adherence to antiretroviral = therapy at=20 primary health care level: a case study of the introduction of = electronic=20 technologies in Guguletu, South Africa. Development Southern = Africa=20 2007; 24: 607=9621.

31. Singh N. = ICTs=20 and Rural Development in India. Available at:=20 ssrn.com/abstract=3D950322.

32. Batchelor = S.=20 Connectivity Africa External Review Report. Ottawa: IDRC, = 2007.

33. Madon S, = Sahay S,=20 Sudan R. E-government policy and health information systems = implementation in=20 Andhra Pradesh, India: need for articulation of linkages between the = macro and=20 the micro. Inf Soc 2007; 23: 327=9644.

6 Global e-health policy: From concept to=20 strategy

Richard E Scott

Introduction

It is likely that all aspects of health or health = care will be=20 affected by e-health, the broad use of information and communications = technology=20 (ICT) in the health sector. No individual, organization, business or = government=20 can therefore afford to ignore this development.

The concept of global health has emerged in the past = decade.=20 Given that the capabilities of e-health and the health needs of the = global and=20 local population are complementary, worldwide provision of the benefits = of=20 e-health, i.e. =91global e-health=92, is also an appropriate concept. = But, to=20 accomplish this, e-health must be integrated into domestic and global = health=20 care systems at both practical and policy levels. The focus to date has = been on=20 addressing matters related to the practical implementation of e-health = in the=20 local or domestic context, which is proving difficult enough. With rare=20 exceptions, attention to the issues of integration and broader e-health = policy=20 development has been fragmented or non-existent.

The rapid development of e-health is causing many = changes, the=20 social outcomes of which will be mixed. Winners will be best placed to = take=20 advantage of the changes. Losers will not only be left behind = technologically,=20 but also be in danger of losing the expanded services capable of being = provided=20 through e-health. In order to maximize the number of winners, many = challenges=20 must be addressed. Principal among these is a global e-health = policy.

Need for a global policy

Does a need exist for a global e-health policy? = Consider the=20 following =91North=96South=92 scenario.

A 55-year-old man has recently returned home to a = remote=20 northern community in a Canadian province after a six-week trip to = Tanzania and=20 South Africa, during which he travelled and camped extensively in the = bush. Upon=20 his return, he has fallen severely ill and is bedridden with an unknown = disease,=20 exhibiting fever, extreme debilitating pain in joints and muscles, and a = skin=20 eruption. The patient=92s doctor has identified a specialist in rare = tropical=20 diseases who works at the Nelson Mandela School of Medicine in Durban, = South=20 Africa. An urgent video consultation is desired for = diagnosis=20 and treatment, and for guidance for local management. Can we do this? = Both=20 locations have access to video-consultation units, good experience with = local=20 use of this equipment and adequate bandwidth. From a technical = perspective,=20 therefore, we can do it.

Both clinicians are agreeable and local chief = information=20 officers are approached to arrange the logistics of the consultation. = Having=20 been alerted, senior administrators in the relevant health region in = Canada ask=20 questions. Who is this specialist in Durban, and what training or = certification=20 does she have? Is her expertise recognized in Canada? Is this within her = scope=20 of practice? Will she expect remuneration? Will this open the flood gate = to many=20 similar requests? Since diagnosis and treatment are needed, will she be=20 considered to be practising in Canada? What are the licensing issues? = Who will=20 have clinical accountability? What about liability to the hospital and = health=20 region? Will there be any ethical, confidentiality or privacy = complications? For=20 clinical continuity and appropriate care, will the consultant need to = review the=20 patient=92s electronic health record, or need to enter her opinion in = the record=20 after remote patient examination? If so, what about security, and how = will=20 access and authorization be achieved since she is not an employee and = does not=20 currently have approval? Is any diagnostic equipment licensed and = approved for=20 use =96 and where? How much does this matter?

The health region=92s risk manager advises against the = teleconsultation, and the Provincial Privacy Commissioner says that he = will=20 examine the issue and provide a response =96 probably next month. The = outcome is=20 confusion and uncertainty about what to do or how to do it, since there = is=20 simply no clear local, subnational, national or even global policy or=20 legislation to show the way. As an alternative, a specialist in another = Canadian=20 province is contacted. But, now sensitized, the administration raises = the same=20 issues. The videoconference is cancelled =91due to technical = difficulties=92.

And the patient =85 ?

Global health

Global health has been defined as those =91health = problems,=20 issues and concerns that transcend national boundaries, may be = influenced by=20 circumstances or experiences in other countries, and are best addressed = by=20 cooperative actions and solutions=92.1 Global health, similar to its = predecessor,=20 international health, maintains a strong focus on the prevention and = treatment=20 of infectious diseases such as HIV, malaria and tuberculosis. In = addition,=20 however, global health is focused on the identification and eradication = of=20 underlying conditions that contribute to the persistence of disease. = These=20 include disparities in access to care, cultural and psychosocial factors = that=20 impede the prevention and treatment of disease, and issues of extreme = poverty,=20 violence and war.1 The use of e-health, i.e. global = e-health, could=20 influence each of these areas.

In most countries, major policy matters include the = need for=20 increased access to health care services and health reduction in = inequity.=20 Complicating factors include the ageing population, the shortage and=20 maldistribution of health care providers, the growth of chronic disease = and poor=20 literacy. Many tools will be needed to address these health care = problems, among=20 which must be global e-health.

Global e-health

The term =91global e-health=92 appears to have been = used from=20 about 2000. The relationship of its components is shown in Figure 6.1. = With=20 recognition of its potential to have a profound effect on the health of = the=20 world=92s population, it has taken on new meaning and new = significance.

A variety of definitions of telemedicine, telehealth = and=20 e-health have arisen over time, leading to some confusion and semantic = debate.=20 Common to all are the elements of the use of ICT, distance between = participants,=20 and health or medical application. Not typically included have been = aspects of=20 global application, crossing of existing boundaries and integration into = current=20 health care practice. Considering these perspectives, a definition was = proffered=20 in 2003 that was consistent with the accepted goals and terms used by = the World=20 Health Organization (WHO). Thus global e-health is:2

The sustainable global integration of information = and=20 communications technologies into the practice of protecting and = promoting health=20 across geo-political, temporal, social, and cultural barriers =96 = including=20 research and education =96 to facilitate health, public and community = health,=20 health systems development and epidemiology.

Global e-health recognizes the interdependence of = all nations=20 and the mutual benefit of a flow of health information, knowledge and = resources=20 between countries.

Relevance of global e-health

MacPherson and Gushulak3 identified the breakdown of traditional = public=20 health barriers to transmissible virulent diseases that has been caused = by=20 modern modes of

3DImage=20

Figure 6.1 The relationship of the = major=20 components of e-health (telemedicine and health informatics) to global = e-health.=20 Also shown are subcategories of both major components, some examples of=20 applications [square brackets], plus distinct but related elements = (e-commerce=20 and e-learning).

transportation. A potentially contagious person or = product can=20 now travel to anywhere in the world within 1=962 days. Kaul and Faust4 noted the relevance of this in terms of = political=20 boundaries =96 =91In today=92s world, globalization has brought about=20 interdependencies that blur the distinction between domestic and = external=20 affairs=92 =96 and noted that =91the best way to ensure one=92s own = well-being is to be=20 concerned about that of others=92.

Given these perspectives, it is important to recognize = the=20 potential for global e-health to affect the health and health care of = the=20 world=92s population. There are many potential benefits:

= System =96=20 improved administration, communication and surveillance capabilities; = better=20 patient self-management; lower health system costs.

= Provider =96=20 improved distance education and remote skill development; networks for = rural or=20 isolated professionals.

= Patient =96=20 improved education and disease management; reduced patient costs = (reduced=20 travel, less time off work, decreased waiting time); positive influence = on=20 health outcomes.

= Public =96=20 improved education to maximize independent living and quality of = life.

Such benefits have already been demonstrated in many = industrialized countries, but usually in small-scale e-health = applications. The=20 opportunity exists to achieve benefits on a more widespread basis, but = several=20 factors will influence this, particularly in regard to developing = countries.=20 Some are health related, some are ICT related, and others touch on=20 socio-political matters, including cultural sensitivities, governance = and=20 policy.

Global e-health and developing = countries

It is reasonable to speculate that most of the = world=92s=20 countries have been exposed to e-health in some fashion. Developing = countries=20 perhaps have both the most to gain and the most to lose from = =91e=92applications,=20 including global e-health (Figure 6.2). = They have=20 the most to gain through providing increased access to, and greater = equity of,=20 health care to their large, under-served populations. They also have the = most to=20 lose, since significant investment in time, effort and funding will be = needed to=20 raise their health and e-health infrastructure to the required levels,=20 potentially increasing their debts and potentially diverting funding = away from=20 already stressed traditional health care delivery and support.

It will become necessary to build a sound business = case for=20 global e-health investment in developing and least developed countries, = and for=20 cogent arguments to be developed about the =91return on investment=92 = (ROI). With=20 more than 80% of the world=92s population living in developing and least = developed=20 countries, there is at least a moral argument for investment in e-health = adoption and integration. However, given that exotic diseases can now = more=20 easily appear in industrialized countries, the North stands to gain from = enhanced global e-health exchange with the South, which represents = another=20 tangible and valuable ROI. The WHO=92s recent macroeconomic study

3DImage=20

Figure 6.2 The potential impact = resulting from=20 access to =91e=92 applications, including global e-health. = Industrialized countries=20 must integrate e-health into existing (legacy) health and health = technology=20 systems, and this may be viewed as a threat to traditional delivery = models.=20 Developing countries, which lack legacy systems and can adopt new = e-health=20 applications relatively easily, have the greatest opportunities to gain = from=20 e-health. Of concern is the potential for the least developed countries = to be=20 excluded from the potential gains of e-health, because of the digital=20 divide.

identifies another ROI. That study noted that = investing in=20 health in developing countries actually has a profound economic benefit = for=20 industrialized and developing countries alike.5 The benefit for developing countries = includes a=20 fitter, healthier and more productive workforce, and decreased = fecundity; the=20 benefits for industrialized countries are =96 crudely =96 more = participants (and=20 buyers) in the global market place.

Global e-health policy perspective

Despite various international health-related = collaborations,=20 notably the WHO, health policy largely remains the sovereign domain of=20 individual countries. But, to be effective, global e-health must become = fully=20 integrated into existing national, international and global = health-related=20 structures, in both a process and a policy sense. This will only be = achieved=20 through implementing globally accepted strategies, principles and = complementary=20 policy options. Such a goal is complicated by several matters, including = existing borders and boundaries, the increasing number of stakeholders = who=20 influence health care and technology activities (particularly in = developing=20 countries), changes in governance, and the breadth and complexity of=20 e-health-related policy matters, each discussed below. Failure to = address these=20 matters will create potentially impenetrable barriers that will deny the = benefit=20 of global e-health to much of the world=92s population.

Borders and=20 boundaries

Some observers consider that national borders are = becoming=20 less meaningful.6 Certainly, they are becoming more = porous to=20 health threats as a result of international mobility.3 Global e-health has the ability =96 if = developed=20 correctly =96 to transcend existing geopolitical, sociocultural and = temporal=20 boundaries. By so doing, it could help to solve some of the health care = problems=20 facing the world=92s population. This potential also raises concerns, = such as the=20 =91jurisdictional gap=92 and fear of loss of control that must be = addressed if=20 e-health is to have the desired global benefits.7=969

Stakeholders

At one time, the WHO dominated international and = global health=20 activities. However, the world health system has grown in complexity, as = well as=20 in capacity, through an increasing number of stakeholders. These now = include=20 development banks, multilateral development agencies, development = assistance=20 agencies of industrialized countries, and non-profit private = organizations such=20 as non-governmental organizations (NGOs), big international NGOs = (BINGOs),=20 international foundations, professional bodies, health and medical = assistance=20 groups, consulting agencies, academic institutions, and finally the = private=20 sector that produces medical products, health services and ICT = components. Each=20 plays a major role in the development and dissemination of ICT and the = provision=20 of health services. Collectively, they possess much of the funding and = expertise=20 necessary for technology innovation, and are now leading global research = and=20 development.

The role of NGOs has been challenged. For many years, = they have=20 performed various service and humanitarian functions, acted as = intermediaries=20 between citizens and governments, and even tended to fill voids in = governance.=20 Now challenging their position are foundations and BINGOs, often created = by=20 private companies with access to substantial resources. For example, the = Bill=20 and Melinda Gates Foundation has assets in excess of US$36 billion. In = 2007, the=20 Foundation granted just over $2 billion for their programmes, which = included the=20 Global Health Program and the Grand Challenges in Global Health.10 Compare this with the total WHO=20 biennial budget of US$2.8 billion.11

Changing=20 =91governance=92

=91Governance=92 concerns the actions and means = adopted by a=20 society to promote collective action and deliver collective solutions in = pursuit=20 of common goals =96 how to direct, shape or regulate use of something.6 It is fairly straightforward to = transfer this=20 concept to the health and =91e=92 environments. Despite various = international=20 initiatives, =91health governance=92 (and associated health policy) has = historically=20 remained largely the sovereign domain of individual countries, and, with = the=20 increasing application of ICT and e-networks within countries, the = concept of=20 e-governance has arisen. E-governance deals with the whole spectrum of = the=20 relationships and networks within government that involve the use and=20 application of ICT. The term =91e-government=92 is sometimes used, = incorrectly, in=20 place of e-governance. The former is a narrower concept and deals with = the=20 development of specific online services to citizens, such as e-tax,=20 e-transportation and e-health. In a similar way, the advent of global = ICT=20 networks and globalization is challenging these recent concepts, and = global=20 e-health governance is emerging as a major issue. How does one control=20 activities (health related and otherwise) that = increasingly=20 reside in the hands of globally distributed entities?

A notable concern is the fundamental shift in balance = and=20 growing influence of all of these entities on local, national and global = health-related decisions and policy making. The dominance of the WHO, = national=20 governments and NGOs has been superseded by a dominance of private = sector=20 conglomerates and private foundations. Each stakeholder has its own = priorities=20 and interests. Despite seeking expert input to guide direction and = investment,=20 how adequately will the needs of small communities and countries be = served? It=20 will be crucial to ensure that local and national needs take precedence = over=20 corporate, donor or facilitator needs. But the reality is that global = e-health=20 policy development is no longer the sole purview of governments and the = WHO.=20 BINGOs and large multinational companies in the health and ICT sectors = are=20 extremely influential.

At a more practical level, the intensification of = flows of=20 people and goods are generating trans-border health risks that are = different=20 from those of previous eras. These new risks require novel approaches to = health=20 governance, and there is widespread belief that the current system of=20 =91international=92 health governance does not sufficiently address = them. E-health=20 applications might assist. As a result, the concept of =91global = e-health=20 governance=92 must become a subject of greater interest, debate and = development.=20 This perhaps represents an opportunity for the WHO to remould its own = policy,=20 reclaim its confidence and influence, and take on a central role in the = global=20 e-health governance agenda.

The breadth of policy=20 issues

E-health has been practised in some countries for = several=20 decades, and comprises health informatics and telehealth (see Figure 6.1). = E-commerce=20 and e-learning are distinct but related elements. Although originally = quite=20 localized in application, e-health solutions have became more national = (crossing=20 domestic borders) and even global (crossing national borders) =96 = referred to as=20 inter-jurisdictional e-health activity.12 Such activity is often performed on = the basis of=20 =91good Samaritan=92, intra-professional consulting, or specific and = limited=20 inter-agency agreements. However, the need for broad policy to = facilitate=20 unfettered inter-jurisdictional activity has been recognized for many=20 years.13=9615

There are several commonly identified policy problems. = For=20 health informatics, they are privacy, confidentiality and security (and, = more=20 recently, patient safety) and, for telehealth, they are licensure, = liability and=20 reimbursement.16 These have, to a large extent, usurped = the=20 limited policy debate, and the fact that they have remained unchanged = for over a=20 decade demonstrates the glacial pace of debate and action. Assuming that = inter-jurisdictional e-health is a desirable goal, attention must be = paid to=20 much more than these limited matters. In earlier (unpublished) work, I=20 identified 34 key e-health policy-related issues, and a recent paper = identified=20 almost 100 issues.17 A three-dimensional =91global e-health = policy=20 matrix model=92 is being developed as a tool to assist in understanding = this=20 complex setting18 (Figure 6.3). = This tool=20 highlights specific policy issues at the intersection of different = policy=20 levels, under specific policy themes, for specific policy = stakeholders.

3DImage=20

Figure 6.3 The three-dimensional = e-health=20 policy matrix model that highlights specific policy issues at the = intersection=20 of different policy levels, under specific policy themes, for specific = policy=20 stakeholders.

Definitive e-health policy is limited in scope, sparse = in=20 quantity and located primarily in a handful of industrialized countries. = In=20 other words, there is a global e-health policy void. Nascent e-health = policy=20 development can be identified in some countries, but is often indirectly = related=20 (information privacy policy) or focused on ICT rather than specifically=20 e-health. Tools for e-health policy research18, 19 and = development20,21 = have been=20 reported. In reality, it will be too much to expect rigid global = e-health=20 policy, and a format encompassing global e-health principles and = =91complementary=92=20 e-health policy20 is = much more=20 likely. This might be structured in the form of a global e-health = convention, as=20 originally suggested by Schwarz and adopted at the Rockefeller = conference on=20 e-health policy.22

Earlier expectations that global e-health might = revolutionize=20 the way in which we perform health care, and maximize our well-being, = have not=20 been realized. The recent resolution by the WHO may be a turning point, = drawing=20 the attention of domestic governments of member countries to the = potential of,=20 and need for, e-health in each of their countries. The next logical step = is to=20 focus that individual effort into the larger concept of global e-health. = Each=20 jurisdiction must accept that internal e-health policy cannot be = independent of=20 the international environment. This current policy fragmentation is as = much a=20 concern as the previously described policy void. An accepted strategy is = needed=20 that attends to global as well as local needs within a = responsive policy environment, giving rise to the idea of =91glocal=92 = e-health=20 policy.

=91Glocal=92 e-health policy development: = cautionary=20 examples

In any policy development, it is possible that = =91domestic=92=20 (i.e. local) policy decisions may prevent e-health from functioning on a = worldwide scale (i.e. global) by putting in place =96 inadvertently or=20 deliberately =96 administrative and policy barriers.20 = When=20 preparing their 1998 directive on protection of personal information, = the EU=20 commented that: =91If each Member State had its own set of rules on data = protection, for example on how data subjects could verify the = information held=20 on them, cross-border provision of services, notably over the = information=20 superhighways, would be virtually impossible.=92 This perspective = exemplifies the=20 need for =91glocal=92 e-health policy development.

Around the world, some policies have been developed = that affect=20 global e-health. These include:

the policy = environment in Africa, which illustrates coincidental policy = development;

the = European Union=92s=20 directive, and Canada=92s response (the Personal Information Protection = and=20 Electronic Documents Act, PIPEDA), which illustrate reactive policy=20 development;

the = e-health policy=20 implemented by Malaysia in the 1990s, which is an example of potentially = restrictive policy development;

the = Legally eHealth=20 initiative of the EU, which is an example of a potentially autocratic=20 approach.

The African policy = environment

Kirigia et al23 provided an optimistic view of the = e-health=20 policy environment in Africa, and concluded that the policy environment = for=20 e-health growth internationally was very encouraging. This was based on=20 observations of a number of international policies that encourage = sustainable=20 e-health usage, such as the World Health Assembly e-Health Resolution24 and the health-for-all policy for the = 21st=20 century.25

In addition, Kirigia et al23 pointed to =91regional development and = political=20 forums such as the New Partnership for Africa=92s Development (NEPAD),=20 sub-regional economic communities, regional development banks and the = United=20 Nations Economic Commission for Africa=92, each of which have = =91elements in their=20 policies and/or strategies encompassing ICT development=92. Finally, = they noted=20 the Blair Commission for Africa, which advocated massive investment in = ICT and=20 Internet connectivity and a =91growing realization among bilateral and=20 multilateral donor agencies of the need for supporting investments in = ICT=20 infrastructure and Internet connectivity in developing countries as an = essential=20 strategy for economic growth=92. In addition, the African Union=92s = strategy for=20 health in Africa lays out the planned development of health initiatives = until=20 2015.26

With the exception of the WHO resolution for e-health, = all of=20 the other documents refer to =91ICT=92 and not specifically to e-health. = While a=20 supportive ICT environment is needed, such policy is = coincidental to, and not focused on, e-health. Developing a clear, = supportive,=20 e-health-specific policy environment is necessary too.

EU directive on protection of personal=20 information

Ironically, as the EU prepared its 1998 directive on = protection of personal information, they also contributed to the = creation of=20 potentially restrictive policy. OECD guidelines for privacy protection = existed,=20 but the European Commission decided to promulgate their own directive. = This=20 directive compelled countries wanting to do business with EU countries = to have a=20 regulatory system in place to protect personal information, and required = businesses to adhere to =91fair information practices=92.

Lacking such legislation, Canada quickly introduced = its own=20 PIPEDA legislation in 2001 =96 a reactive response. But this also = affected=20 cross-border activities with Canada=92s largest trading partner, the = USA, since=20 they had to meet the specified requirements in order to do business with = Canada=20 and the EU. This form of reactive, snowball, and ad hoc policy = development is=20 inappropriate. Furthermore, it may well cause difficulties for = developing=20 countries, effectively setting the policy bar too high. If =91glocal=92 = e-health=20 policy is permitted to develop in this fashion, those countries that = could=20 benefit most may be excluded from the outset.

Malaysia=92s e-health = policy

Malaysia was very proactive in developing both = legislation=20 (e.g. the Telemedicine Act27) and guidelines (e.g. for = teleconsultation) for=20 domestic telemedicine. These were intended to broaden access to health = care in a=20 borderless fashion. They achieved this for domestic purposes, but may be = viewed=20 as restrictive for global e-health activities. For example, the section=20 =91Teleconsultation Beyond National Borders=92 states that =91Patients = and health care=20 professionals should be provided the opportunity to seek an expert = opinion and=20 treatment from overseas through teleconsultation=92. But then two = subclauses state=20 =91Foreign experts can provide teleconsultation to health care = professionals=20 and/or patients in Malaysia only at the invitation of the local = health care=20 personnel=92 and =91All overseas experts who are invited to provide = opinion or=20 who are referred cases must be registered with the appropriate = regulatory=20 authorities in Malaysia=92. Processes for invitation and/or = registration are=20 not provided, and penalties for transgression are severe, including = fines and=20 imprisonment.27 Such legislation raises potential = administrative=20 barriers to borderless global e-health initiatives.

EU initiative

In support of the European eHealth Action Plan, a = report=20 called Legally eHealth28 was intended to place e-health in a = European=20 legal and regulatory context. The report focused on how EU legislation = on data=20 protection, product and services liability, and trade and competition = law=20 applies. The report correctly noted that =91until these issues are = tackled head-on=20 in real cases, we will not begin to change the legal landscape in order = to=20 provide fertile ground for new developments=92. However, if the = resulting EU=20 e-health policy is implemented then once more the EU will be forcing = their requirements on the practice of global e-health. At the = very=20 least, such an approach will result in many years of retrospective = policy=20 realignment with other jurisdictions, maintaining rather than removing=20 inter-jurisdictional barriers to global e-health practice. At the worst, = it may=20 ostracize developing countries from the global e-health community. Such=20 approaches are not appropriate in the context of global e-health.

The way forward: a strategy

There are two basic policy options for global = e-health:

1. Continued ad hoc development followed by = policy=20 realignment. This is the status quo. It maintains the confusion and = prevents streamlined global e-health, and will require years of = retrospective=20 policy realignment to bring the many disparate approaches together. In = the=20 interim, many potential benefits of global e-health may be denied to the = world=92s=20 population.

2. Progressive and collaborative complementary = policy=20 development. A better approach, likely to permit the benefits of = global=20 e-health to be realized sooner, would be to initiate a process to guide = global=20 e-health policy development. The goal would be to identify common = principles=20 that can be agreed with relative ease, and then to use these to = encourage=20 development of domestic policy that is in line with global e-health = principles,=20 and is thereby complementary. The outcome would be removal of = administrative and=20 political barriers to global e-health.

Collaborative policy development would necessitate = the=20 creation of an inclusive and =91glocal=92 process whereby policy = implemented at each=20 level permits meaningful access to ICT in a country and therefore in the = health=20 sector. To guide this process, the Glocal E-health Policy Development = Framework=20 has been proposed.21

Conclusion

Global e-health has the ability to cross all = geopolitical,=20 socioeconomic, cultural and temporal barriers =96 to provide health and = health=20 care to anyone, anytime, anywhere. But how do we facilitate, yet also = manage,=20 this new paradigm? Any future activities have the potential to create = functional=20 or policy barriers. To avoid this, and to allow the benefits of global = e-health=20 to be equitably distributed, a coherent strategy is required that is = based on=20 both global and local (i.e. =91glocal=92) thinking.

The potential impact of global e-health is huge. = However,=20 awareness must be raised of the improvements in health care that could = be=20 achieved through global e-health. There is a need for consistency in = approach to=20 complex inter-jurisdictional issues. There is also a need for concerted=20 development of =91glocal=92 e-health principles and complementary = domestic policy.=20 The current global e-health policy void is a serious concern. = Inappropriate=20 policy developed in one jurisdiction could hamper the ability of = e-health to=20 fulfil its potential.

Global e-health is no different from any other tool. = To use this=20 tool for global good requires a common vision and = collective=20 determination to achieve that vision. At present, e-health is struggling = to=20 establish itself even on a local or national basis in many countries,=20 particularly developing countries. Policy can determine the pace and = direction=20 of change. If the potential of global e-health is to be realized, a = strategy is=20 required that will identify globally acceptable principles and thereby = allow=20 complementary domestic policy to be developed.

References

1.=20 Institute of Medicine. America=92s Vital Interest in Global = Health.=20 Washington, DC: National Academy Press, 1997.

2.=20 Scott RE, Palacios MF. E-health =96 challenges of going global. In: = Scott CM,=20 Thurston WE, eds. Collaboration in Context. Calgary: Institute = for=20 Gender Research and Health Promotion Research Group, University of = Calgary,=20 2003.

3.=20 MacPherson DW, Gushulak BD. Human mobility and population health: new = approaches=20 in a globalizing world. Perspect Biol Med 2001; = 44:=20 390=96401.

4.=20 Kaul I, Faust M. Global public goods and health: taking the agenda = forward.=20 Bull World Health Organ 2001; 79: = 869=9674.

5.=20 World Health Organization. Macroeconomics and Health: Investing in = Health=20 for Economic Development. Available at:=20 whqlibdoc.who.int/publications/2001/924154550X.pdf.

6.=20 Dodgson R, Lee K, Drager N. Global Health Governance: A Conceptual=20 Review. Available at:=20 whqlibdoc.who.int/publications/2002/a85727_eng.pdf.

7.=20 Bettcher D, Lee K. Globalisation and public health. J. Epidemiol = Community=20 Health 2002; 56; 8=9617.

8.=20 Rigby M. The management and policy challenges of the globalisation = effect of=20 informatics and telemedicine. Health Policy 1999; = 46:=20 97=96103.

9.=20 Scott RE, Lee A. E-health and the Universitas 21 organization: 3. Global = policy.=20 J Telemed Telecare 2005; 11: 225=969.

10. Bill and = Melinda=20 Gates Foundation. Foundation Fact Sheet. Available at:=20 www.gatesfoundation.org/MediaCenter/FactSheet/.

11. World = Health=20 Organization. Policy and Budgets for One WHO. Available at:=20 ftp.who.int/gb/archive/e/e_ppb2003.html.

12. Scott RE, = Jennett=20 P, Yeo M. Access and authorisation in a glocal e-health policy context. = Int=20 J Med Inform 2004; 73: 259=9666

13. Bashshur = RL. Health=20 policy and telemedicine. Telemed J 1995; 1: = 81=963.

14. Gobis LJ. = Licensing=20 and liability: crossing borders with telemedicine. Caring 1997; = 16: 18=9624.

15. White AW, = Wager KA,=20 Lee FW. The impact of technology on the confidentiality of health = information.=20 Top Health Inf Manage 1996: 16; 13=9621.

16. Stanberry = B. Legal=20 and ethical aspects of telemedicine. J Telemed Telecare 2006;=20 12: 166=9675.

17. Khoja S, = Durrani H,=20 Fahim A. Scope of Policy Issues for eHealth: Results from a = Structured=20 Review. Available at:=20 ehealth-connection.org/files/conf-materials/ScopeofPolicyIssuesforeHealth= _0.pdf

18. Scott RE. = Investigating e-health policy =96 tools for the trade. J Telemed = Telecare=20 2004; 10: 246=968.

19. Varghese = S, Scott=20 RE. Categorising the telemedicine policy response of countries and their = implications for complementarity of telemedicine policy. Telemed J E = Health 2004; 10: 61=969.

20. Scott RE, = Chowdhury=20 MFU, Varghese S. Telemedicine policy =96 looking for global = complementarity. J=20 Telemed Telecare 2002; 8(Suppl 3): 55=967.

21. Scott RE. = =91Glocal=92 e-Health =96 A Conceptual Policy Development = Framework.=20 Available at: www.mrc.ac.za/conference/satelemedicine/Scott3.pdf.

22. = Rockefeller=20 Foundation. National eHealth Policies =96 an Overview. = Available at:=20 ehealth-connection.org/content/national-ehealth-policies-an-overview.

23. Kirigia = JM, Seddoh=20 A, Gatwiri D et al. E-health: determinants, opportunities, challenges = and the=20 way forward for countries in the WHO African Region. BMC Public = Health=20 2005; 5: 137.

24. World = Health=20 Organization. WHA58.28 e-Health. Available at:=20 www.who.int/gb/ebwha/pdf_files/WHA58/WHA58_28-en.pdf.

25. World = Health=20 Organization. Health-for-All Policy for the Twenty-First Century = (Resolution=20 WHA51.7). Available at: = www.paho.org/English/GOV/CSP/csp25_27.pdf.

26. African = Union.=20 Africa Health Strategy 2007=962015. Available at:=20 www.africa-union.org/root/UA/Conferences/2007/avril/SA/9-13%20avr/doc/en/= SA/AFRICA_HEALTH_STRATEGY_FINAL.doc.

27. Malaysian = Government. Laws of Malaysia, Act 564, Telemedicine Act, 1997.=20 Available at: www.parlimen.gov.my/actindexbi/pdf/ACT-564.pdf.

28. European=20 Commission. Legally eHealth. Putting eHealth in its European Legal=20 Context. Available at:=20 ec.europa.eu/information_society/activities/health/docs/studies/legally-e= health-report.pdf.

7 Experiences and lessons learnt from = telemedicine projects=20 supported by the IDRC

Laurent Elder and Michael = Clarke

Introduction

In 1970, Lester B Pearson, then Prime Minister of = Canada and a=20 strong proponent of international development, stated the need for =91a = new=20 instrument concentrating more attention and resources on applying = technology to=20 the solution of =85 economic and social problems on a global basis=92.1 In May 1970, the International = Development=20 Research Centre (IDRC) was founded by an act of the Canadian parliament. = One of=20 the Centre=92s priorities was Information and Communication Technologies = for=20 Development (ICT4D), since access to information and an effective means = to=20 communicate are necessary for sustainable development. IDRC=92s ICT4D = programme=20 now supports projects in Africa, Asia, Latin America and the Caribbean = at a cost=20 of nearly Can$20 million each year.

Exploring the means by which information and = communication=20 technology (ICT) can solve health problems was part of IDRC=92s early = work in=20 ICT4D. The IDRC was interested in answering questions such as the = following:

How can = ICTs play a=20 role in providing health care services to rural and remote regions of = developing=20 countries?

Which = applications=20 afford the most potential with respect to effectiveness, adaptability = and=20 sustainability?

What are = the=20 challenges to setting up e-health programmes in developing = countries?

How do = different=20 user groups access and use these programmes?

Early work

Much of the work supported by IDRC in the 1990s in = the area of=20 health and ICT focused on the development of health information systems. = It=20 included projects such as the Latin American Health Information Network, = the=20 National Health Information Network (Colombia) and HealthNet. The IDRC = also=20 supported the application of geographical = information systems=20 for mapping malaria risk in Africa, for endemic disease control in = Botswana and=20 Senegal, and for malaria control in the Amazon Basin. Telemedicine = projects did=20 not begin until the late 1990s, because of the generally poor = telecommunications=20 infrastructure in developing countries. It was not until the Internet = started to=20 become available in developing countries that IDRC began to investigate = the=20 potential of telemedicine.

Telemedicine in Uganda

An early project to establish telemedicine in Uganda = began in=20 2000. The project, which received Can$452 300 in funding, focused on = health=20 problems such as cholera, malaria, HIV/AIDS and the application of = telemedicine=20 to address them. To achieve this, Makerere University School of Medicine = aimed=20 to establish telemedicine centres at Mulago and Butabika, set up the=20 telemedicine infrastructure in the centres, conduct online consultations = with=20 the rural centres and start a continuing medical education = programme.

What actually happened? As was typical of early = telemedicine=20 projects in Africa, there were difficulties in procuring appropriate=20 telemedicine equipment and in setting up the telecommunications, which = were=20 based on VSAT. (A very small-aperture terminal, or VSAT, is a two-way = satellite=20 ground station with a dish antenna.) No online consultations actually = took place=20 between Kampala and the rural health centres, and there was no evidence = of any=20 beneficial health outcomes for the rural population.

None the less, with the support of Memorial University = in=20 Canada, the telemedicine in Uganda project helped to train staff in = telemedicine=20 activities. It also helped to focus government attention on rural health = problems and it developed educational materials that are still used to = this day.=20 The project also contributed valuable lessons for future e-health = projects. It=20 set the stage for more successful e-health projects in Uganda, such as = the=20 Uganda Health Information Network and a subsequent telemedicine project = in=20 Mengo.

As far as IDRC was concerned, the project helped the=20 organization better understand the challenges of supporting telemedicine = projects in Africa and helped define some of the key questions that it = would try=20 to answer. These questions included how appropriate local capacities = should be=20 built, both technical and institutional. Second, there was a need to = focus on=20 =91e-readiness=92, which is the state of a country=92s ICT = infrastructure and the=20 ability of its consumers, businesses and governments to use ICT for = their=20 benefit. Finally, the IDRC needed to think about how it could help = answer the=20 key underlying question: is telemedicine a viable method for solving = health=20 problems in developing countries? In the Uganda project, cost=96benefit = analyses=20 had not been conducted and health outcomes had not been measured, mainly = because=20 of the problems of implementing the pilot. All of these lessons helped = shape=20 IDRC=92s thinking about supporting the development of effective health=20 applications (see below).

E-health applications in = Asia

The IDRC programme, Pan Asia Networking (PAN), = supports=20 research into new ways of using ICT in the areas of health, education,=20 livelihoods and governance.2 Most of

Table 7.1 Telemedicine and = e-health=20 projects funded by the PAN Asia small grants = programme
Country	Project	Organization	Grant (US$)
India	ICT-enabled life skill and sexuality education = for=20 adolescent girls	Centre for Women=92s Development and = Research	8911
India	Using ICT to build capacities of HIV/AIDS = service=20 providers in India	SAATHII (Solidarity and Action Against The HIV = Infection=20 in India)	29 786
India	Impact of remote telemedicine in improving = rural health,=20 India	n-Logue Communications Pvt Ltd	29 313
Indonesia	Development of ICT-based telemedicine system = for primary=20 community health care in Indonesia	Biomedical Engineering Program, Department of = Electrical=20 Engineering, Institut Teknologi Bandung (ITB)	29 479
Indonesia	Development of ICT-based mobile telemedicine = system with=20 multiple communication links for urban and rural areas in = Indonesia	Biomedical Engineering Program, Department of = Electrical=20 Engineering, Institut Teknologi Bandung (ITB)	29 479
Nepal	Telemedicine in Nepal: a pilot project	HealthNet Nepal	30 000
Pakistan	ICT-assisted learning tool for the deaf in=20 Pakistan	Sustainable Development Networking Programme,=20 Pakistan	28 500
Philippines	A community-based child injury surveillance = system: rapid=20 data collection using SMS	Medical Informatics Unit, College of Medicine, = University=20 of the Philippines	22 642
Philippines	Mobile telemedicine and information resource = system for=20 community health workers	SynapseHealth Solutions, Inc	29 784

the activity related to health occurs in the PAN = R&D=20 Grants Program.3 An example is the Pan Asian = Collaborative for=20 Evidence-Based eHealth Adoption and Applications (PANACeA) project, = discussed in=20 greater detail below. The health-related projects that have been funded = are=20 summarized in Table=20 7.1. Some recent evaluations have helped to shed light on the = outcomes of=20 some of these projects.4 There were two activities related to = telemedicine=20 in India and Indonesia.

The first project concerned the impact of telemedicine = on rural=20 health in selected villages in India. The project aimed to field test = with the=20 help of N-Logue,5 a low-cost medical kit, called = ReMeDiTM. The=20 equipment was developed by Neurosynaptic Communications Pvt Ltd6 and installed in rural Internet kiosks = around=20 Tirupattur. The object was to transmit medical information to a doctor = in=20 Tirupattur.

After the service was launched, there was an increase = in the=20 number of visitors to the kiosk. However, following the initial = interest, the=20 number of visitors dropped precipitously to a few regular, repeat = visitors. The=20 drop was explained by the following factors: the kiosk operator=92s = ability to=20 administer the equipment properly; acceptability by the villagers;=20 identification of the kiosk in a place where medical care is already = dispensed;=20 lack of awareness of the service; distance of the doctor from the = village; and=20 availability of competing services such as Registered Indian Medical=20 Practitioners, Primary Health Centres and local doctors.4 Although the project was not able = to

3DImage=20

Figure 7.1 Indonesian mobile = telemedicine=20 application being demonstrated

3DImage=20

Figure 7.2 Indonesian mobile = telemedicine=20 application

document any health outcomes, it was =96 contrary to = the Ugandan=20 experience =96 able to demonstrate actual telemedicine activity.

The second project, in Indonesia, was to develop a = telemedicine=20 system for primary community health care. It was based on existing = Internet=20 technology to enhance PC-based medical stations. The pilot telemedicine = network=20 consisted of six medical stations in community health centres, and a = station for=20 the referral hospital, health office and a test laboratory. The system = included=20 teleconsultation and telediagnosis applications, medical information = display=20 software, a blood pressure and fetal heart rate interface, and an ECG = interface=20 (Figures = 7.1 and 7.2).

It was found that human resource capacity building, in = particular training to facilitate computer and telemedicine adoption, = required=20 substantially more time than expected. The project therefore = demonstrated the=20 significant role that human resource development plays in the = implementation of=20 telemedicine systems. However, as before, no findings were documented on = the=20 effect that the pilots had on people=92s health or health systems.

In a report commissioned by IDRC, the projects listed = in Table 7.1 were = assessed=20 in order to evaluate their outcomes.7 The factors examined were:

knowledge = production=20 =96 any type of publication

research = targeting,=20 capacity building and absorption =96 follow-on research, training of = staff

e-health = solution=20 adoption or integration =96 expansion or adoption of an e-health = solution

informing = policy =96=20 policy documents, meetings with government officials

broader = community,=20 institutional, or country benefit =96 including social and economic = benefit

health = benefits to=20 individuals or the population =96 more effective health care.

All projects were then ranked in terms of health = outcomes and=20 common themes were identified. The most troubling common theme was that = all=20 projects ranked =91low=92 with respect to demonstrated health = benefits.

When Scott compared the projects, he saw that several = common=20 deficiencies had an adverse effect on nearly all of them. The = deficiencies=20 included:7

Lack of planning for a sound, strategic health = needs=20 assessment, lack of planning for sustainability of (proven) solutions, = lack of=20 consideration for and mitigation of change management issues, lack of = sound=20 evaluation planning or execution, limited or no dissemination (formal or = informal) of findings, and no significant or structured knowledge = translation=20 and transfer to influence decision- or policy-making around future = e-health=20 implementations. =85 In addition, several general issues came to light, = which also=20 will need to be addressed. These included considerations around = application=20 software (i.e. open source versus proprietary solutions), application = focus=20 (e.g. use of traditional versus more novel technology such as GIS or = m-health=20 tools8), and local e-health knowledge and = expertise=20 (i.e. need for skill transfer and capacity building).

Present work

The early telemedicine projects that IDRC supported = did not=20 achieve all that was expected of them and raised more questions than it=20 answered. Present projects include work in Africa and Asia.

Eastern and southern = Africa

In 2004, the AfriAfya organization9 undertook a study in eastern and = southern Africa=20 in conjunction with other African partners. The project was designed to = study=20 the application of ICT in the HIV/AIDS response in Uganda, Kenya, = Tanzania,=20 South Africa and Botswana. After conducting a literature review, the = project=20 staff undertook an electronic survey of individuals and organizations = involved=20 in HIV/AIDS matters. There were 990 respondents in a face-to-face survey = undertaken in Tanzania and South Africa.

Unsurprisingly, the study found that South Africans = and=20 Tanzanians generally obtained their information on antiretroviral = treatment=20 (ART) from traditional media, rather than new media (Table 7.2). = However, a=20 surprisingly high proportion (30%) of South Africans obtained = information from=20 mobile phones and SMS. The assumption is that, as access to mobile = telephony and=20 the Internet rises in Africa, so will the number of people accessing = health=20 information from mobile phones.

According to the survey, illiteracy ranked highest of = the=20 factors impeding the use of ICT in both Tanzania and South Africa = (although all=20 factors scored highly in the latter). The results echo most of the = research done=20 by IDRC, which shows that illiteracy and localization matters are = generally seen=20 as among the most important factors impeding the more widespread use of = ICT (Table = 7.3).

Table 7.2 Sources of = information on=20 antiretroviral therapy.10 = Values=20 shown are percentages of sample (n =3D 990)
ICT	South Africa (%)	Tanzania (%)
Print	75	53
Radio	88	81
TV	83	50
Video	21	20
Audiotapes	17	18
Telephones	24	4
Face-to-face meetings	77	82
Mobile phones and SMS	31	10
Computer/CDs	23	3
Email	22	2
Internet	25	2

Table 7.3 Factors impeding = the use of=20 ICTs for the fight against HIV/AIDS.10 = Values=20 shown are percentages of sample (n =3D 990)
Factor	South Africa (%)	Tanzania (%)
Inappropriate language	81	58
Inappropriate and embarrassing = messages	73	49
Lack of information, education and = communication=20 materials	80	81
Lack of feedback mechanism	82	67
Lack of enabling ICT policies	82	63
Poor infrastructure/physical access	86	80
People=92s attitudes	85	75
Traditional/cultural beliefs	87	80
Cost	85	68
Illiteracy	90	81

Table 7.4 Effectiveness of = ICTs.10 = Values=20 shown are percentages of sample (n =3D 990)
ICT	Don=92t know (%)	Harmful (%)	Extremely = effective (%)
Print	7	2	46
Radio	2	8	65
TV	6	2	54
Video	30	6	14
Audiotapes	39	3	9
Telephone	43	3	8
Face-to-face meetings	6	3	61
Mobile phones/SMS	31	3	13
Computer/CDs	52	5	8
Email	59	5	9
Internet	56	9	10

The respondents perceived that radio, print media and = TV, as=20 well as face-to-face meetings, were =91extremely effective=92. However, = the majority=20 of respondents did not know whether computers, email and the Internet = could be=20 effective (Table=20 7.4). Strangely, almost 9% saw the Internet as =91harmful=92, the = highest=20 percentage in that category. One can question the methodology of a = perception=20 questionnaire, as well as the terms used. For example, what does = =91harmful=92=20 actually mean? What is meant by =91extremely effective=92? However, one = cannot deny=20 that conventional communication methods are still perceived as the most = widely=20 used modes of information transmission.

Finally, according to the AfriAfya study, the best = practices for=20 using ICT in the fight against HIV/AIDS were:

1. Use of mobile phones and SMS

2. ICT for up-to-date HIV management information

3. ICT for mobilization

4. A combination of different forms of ICT

5. Telephone counselling.

The main lessons from this research were: that the = use of=20 =91modern=92 ICT is still very limited, but that there is huge = potential; that=20 institutions and health workers remain reliant on =91conventional=92 ICT = and that=20 there is therefore a need to integrate both =91modern=92 and = =91conventional=92to obtain=20 the best results; and, perhaps most important, that to change = perceptions and=20 behaviours requires careful planning and patience.

Acacia project

Most mobile telecommunications infrastructure in = Africa is too=20 slow and expensive for connecting computers to the Internet. However,=20 low-bandwidth applications have emerged that use mobile phones or = personal=20 digital assistants (PDAs) such as Palm Pilots, to connect via mobile = networks.=20 While information designed and formatted for the web is generally too = bandwidth=20 intensive to be transmitted over mobile networks, it can be formatted = for small=20 devices and low-bandwidth transmission. PDAs and smart phones are also = seen as=20 advantageous because of their robustness (no moving parts), their = relative=20 affordability, and their ability to be maintained in areas with little = or no=20 electricity infrastructure through the use of solar power rechargers. = Examples=20 of Acacia-supported mobile-enabled health applications include:

automation = of=20 demographic surveillance activities, such as those at the core of = pioneering=20 health care initiatives, for example the Tanzanian Essential Health=20 Interventions Project;10

the use of = SMS=20 reminders in the treatment of tuberculosis in Cape Town; 11

delivery = of=20 continuing medical education and professional development via PDAs;12

delivery = of=20 time-sensitive alerts to patients and health workers;

= maintenance of=20 patient records for HIV-positive patients=92 lifelong drug = treatments;

management = of=20 specific health care initiatives such as the roll-out of ART and = tuberculosis=20 treatment initiatives.13

The IDRC programme Acacia has funded projects in all = of these=20 areas. The main research questions are:

What are = the most=20 effective, relevant, affordable and scalable technologies to facilitate = mobile=20 health delivery?

Can = mobile-enabled=20 health services and applications reduce the costs of health service = management=20 and delivery? What is the cost=96benefit of using these = applications?

What kinds = of health=20 services can best be enabled through a mobile infrastructure?

How are = economies of=20 scale being realized across the continent, and how can innovations be = shared=20 between African countries?

What are = the social=20 effects of the introduction of these technologies in rural areas?

What is = the=20 relationship between mobile health applications and broadband = technologies,=20 including VSAT?

Pan Asia Networking

In the Pan Asia Networking programme, more pervasive = technologies, such as mobile phones and PDAs, are expected to be = important for=20 health applications.14 Since mobile phone use is more = widespread in=20 Asia than in Africa, it is clear that there is great potential in Asia. = The PAN=20 programme emphasizes that more research is needed to gauge which = applications=20 and projects in the area of health have made a difference, to understand = why=20 they have or have not been successful, and, when warranted, to scale = them up.=20 However, the fast pace of innovation in both ICT and health research = means that=20 there is also a need for developing, implementing and evaluating new=20 applications, particularly in the area of demographic surveillance of = disease=20 incidence and medical compliance, using new technologies such as mobile=20 devices.

Another important matter in Asia is pandemics. Severe = acute=20 respiratory syndrome (SARS) and Avian influenza are serious threats to = the=20 health of Asians, as well as the rest of the world. A key to reducing = the spread=20 of these infectious diseases is to ensure that appropriate information = on=20 outbreaks is captured and communicated to the relevant experts as = quickly as=20 possible. ICT can therefore play an important role in helping to prevent = or=20 control pandemics, although more research and experimentation are needed = to=20 identify the best means of communication in rural and remote areas, = where many=20 of these outbreaks begin.

The questions that PAN would like to answer are:

Which ICT = health=20 applications have had the most beneficial outcomes on people=92s health = and health=20 systems? What are the best ways of ensuring that beneficial outcomes can = reach=20 the segment of the population that does not have adequate access to = health=20 services?

What is = the=20 potential of using new pervasive technologies, such as mobile phones, to = make=20 the delivery of health services or information more effective?

What types = of=20 applications are best suited to help prepare for, or mitigate the = effects of,=20 pandemics such as SARS and Avian influenza?

PANACeA project

The PANACeA project (Pan Asian Collaborative for=20 Evidence-Based eHealth Adoption and Application) will support research = on=20 e-health solutions in Asia. The research programme includes:

a portable = system=20 for telemedicine and health information in rural and remote areas;

a pilot = programme in=20 Mongolia and the Philippines of remote consultation to improve health = services=20 for rural mothers;

a = disaster/emergency=20 telemedicine system;

a = cost=96benefit=20 analysis of hospital information management system data mining and data=20 warehousing;

an = evidence-based=20 approach to mainstreaming e-health initiatives in primary care;

basic = intervention=20 research on e-health for persons with disabilities;

online = tuberculosis=20 diagnostic committees for clinically suspect, sputum-negative patients = in the=20 TB-DOTS programme;

use of = mobile phones=20 for referral of pregnant women.

The research programme also includes research = activities such=20 as reviews of telemedicine and health informatics in Asia.

Future work

IDRC will continue to support research and = development=20 projects in telemedicine and e-health in its next five-year planning = cycle=20 beyond 2010. Sufficient evidence has been generated from work carried = out by=20 IDRC partners and others to show that implementing telemedicine and = e-health=20 applications can have many benefits, including direct benefits to = patients. The=20 benefits include reductions in medical errors, cost savings, real-time=20 monitoring of public health incidents, and provision of validated data = and=20 information for health systems decision and policy making. However, = there is a=20 continuing need to support research that demonstrates these benefits = within the=20 framework of a cost=96benefit analysis in order to justify the often = substantial=20 initial investments associated with telemedicine. This, of course, is=20 particularly significant in the context of developing countries with = limited=20 financial resources and telecommunications infrastructure.

Telemedicine and e-health applications that are shown = to be=20 appropriate, affordable and effective in one region can be adopted in = other=20 regions, provided that they are localized and contextualized. This = should be=20 within the capacity of the networks of ICT workers and researchers that = IDRC now=20 supports around the world.

IDRC=92s work on telemedicine and e-health research in = developing=20 countries depends on innovation. Unfortunately, in several projects,=20 satisfactory results were not achieved, for the reasons indicated above. = However, it should be noted that the average failure rate for ICT = projects is=20 about 50%15 and is no different in the health care = sector=20 specifically.16 Such high failure rates are not = acceptable in=20 most countries. The research that IDRC supports in this area should = improve the=20 likelihood of success.

Our research programmes will also continue to respond = to=20 emerging technologies and markets. As pointed out above, we have = developed a=20 number of research collaborations focusing on the use of mobile = telephony as a=20 device for the monitoring, management and delivery of health care. The = needs of=20 people living in developing countries are evident, = but,=20 ultimately, depend on a healthy society with full access to effective = health=20 care. IDRC is committed to helping them achieve just that.

References

1.=20 IDRC. History of IDRC. Available at:=20 www.idrc.ca/en/ev-26547-201-1-DO_TOPIC.html.

2.=20 IDRC. Pan Asia Networking. Available at: www.idrc.ca/pan.

3.=20 IDRC. ICT R&D Grants Programme. Available at:=20 www.idrc.ca/panasia_grants/.

4.=20 Dougherty M. Exploring New Modalities. Experiences with Information = and=20 Communications Technology Interventions in the Asia=96Pacific = Region.=20 Bangkok: UNDP Asia=96Pacific Development Information Programme, 2006. = Available=20 at: = www.idrc.ca/uploads/user-S/11685405431ExploringNewModalities.pdf.

5.=20 N-Logue Communications Pvt Ltd. N-logue. Available at:=20 www.digitaldividend.org/case/case_nlogue.htm.

6.=20 Neurosynaptic Communications Pvt Ltd. ReMeDi. Available at:=20 www.neurosynaptic.com.

7.=20 Scott R. IDRC Internal Report, 2006 (available from the authors).

8.=20 MoHCA. Mobile Healthcare Alliance. Available at:=20 www.mobilehealthcarealliance.org/index.shtml.

9.=20 IDRC. The Impact of ICTs in HIV/AIDS Programs in Eastern and = Southern=20 Africa. Available at: = www.idrc.ca/en/ev-87732-201-1-DO_TOPIC.html.

10. IDRC. = Tanzania=20 Essential Health Interventions Project (Archive). Available at:=20 www.idrc.ca/en/ev-3170-201-1-DO_TOPIC.html.

11. = Bridges.org.=20 Testing the Use of SMS Reminders in the Treatment of Tuberculosis in = Cape=20 Town, South Africa. Available at: = www.bridges.org/publications/11.

12. IDRC. = Uganda=20 Health Information Network (UHIN). Available at:=20 www.idrc.ca/en/ev-86353-201-1-DO_TOPIC.html.

13. IDRC. = Free=20 State HIV Therapy Database (ART-HIV). Available at:=20 www.idrc.ca/en/ev-86361-201-1-DO_TOPIC.html.

14. IDRC. = PAN=20 Prospectus 2006=962011. Available at:=20 www.idrc.ca/en/ev-9622-201-1-DO_TOPIC.html.

15. IT = Cortex.=20 Failure Rate: Statistics over IT Projects Failure = Rate.=20 Available at: www.it-cortex.com/Stat_Failure_Rate.htm.

16. Gauld R. = Public=20 sector information system project failures: lessons from a New Zealand = hospital=20 organization. Government Information Quarterly 2007;=20 24: 102=9614.

8 Strategies to promote e-health and telemedicine = activities in developing countries

Sisira Edirippulige, Rohana B Marasinghe, = Vajira H W=20 Dissanayake, Palitha Abeykoon and Richard Wootton

Introduction

Logic suggests that employing information and = communication=20 technology (ICT) to deliver health care at distance (i.e. telehealth or=20 e-health) would be useful to address at least some of the problems in = developing=20 countries. There is a growing body of literature to attest to this = argument.1=963 In = the early=20 1990s, there was a general expectation that e-health would solve the = main=20 problems in health care in developing countries. However, the progress = actually=20 made with e-health in developing countries has been rather limited to = date. It=20 is also true that the use of e-health in industrialized countries is = limited.4

What are the factors that have prevented developing = countries=20 from using e-health? What strategies might promote the use of = e-health?

Role of national governments in=20 promoting
e-health

Governments as policy-making organizations play a = pivotal role=20 in formulating regulations in the health sector. The contribution of the = government is particularly important in developing countries, where the = public=20 health system is usually the major provider of services. Government = policies=20 often have a significant impact on governing, financing and regulating = the=20 health sector in developing countries.5

Most developing countries in recent years have = recognized the=20 importance of ICT in their economic development and social progress.6=968 A = number of=20 countries in the developing world have initiated national policies = towards=20 integrating ICT into their economic plans.9=9612 = However, it=20 is surprising that, in most cases, these national ICT initiatives have not considered the health sector as an = important=20 sector.

We believe that the exclusion of the health sector in = national=20 ICT initiatives is a major cause of the slow progress of e-health in = developing=20 countries. The factors contributing to this situation are described = below.

Reasons for non-adoption of = e-health

The reasons for the non-adoption of e-health = include:

lack of = awareness of=20 the benefits among policy makers

lack of = evidence for=20 the benefits

limited = finance

= prejudice

lack of=20 expertise

health = system=20 inertia.

First, we assume that one powerful reason for this = situation=20 is a lack of awareness of policy makers about the benefits of = e-health.13 Although policy makers in developing = countries=20 commonly believe that ICT can be used in the development of industry,=20 agriculture and other economic and social activities, they are not aware = of the=20 benefits that the health sector can derive through the use of ICT. There = can be=20 many reasons for this. The health/medical sector is a very sensitive = area where=20 traditional ways of working have evolved over centuries and, as a = result, there=20 is resistance to change. Health is also closely linked with privacy and = security=20 concerns. Therefore, the introduction of ICT into health care = institutions may=20 not be as straightforward as in other sectors, such as commerce and=20 education.

Lack of evidence about the benefits of e-health may be = another=20 reason for policy makers being unaware of e-health. Even in = industrialized=20 countries, there is a dearth of hard evidence with regard to the = successful use=20 of e-health. Similar evidence from developing countries is even scarcer. = The=20 lack of a sustainable business case to demonstrate cost-effectiveness is = the=20 root cause.

Although policy makers in developing countries are = aware of the=20 benefits of e-health, for a range of reasons they are reluctant to = include this=20 tool in their ICT initiatives. First, this may be due to limited = financial=20 capability. Policy makers are more likely to spend their limited = resources on=20 interventions that are known to produce health gain, such as sanitation, = clean=20 drinking water and vaccination, rather than funding e-health projects. = The=20 critical state of the health sector and its financial limitations may = not allow=20 policy makers to change their traditional patterns of spending health = funding,=20 even when they are aware of the benefits of e-health. In some of the = wealthier=20 developing countries that have good health care services, there seems to = be a=20 lack of people within the health sector who can champion the cause of = e-health=20 with policy makers.

Reluctance to use e-health may also stem from certain=20 prejudices. Policy makers in developing countries may regard e-health as = a=20 family of methods imported from the industrialized world that have = little=20 relevance in their own countries. E-health may even = be seen as=20 the imposition of new methods from the Western world or former colonial=20 authorities, i.e. as a form of neocolonialism.

Even when they have an understanding of the benefits = of=20 e-health, policy makers in developing countries may be hesitant to use = it owing=20 to a lack of expertise, infrastructure, technical knowledge and = skills.14,15 Starting an e-health project requires = the=20 presence of people with a certain level of technical expertise, and this = may not=20 be available in many developing countries.16 In addition, the telecommunication=20 infrastructure in developing countries is still limited.17 These factors make it difficult for = developing=20 countries to launch e-health projects on their own.

Aspects such as inertia, reluctance to change and a = lack of=20 political will are also important factors that prevent policy makers = from=20 considering e-health as an alternative for addressing health problems in = developing countries. Reluctance to change traditional methods of = practice has=20 been a serious obstacle to integrating e-health in the industrialized = world=20 too.18 The introduction of a new practice is = always=20 demanding, and in that respect the role of champions or enthusiasts is = extremely=20 important. The lack of such champions in policy-making circles may be a = strong=20 reason for the current situation.

Another important factor, perhaps due to a combination = of the=20 factors mentioned above, is the need for long-term investment in = telehealth and=20 e-health, in order to build an infrastructure and the human resources = required=20 to demonstrate success. This is impeded by the relatively short = political cycle,=20 which requires short-term political rewards for investments.

Strategies at national level

Strategies to promote e-health at national level = include:

raising = awareness of=20 policy makers

expanding = e-health=20 education

changing = the=20 attitude of policy makers

using = expatriate=20 communities.

One way of addressing the problems outlined above is = to alert=20 policy makers to the benefits of e-health. There needs to be a = systematic way of=20 making them aware of the current state of e-health practice and = successful=20 applications. It is important to make them aware of aspects of e-health = that are=20 applicable in developing countries. To do so, improving access to the = evidence=20 base in e-health is extremely important. Making updated information = about=20 successful e-health projects available to policy makers is one way of = achieving=20 this goal. Enthusiasts within the health sector, both IT and health=20 professionals, may also play a pivotal role in making policy makers = aware of the=20 benefits of e-health.

The importance of e-health education has so far been = overlooked.=20 Evidence shows that access to systematic education in e-health is = limited in=20 both industrialized and developing countries.16,19 Systematic education in e-health for = health=20 personnel must be at the heart of any strategy designed to facilitate = e-health.=20 An understanding of the benefits of e-health, = current=20 applications, technical requirements and the ethical/legal aspects would = enable=20 health professionals to adopt this new technique. In this task, local = academics=20 and researchers can play an important role. It is important to encourage = academics to publish the outcomes of any e-health projects = internationally. By=20 doing so, local academics and health scientists can influence policy = makers to=20 facilitate the wider use of e-health.

On the other hand, policy makers must adopt an = open-minded=20 approach to these new changes. Political will and commitment, which have = often=20 been lacking in developing countries, are important elements in bringing = about=20 changes in these societies. The willingness of policy makers to use ICT = in=20 health is important in integrating this tool into the health sector.

While the continuing brain drain is a serious problem = in=20 developing countries, little attempt has so far been made to use = expatriate=20 communities to the benefit of the development of these countries. This = is=20 certainly not a problem specific to e-health. However, in promoting = e-health,=20 expatriate experts (particularly experts in the areas of health and ICT) = can=20 make a significant contribution by bringing their knowledge, skills and=20 expertise. Mobilization of experts from expatriate communities must be = promoted,=20 as these people have knowledge and skills not only in the subject area, = but also=20 about specific needs and cultural issues. From the policy makers=92 side = there=20 must be an attitudinal change to accept and facilitate these = experts.

In any environment, however, change is driven by = individuals who=20 have the motivation and desire to do so. In countries such as Sri Lanka, = where=20 national level e-health initiatives have lagged behind, there are = numerous=20 anecdotal examples of successful institutional level initiatives driven = by such=20 champions of e-health. Thus, it is clear that what is lacking in some = countries=20 is not resources or finances but leadership. Identifying such = individuals within=20 the heath care system of the country and providing the necessary support = to them=20 to bring about the desired change are very important.

Role of international agencies

International agencies such as the World Health = Organization=20 (WHO), the United Nations (UN), the World Bank and certain regional=20 organizations (e.g. the African Union and SAARC) have recognized the = value of=20 ICT in development.20=9622 In = fact the=20 WHO has been instrumental in promoting e-health in a number of ways.23 Some of these organizations have been = involved=20 in e-health projects in different parts of the world.24

Regardless of the enthusiasm of these organizations = for=20 e-health, their activities have so far been piecemeal and fragmented. In = most=20 cases, the primary responsibility of these organizations has been = limited to=20 providing funds. Often, the outcome of these initiatives has been = unhappy: once=20 the initial funding dried up, the e-health projects stopped = functioning.24 Another feature of these projects has = been their=20 disconnectedness. That is, most of them have functioned in isolation, = and have=20 not had links to other health work within the region concerned. There = may be a=20 number of factors contributing to this situation. International = organization(s)=20 initiating e-health projects in developing countries = often=20 have very limited understanding of the local situation. They may also = have=20 limited authority and recognition.

Another feature of e-health projects undertaken in = developing=20 countries is that they are commonly nothing more than a replication of = projects=20 carried out in industrialized countries. There is often no attempt to = understand=20 the specific needs of the locality and to find appropriate solutions to = address=20 those needs.

Thus, one of the main problems with international = involvement=20 in developing countries undertaking e-health projects has been a lack of = coordinated management. This certainly invites another important = question: =91Who=20 should drive e-health globally?=92 There is no conclusive answer to this = question.=20 There is no authoritative organization to oversee e-health activities = around the=20 world =96 or in developing countries in particular. The question as to = whether the=20 UN, the WHO, the World Bank or any other

Box 8.1 Summary of the report of the = WHO Global=20 Observatory for eHealth26

Key findings

1. Active involvement of the WHO in the = development of=20 generic e-health tools, and guidance in creating and implementing = e-health=20 services would be welcomed by Member States.

2. The need for guidance in a broad range of = e-health=20 areas was expressed in particular by countries that do not belong = to the=20 Organization for Economic Co-operation and Development = (OECD).

3. OECD countries did not express consistent = views of=20 their needs in e-health areas.

4. There is a need to raise awareness as to = what=20 e-health tools and services already exist at global and national=20 levels.

Proposed action

The WHO, in collaboration with public and = private sector=20 partners, should take action in the following key = areas:

1. Provision of generic tools. The = WHO should=20 facilitate the development of those generic e-health tools most = sought=20 after by its Member States, including tools for monitoring and = evaluation=20 of e-health services; drug registries; institutional = patient-centred=20 information systems that could be extended to include electronic = health=20 record systems; and directories of health care professionals and=20 institutions.

2. Access to existing tools. As a = parallel and=20 complementary action, electronic directories of existing e-health = tools=20 and services should be created, with an emphasis on open-source=20 solutions.

3. Facilitating knowledge exchange. = An=20 international knowledge exchange network to share practical = experiences on=20 the application and impact of e-health initiatives should be = built. This=20 would be Internet based and could be complemented by international = e-health conferences to facilitate networking.

4. Providing e-health information. = The WHO=20 should create a digital resource of e-health information to = support the=20 needs of Member States in key areas such as e-health policy, = strategy,=20 security and legal matters.

5. Education. The use of e-learning = programmes=20 for professional education should be promoted in the health = sciences, as=20 well as in ongoing professional development. Collaborations should = be=20 developed to generate databases of existing e-learning courses. = The WHO=20 should advocate the inclusion of e-health courses within = university=20 curricula.

organization should take the responsibility for = e-health=20 activities in developing countries remains unanswered. What makes = responding to=20 this question even harder is that it implies a number of other = questions:=20 whether this organization has the capacity to fulfil the expectations; = whether=20 it is willing to take this role; whether the role would be acceptable to = the=20 members of the international community. These are hard questions to = answer.=20 Without answers to these questions, it is difficult to formulate a = global=20 strategy for e-health.

The role of the WHO in promoting e-health globally has = to be=20 acknowledged. The WHO has recognized the need for e-health to address = health=20 issues in developing countries.25 It has also been instrumental in = forming=20 strategies, policies and standards for the utility of e-health. For = example, the=20 WHO Global Observatory for eHealth (GOe) was established to provide = Member=20 States with strategic information and guidance on effective practices, = policies=20 and standards in e-health.26 The GOe produced the first WHO Global = Survey on=20 e-health, eHealth Tools & Services: Needs of the Member = States, in=20 2005 (Box = 8.1).27

The WHO has formed an e-health standardization = coordination=20 group as a platform to promote stronger coordination among the key = players in=20 all technical areas of e-health standardization.28 The WHO has also initiated and = assisted a number=20 of e-health projects in different parts of the world. For example:

The = Telemedicine=20 Alliance was implemented with the collaboration of the European Union = and the=20 International Telecommunication Union.29

The WHO = Regional=20 Office for the Eastern Mediterranean (EMRO), in collaboration with the = Islamic=20 Republic of Iran Ministry of Health and Medical Education, organized the = Fourth=20 Regional e-Health Conference, which aimed to promote e-health.30

The WHO = has=20 initiated several e-health projects in African countries to address = health=20 issues, advance health and medical education, and raise awareness of = policy=20 makers in the use of ICT in health.31

A number = of e-health=20 projects have been undertaken in Sri Lanka (Table = 8.1).

However, there is little evidence to show the = success of any=20 of these activities. One of the most critical problems has been the = WHO=92s role=20 in funding e-health.

Strategies at international level

Strategies to promote e-health at international = level include=20 appointing an e-health governing body and linking international aid to=20 e-health.

As already mentioned, there is a critical need for a = global=20 governing body to oversee e-health activities. Setting up such an = organization=20 with appropriate legal and regulatory rights should be a priority. While = this=20 body would have authority relating to e-health activities across the = world, it=20 should also have the necessary financial capability to fund its = activities. An=20 organization with no financial capability will be doomed to failure. A = global=20 authority in e-health would be instrumental in defining matters such as=20 standards of practice, regulations and funding. Among other things, the=20 agenda

Table 8.1 E-health projects = in Sri=20 Lanka
Date	Project	Description
2001	Three-day course on basic and specialist = skills in=20 general surgery	The course was conducted by the Royal College = of=20 Surgeons of England and was delivered by distance education11 <= /TD>
2001	Feasibility study in partnership between the = WHO and the=20 Norwegian Centre for Telemedicine	This aimed to examine the potential for = telemedicine in=20 addressing problems of the health care sector in Sri Lanka12 <= /TD>
2003	Pilot e-health project funded by the WHO in=20 collaboration with the Ministry of Health of Sri Lanka	This low-cost, store-and-forward telemedicine = system was=20 designed to connect doctors in remote hospitals with specialists = for=20 consultation13 <= /TD>
2003	WHO-initiated pilot programme	This was designed to create a national = telemedicine=20 system, paying attention to wireless communication technologies in = telehealth14
2005	=91E-health Emergency Hospital=92 = project	The objectives of the project were to improve = recording=20 and reporting, improve communication via the Internet and email, = and=20 improve access to specialist advice in cases of emergency14

of such an organization should include education = and training=20 as a priority. Accreditation by this global e-health body would provide=20 much-needed recognition for e-health education to flourish. The = existence of a=20 global body would also assist the private sector to explore business=20 opportunities in this new field.

It is important that international development = assistance=20 schemes should be linked to the promotion of e-health. Currently, there = are=20 various overseas development funds that assist health and ICT projects. = Yet,=20 development assistance funds are not designed to help e-health. = International=20 donors must acknowledge that promotion of e-health is an integral part = of the=20 development of health in developing countries. Similarly, international = aid for=20 infrastructure development should be tied to the promotion of = e-health.

Conclusion

Although e-health has been generally accepted as a = useful=20 technique for improving access to health services in developing = countries, for=20 various reasons it has made very little progress. Policies at national = and=20 international level have not yet been able to facilitate e-health. At = the=20 national level, efforts must be made to raise awareness of policy = makers, health=20 personnel and business communities about the benefits of e-health. = Policy makers=20 must also have a more open-minded attitude towards e-health. At the=20 international level, there is a pressing need for a global authority to = oversee=20 e-health. This organization must have the financial and legal capacity = to=20 promote e-health. Overseas development assistance schemes must include = e-health=20 as an integral part of the development and promotion of health = generally.

References

1.=20 Al-Shorbaji N. WHO EMRO=92s approach for supporting e-health in the = Eastern=20 Mediterranean. East Mediterr Health J 2006; 12 = (Suppl=20 2): S238=9652.

2.=20 International Telecommunication Union. Telemedicine & eHealth = Directory,=20 2004. Available at:=20 www.itu.int/ITU-D/cyb/publications/2004/180ANN1E.pdf.

3.=20 E-Health Innovation Professionals Group. The Impact of e-Health and=20 Assistive Technologies on Health-care. 2005. Available at:=20 www.health-informatics.org/tehip/tehipstudy.PDF.

4.=20 Ray P, Androuchko L, Androuchko V. A comparative overview of e-health=20 development in developing and developed countries. 2006. Available at:=20 www.medetel.lu/download/2006/parallel_sessions/abstract/0406/Ray1.doc.

5.=20 Kumaranayake L, Mujinja P, Hongoro C, Mpembeni R. How do countries = regulate=20 health sector? Evidence from Tanzania and Zimbabwe. Health Policy = Plan=20 2000; 15: 357=9667.

6.=20 Islamic Development Bank. Importance of ICT to Economic = Development.=20 Available at: www.msctc.com.my/idb/2-3.htm.

7.=20 Wang EH. ICT and economic development in Taiwan: analysis of the = evidence.=20 Telecommunications Policy 1999; 23: = 235=9643.

8.=20 International Telecommunication Union. World Telecommunication/ICT=20 Development Report 2006: Measuring ICT for Social and Economic=20 Development. Available at:=20 www.itu.int/dms_pub/itu-d/opb/ind/D-IND-WTDR-2006-SUM-PDF-E.pdf.

9.=20 Islam KMB. National ICT Policies and Plans towards Poverty = Reduction:=20 Emerging Trends and Issues. Available at:=20 www.uneca.org/disd/events/accra/Poverty/ICT%20for%20Poverty%20Reduction-%= 20Paper%20by%20Baharul%20Islam.pdf.

10. World = Summit on the=20 Information Society. Plan of Action: Civil Society=92s = Priorities.=20 Available at: www.genderit.org/wsis/WSIS-CS-ActionPlan.doc.

11. United = Nations=20 Economic and Social Council. Economic and Social Commission for Asia and = the=20 Pacific. Report on the Current Economic Situation in the Region and = Related=20 Policy Issues. Available at:=20 www.unescap.org/EDC/English/Commissions/E63/E63_3E.pdf.

12. Kearns P. = An=20 International Overview of Trends in Policy for Information and = Communication=20 Technology in Education. Available at:=20 www.dest.gov.au/sectors/higher_education/publications_resources/summaries= _brochures/towards_the_connected_learning_society.htm.

13. World = Health=20 Organization Regional Office for the Eastern Mediterranean. Intercountry = Meeting=20 on Tele-medicine (Riyadh, Saudi Arabia, 7=969 February = 1999).Conclusions and=20 Recommendations. Available at:=20 www.emro.who.int/HIS/ehealth/Meetings-TelemedicineSAA1999.htm.

14. Drury P. = The=20 eHealth agenda for developing countries. World Hosp Health = Serv, 2005;=20 41: 38=9640.

15. = Metaxiotis K,=20 Ptochos D, Psarras J. E-health in the new millennium: a research and = practice=20 agenda Int J Electron Healthc 2004; 1: = 165=9675.

16. = Edirippulige S,=20 Marasinghe RB, Smith AC et al. Medical students=92 knowledge and = perceptions of=20 e-health: results of a study in Sri Lanka. In: MEDINFO 2007. = Amsterdam:=20 IOS Press, 2007: 1406=969.

17. = Parliamentary=20 Office of Science and Technology. ICT in Developing Countries.=20 Available at: www.parliament.uk/documents/upload/postpn261.pdf.

18. World = Bank.=20 2006 Information & Communications for Development (IC4D) =96 = Global Trends=20 and Policies. Available at: www.worldbank.org/ic4d.

19. = Edirippulige S,=20 Smith AC, Young J, Wootton R. Knowledge, perceptions and expectations of = nurses=20 in e-health: results of a survey in a children=92s hospital. J = Telemed=20 Telecare 2006; 12(Suppl 3): 35=968.

20. UNESCO = Secretariat.=20 Information and Communication Technologies in Development: A UNESCO=20 Perspective. Available at:=20 www.unesco.org/webworld/telematics/uncstd.htm.

21. Boucher = P.=20 Guidelines Public/Private Collaboration for ICT Development in = Health=20 Department of Knowledge Management and Sharing. Available at:=20 www.who.int/kms/initiatives/Guidelines.pdf.

22. United = Nations.=20 Fourth Annual Report of the Information and Communication = Technologies Task=20 Force. New York: United Nations, 2006.

23. Merchant = JA, Cook=20 TM, Missen CC. The Role of Information and Communications = Technology.=20 Available at: = www.who.int/bulletin/volumes/85/12/07-048975/en/print.html.

24. = Marasinghe RB,=20 Edirippulige S, Smith AC et al. A snapshot of e-health activities in Sri = Lanka.=20 J Telemed Telecare 2007; 13(Suppl 3): = 53=966.

25. World = Health=20 Organization. World Health Assembly Resolution on E-health = (WHA58.28,=20 May 2005). Available at: www.euro.who.int/telemed/20060713_1.

26. World = Health=20 Organization. Global Observatory for eHealth (GOe). Available = at:=20 www.who.int/kms/initiatives/ehealth/en/.

27. World = Health=20 Organization. eHealth Tools & Services: Needs of the Member = States.=20 Available at: = www.who.int/kms/initiatives/tools_and_services_final.pdf.

28. World = Health=20 Organization. eHealth Standardization Coordination Group. = Available at:=20 www.who.int/ehscg/en/.

29. World = Health=20 Organization Regional Office for Europe. Reports and Guidelines from = the=20 Telemedicine Alliance and Telemedicine Bridge Projects. Available = at:=20 www.euro.who.int/telemed/Publications/20060718_2.

30. World = Health=20 Organization Regional Office for the Eastern Mediterranean. Fourth = Regional=20 e-Health Conference: Building the Electronic Health Record = (Teheran,=20 Islamic Republic of Iran, 7=969 September 2004).Conclusions and=20 recommendations. Available at:=20 www.emro.who.int/his/ehealth/meetings-iran2004-recommendations.htm.

31. World = Health=20 Organization Regional Office for Africa. Knowledge Management in the = WHO=20 African Region: Strategic Directions. Available at:=20 afrolib.afro.who.int/RC/RC%2056/Doc_En/AFR-RC56-16%20Knowledge%20Manageme= nt%20-%20Final.pdf.

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SECTION 3
EDUCATIONAL

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9 Telemedicine in low-resource settings: = Experience with a=20 telemedicine service for HIV/AIDS care

Maria Zolfo, Verena Renggli, Olivier Koole = and Lut=20 Lynen

Introduction

In December 2003, the World Health Organization = (WHO) and the=20 Joint United Nations Programme on HIV/AIDS launched the =913 by 5=92 = initiative to=20 help low- and middle-income countries provide treatment to three million = people=20 living with HIV/AIDS. Although the target date of December 2005 was not = met, the=20 global efforts to scale up access to antiretroviral therapy (ART) have = brought=20 positive changes worldwide. At the end of 2006, more than two million = people=20 living with HIV were being treated with ART in low- and middle-income=20 countries.1

It has been an enormous challenge to introduce ART in = a safe and=20 effective way in resource-limited settings. The lack of human resources = and=20 clinical expertise has required approaches such as task shifting and=20 continuum-of-care models where non-HIV specialists, nurses and lay = providers all=20 play a role in HIV/AIDS care. The public health approach that was = proposed by=20 the WHO in 2003 has provided the tools necessary to deliver = decentralized HIV=20 care, including ART with limited resources.2

It is clear that supportive supervision and clinical = mentoring=20 is the cornerstone of this public health approach in most of the=20 resource-constrained clinical settings, where the health system is = already weak=20 and overwhelmed. Telemedicine (using the telephone, email, Internet or=20 videoconferencing) is one possible way of offering clinical mentoring. = We have=20 established a telemedicine service for physicians working in HIV/AIDS = services=20 in low-resource settings.

The HIV/AIDS TELEmedicine service

The Institute of Tropical Medicine in Antwerp (ITMA) = has run a=20 short course on ART (SCART) every summer since 2003. The course provides = three=20 weeks of training on ART and clinical management of HIV infection for = more than=20 40 physicians from resource-poor countries. After = completing=20 the course, a hybrid web/email forum is offered to the participants to = support=20 their decision-making and assist in the management of difficult HIV/AIDS = cases=20 in their daily clinical practice (Figure 9.1).3

The patient=92s history, physical examination, = laboratory findings=20 and questions to be answered are sent to a network of HIV/AIDS = specialists using=20 a discussion forum accessed through the TELEmedicine website (Figure 9.2). = All=20 postings submitted to this discussion forum are stored in a database and = available for consultation. An internal email account is also available = for=20 direct contact between members, facilitating the exchange of recent = literature,=20 policy documents and interaction between sites. In addition, a system of = email=20 warning messages can be used to give early notice when a new posting is=20 available on the discussion forum.

The TELEmedicine website contains interesting clinical = cases and=20 answers to common questions. This information can be consulted through a = search=20 function for continuing medical education (CME). Policy documents, = guidelines=20 and supporting material on HIV/AIDS care in low-resource settings and = links to=20 other important web-sites are also accessible.4,5 The = website=20 conforms with the Health On the Net Foundation Code of Conduct.6 This = code is=20 designed to improve the reliability of health information on the web. It = defines=20 a set of rules for website developers to ensure that readers always know = the=20 source and the purpose of the information that they are reading.

Service usage

Between April 2003 and March 2007, the TELEmedicine = service=20 received 642 second-opinion requests, from more than 35 = resource-constrained=20 countries. Three-quarters of the teleconsultations concerned management = of=20 complex medical problems in a specific patient and one-quarter were = questions in=20 the field of organization of health services for HIV prevention, = treatment and=20 care, vaccination programmes and guidelines.

In the first three years of activity (April = 2003=96March 2006),=20 there were 491 queries. Of these, 47% (n =3D 230) were related = to the=20 general use of antiretrovirals, side effects, second-line regimens, = prevention=20 of mother-to-child transmission (PMTCT), immune reconstitution syndrome, = TB/HIV=20 and management of other co-infections during ART; 40% (n =3D = 197) were=20 related to the diagnosis and treatment of specific opportunistic = infections and=20 13% (n =3D 64) to general topics such as the organization of = health=20 services for AIDS care, directly observed TB therapy, vaccination = programmes and=20 guidelines (Figure=20 9.3).

During the first three years of TELEmedicine activity, = we=20 noticed a significant increase in the proportion of questions related to = organizational issues of HIV programmes: from 8% during the first year = to 27%=20 during the third year (P < 0.001). The opposite occurred for = questions on=20 general use of antiretrovirals (from 14% to 5%), management of side = effects=20 (from 12% to 5%) and management of specific opportunistic infections = (from 44%=20 to 30%); these differences were significant (P < 0.05).

There was a clear reduction in the numbers of = questions on=20 general use and side effects of antiretrovirals and a significant = increase in=20 questions concerning the

3DImage=20

Figure 9.1 TELEmedicine website3

3DImage=20

Figure 9.2 TELEmedicine website = discussion=20 forum

3DImage=20

Figure 9.3 Telemedicine referrals = (first three=20 years of service). ARVs, antiretrovirals; IRIS, immune reconstitution=20 inflammatory syndrome; OIs, opportunistic infections; TB, tuberculosis; = PMTCT.=20 prevention of mother-to-child transmission

organizational issues of ART programmes. This is = related to=20 the maturing of the HIV/AIDS programmes. Thus, in the last two years, we = have=20 received many questions about ART roll-out: how to increase access to = treatment=20 and care, how to implement PMTCT services in ART clinics, and how to = extend care=20 to paediatric HIV cases. These questions do not arise in the early = stages, when=20 the burden of first-line access to HIV care is the main problem. It is = also=20 clear that management of opportunistic infections remains a challenge, = and=20 training programmes should not neglect this aspect of HIV care.7

User satisfaction

A survey was conducted in 2006 to evaluate = clinicians=92=20 perception of the TELEmedicine service. The members were divided into = =91active=20 users=92 (i.e. clinicians who participated in the discussion forum) and = =91passive=20 users=92 (i.e. clinicians who consulted the TELEmedicine forum but did = not post=20 clinical cases and/or questions there).

There was a response rate of 53% among active users = (18/34).=20 Among these respondents, the service was judged to have been useful in=20 influencing the management of the patients in 100% of cases, and 67% of = the=20 users perceived that the advice was useful in more than 75% of cases. = The=20 service was beneficial for the establishment of the diagnosis (78%), for = the=20 referring clinician=92s education (55%) and for reassurance (39%).8

Computer skills

Lack of access to information remains one of the = major=20 barriers to the practice of evidence-based medicine in low-resource = settings.=20 The problems include limited access to computer facilities, to = literature=20 databases and to CME programmes.

At the end of the short courses in 2004 and 2005, we = assessed=20 physicians=92 access to the web and their abilities to use computers = while working=20 in the field. Out of the total of 84 trained physicians, who were mainly = African=20 and Asian nationals working for international organizations or for the = ministry=20 of health, 75 completed the questionnaires. While = 11% of the=20 physicians stated that they did not have access to the web, almost all = of them=20 (74/75) said that they had their own email account. Of the respondents, = 69%=20 preferred to access the Internet in the evening (17:00=96midnight). A = connection=20 speed of at least 28.8 kbit/s was available to 40% of them. For 83%, the = operating system they used was Windows 2000/XP, 93% had a CD reader and = 63% had=20 a sound card on their computers. Two-thirds of the users reported that = they were=20 able to download files and to use software such as Acrobat, Excel, = PowerPoint,=20 WinZip and Word.

Online course

Although web access and information and = communication=20 technology (ICT) ability and use remain limited in low-resource = settings, our=20 selected group of physicians who attended the short course showed a good = level=20 of basic informatics knowledge, ability to use computers and access to = the=20 Internet.9 This = type of=20 information helped us to plan the delivery of online modules through the = website=20 for CME purposes and to start the conversion of the face-to-face course = to an=20 online training modality (eSCART).

The eSCART content is structured into 13 different = modules and=20 uses a problem-based learning approach with clinical cases, tutorials,=20 additional readings and self-assessments. At a workload of 4=965 study = hours per=20 week, the 3-week face-to-face course requires a minimum of 3 months=92 = online=20 training. To expand the availability of the eSCART course, we intend to = work=20 with appropriate international organizations and offer adaptations for = HIV/AIDS=20 programmes in low-resource settings.

Other telemedicine approaches

Consultations

Some HIV/AIDS programmes in low-resource settings = have=20 developed a consultation system that allows newly trained providers to = ask=20 questions of an expert through direct telephone calls, email and call = centres.=20 Telephone contact is usually set up so that health care workers and = patients can=20 make a toll-free or low-cost phone call to a central location.

Call centre in Uganda

The AIDS Treatment Information Centre at the = Infectious=20 Disease Institute (IDI) of Makerere University in Kampala hosts a call = centre=20 that responds to providers=92 treatment questions. The centre operates = during=20 normal office hours.10 It = is staffed=20 by clinical pharmacists, who are supported by the IDI faculty. The call = centre=20 automatically records the caller=92s telephone number, and the staff = return the=20 call at no cost to the caller. The centre automatically develops a = database of=20 the most frequently asked questions.11

Satellife (HealthNet)

This is an international not-for-profit organization = that uses=20 the Internet for health information purposes in the developing world.12 The = organization aims to improve the communication and = exchange of=20 information in the fields of public health, medicine and the = environment. There=20 are global discussion groups (e.g. in nutrition, essential drugs, = paediatric=20 management and nursing). Using a low-Earth-orbit satellite and telephone = lines=20 for telecommunication, the organization provides email access in 140 = countries,=20 to a total of about 10 000 health care workers. Special emphasis is = placed on=20 areas of the world where access is limited by poor communications, = economic=20 conditions or disasters. Where adequate telecommunication links exist, = Satellife=20 and other organizations provide higher-capacity email and Internet = connections.=20 These allow the transmission of email attachments such as image files. = The=20 patient=92s findings can be described in an email message, and digital = photographs=20 of the patient and their investigations, such as electrocardiograms and = X-ray=20 films, can then be attached. This =91store-and-forward=92 telemedicine = does not=20 allow real-time interaction, but it permits specialist support in the = management=20 of difficult cases (see Chapter 19).

Case conferences

Another way to mentor health care workers is through = case=20 conferences, i.e. regular meetings to discuss complex problems in HIV = care and=20 to provide updates on practices or guidelines. For example, telephone=20 conferences are used by the Heineken Company for mentoring its health = care=20 workers. In the period October 2001 to December 2003, the company had 10 = health=20 care workers operating in 5 different African countries. A total of 268 = problems=20 were raised during 45 telephone conferences. There were 79 questions = (29%) about=20 ART, 53 (20%) about the diagnosis and treatment of opportunistic = infection, 43=20 (16%) about antiretroviral toxicity, 40 (15%) about care organization = and=20 policy, 32 (12%) about laboratory or drug supply, and 21 (8%) about = biological=20 parameters. The level of satisfaction among local company physicians was = 65% for=20 logistics, 89% for scientific relevance, 84% for applicability of advice = and 85%=20 overall. The most common complaints concerned the poor quality of the = telephone=20 connection and language problems for francophone participants. This = showed that=20 database-supported telephone conferencing could be useful for mentoring = company=20 health care workers in their routine care of HIV-infected workers and = family=20 members.13

Twinning

An established relationship between two institutions = to share=20 expertise is referred to as twinning. Ideally, these are long-term = partnerships=20 (at least three years), with clear, common objectives that serve as a = basis for=20 exchanging expertise and experience for the benefit of both = institutions. A=20 twinning broker, such as the Twinning Center,14 = develops and=20 supports twinning partnerships. The Twinning Center is also exploring = mechanisms=20 to support collaboration between institutions in resource-constrained=20 settings.11

Another example of this approach is the collaboration = between=20 the Moi University Faculty of Health Sciences in Kenya and both the = Indiana=20 University School of Medicine and the Brown University School of = Medicine in the=20 USA.

Twinning increases resources for individual = institutions by=20 facilitating a flow of funds and an exchange of information and = expertise from=20 one institution to the other. There is, however, a = limit to=20 the number of available twinning programmes, and trainers from foreign=20 institutions are not always knowledgeable about local conditions, = language or=20 policy.15

Other web-based collaboration and = telemedicine=20 systems

There are a number of other web-based collaboration = and=20 telemedicine systems, not restricted to the field of HIV.

AIDSPortal

This is an Internet portal that provides tools to = support=20 global collaboration and knowledge sharing among new and existing = networks of=20 people responding to the AIDS epidemic.16 = AIDSPortal=20 offers: networking (members can access a directory of people and = organizations=20 to locate others interested in similar problems or working in a = particular=20 place); policy dialogue (the most up-to-date information on policy = initiatives=20 and international processes is easily accessible through AIDSPortal, and = people=20 can share information about their engagement); country-led management=20 (supporting constructive dialogue between national responses and = experiences and=20 international processes); and access to information (AIDSPortal = facilitates=20 access to information given the time and resource constraints facing=20 organizations responding to HIV and AIDS).

Community-based HIV treatment programme in=20 Haiti

Partners In Health and Zanmi Lasante launched a=20 community-based HIV treatment programme in Haiti=92s impoverished = central plateau.=20 It is a web-based medical record system linking remote areas in rural = Haiti. It=20 is used to track clinical outcomes, laboratory tests, drug supplies,=20 communications, data analysis and drug supply management. Decision = support is=20 particularly useful for interpreting laboratory results. Technicians at = two=20 clinical sites enter patients=92 CD4 cell counts. Each night, a program = checks for=20 patients with low CD4 counts who are not receiving the appropriate drug = regimen.=20 A warning email message is sent to all 20 Zanmi Lasante clinicians and = contains=20 a link to the electronic medical records of patients who require = additional=20 treatment. Reminders can also be generated for patients who require = extra drugs=20 or investigations.17

Cell-Life

This is a platform for communication, information = and=20 logistical support to manage HIV/AIDS patients, enabling close = monitoring of ART=20 adherence and providing support to health care workers visiting AIDS = patients in=20 remote areas. The system supports communications technology, such as = mobile=20 phones and the Internet.18,19

RAFT (R=E9seau en Afrique Francophone pour la=20 T=E9l=E9medecine)

The RAFT project permits remote collaboration, case = discussion=20 and data sharing over low-bandwidth networks between the Geneva = University=20 Hospitals and 10 French-speaking African countries.20,21 The = core=20 activity of the RAFT is the webcasting of interactive courses. Other = activities=20 include videoconferences, teleconsultations based on = the iPath=20 system, collaborative knowledge base development, support for medical = laboratory=20 quality control, and the evaluation of the use of telemedicine in rural = areas=20 (via satellite connections) in the context of multisectorial = development. The=20 project uses Linux and other open source software.

iPath

This is Internet-based software for the exchange of = medical=20 knowledge, distance consultations, group discussions and distance = teaching in=20 medicine and allows image sharing in pathology, radiology and = dermatology.22,23 It = is being=20 used in Africa, Asia and the Pacific. It is built with open source = software,=20 which is available free at http://www.sourceforge.net/. More=20 than 200 discussion groups use the iPath system.

Conclusions

More than two million people infected with HIV are = now=20 receiving ART in middle-and low-income countries. However, this has = created=20 extraordinary demands on health care workers in areas where health = systems were=20 already weak and overwhelmed. Thus, there are several problems in = scaling up=20 treatment programmes. A number of approaches are being tried, including=20 mobilization of national and private partners, decentralization of = HIV/AIDS=20 services, and training and mentoring of health care workers.

It is evident that training and supervision are = critical=20 factors. Over the past few years, private donors and large = organizations, such=20 as the President=92s Emergency Plan for AIDS Relief and the Global Fund, = have=20 begun to be involved in pre-service training and mentoring of health = care=20 workers dealing with HIV/AIDS care in low-resource settings. Some = developing=20 countries have established collaborations with external partners to = access=20 training curricula or shape existing didactic material into a new model = of=20 teaching (training of trainers, onsite refresher courses, CME and = distance=20 learning), and some of the programmes have even expanded the range of = support,=20 offering attachments or onsite mentoring.

Telemedicine is one of the approaches to mentoring = health care=20 workers in low-resource settings, even though exhaustive data about its=20 effectiveness are not yet available. In many settings, connectivity and = computer=20 literacy are still major limitations. In our experience, the opportunity = for=20 continued dialogue with physicians in the field has been valuable. It = has=20 allowed the identification of HIV/AIDS knowledge gaps and provided = answers to=20 some critical questions. Decisions on how to best support programmes on = HIV/AIDS=20 care in low-resource settings should really be made after taking into = account=20 the questions raised in the field.

The Institute of Tropical Medicine in Antwerp offers = both=20 face-to-face training courses and online training in ART. The = TELEmedicine=20 website also supports the management of difficult HIV/AIDS clinical = cases via a=20 discussion forum, where a network of international specialists is = available to=20 give second opinion advice. This is just one example of mentoring health = care=20 workers and providing direct support in the management of HIV/AIDS = clinical=20 cases. We believe that by giving clinicians the opportunity to=20 access support and clinical mentoring, it is possible to lower the = threshold for=20 launching ART programmes. In addition, updating staff through CME helps = to=20 maintain quality in ART programmes, even in resource-limited = settings.

Acknowledgements

This work was supported by the Belgian Directory = General of=20 Development Cooperation. We thank Vera Van Boxel and Joris Menten for = the data=20 analysis and Carlos Kiyan for offering advice.

References

1.=20 World Health Organization. Towards Universal Access: Scaling up = Priority=20 HIV/AIDS Interventions in the Health Sector. Geneva: WHO, 2007. = Available=20 at: = www.who.int/hiv/mediacentre/univeral_access_progress_report_en.pdf.

2.=20 World Health Organization. Antiretroviral Therapy for HIV Infection = in=20 Adults and Adolescents: Recommendations for a Public Health = Approach.=20 Geneva: WHO, 2006. Available at:=20 www.who.int/hiv/pub/guidelines/artadultguidelines.pdf.

3.=20 TELEmedicine website. Available at: telemedicine.itg.be.

4.=20 Zolfo M, Lynen L, Dierckx J, Colebunders R. Remote consultations and = HIV/AIDS=20 continuing education in low-resource settings. Int J Med Inform = 2006;=20 75: 633=967.

5.=20 Zolfo M, Arnould L, Huyst V, Lynen L. Telemedicine for HIV/AIDS care in = low=20 resource settings. Stud Health Technol Inform 2005;=20 114: 18=9622.

6.=20 Health On the Net Foundation. Quality and Trustworthiness of the = Medical and=20 Health Web. Available at: www.hon.ch/visitor.html.

7.=20 Zolfo M, Koole O, Renggli V et al. Online consultations for HIV/AIDS = care in=20 resource-limited settings. In: Proceedings of the 11th Congress of = the=20 International Society for Telemedicine, 26=9629 November 2006, Cape = Town,=20 South Africa.

8.=20 Zolfo M, Renggli V, Koole O et al. Telemedicine survey on users=92 = satisfaction.=20 In: Proceedings of the 11th Congress of the International Society = for=20 Telemedicine, 26=9629 November 2006, Cape Town, South Africa.

9.=20 Zolfo M, Lynen L, Renggli V et al. Computer skills and digital divide = for=20 HIV/AIDS doctors in low resource settings. In: Proceedings of Med-e-Tel, = 5=967=20 April 2006, Luxexpo, Luxembourg.

10. AIDS = Treatment=20 Information Centre Website. Available at:=20 www.idi.ac.ug/index.php?m=3Dmenu&i=3D170.

11. World = Health=20 Organization. WHO Recommendations for Clinical Mentoring to Support = Scale-up=20 of HIV Care, Antiretroviral Therapy and Prevention in Resource = Constrained=20 Settings. Geneva: WHO, 2006. Available at:=20 www.who.int/hiv/pub/guidelines/clinicalmentoring.pdf.

12. = AED-SATELLIFE=20 website. Available at: www.healthnet.org.

13. = Clevenbergh P, Van=20 der Borght SF, van Cranenburgh K et al. Database-supported = teleconferencing: an=20 additional clinical mentoring tool to assist a multinational company = HIV/AIDS=20 treatment program in Africa. HIV Clin Trials 2006; = 7:=20 255=9662.

14. HIV/AIDS = Twinning=20 Center website. Available at: www.twinningagainstaids.org.

15. McCarthy = EA,=20 O=92Brien ME, Rodriguez WR. Training and HIV-treatment scale-up: = establishing an=20 implementation research agenda. PLoS Med 2006; = 3:=20 e304.

16. = AIDSPortal website.=20 Available at: www.aidsportal.org.

17. Jazayeri = D, Farmer=20 P, Nevil P et al. An Electronic Medical Record system to support HIV = treatment=20 in rural Haiti. AMIA Annu Symp Proc 2003: 878.

18. Cell-Life = website.=20 Available at: www.cell-life.org.

19. Skinner = D, Rivette=20 U, Bloomberg C. Evaluation of use of cellphones to aid compliance with = drug=20 therapy for HIV patients. AIDS Care 2007; 19:=20 605=967.

20. AFT = website.=20 Available at: raft.hcuge.ch.

21. = Geissbuhler A,=20 Bagayoko CO, Ly O. The RAFT network: 5 years of distance continuing = medical=20 education and tele-consultations over the Internet in French-speaking = Africa.=20 Int J Med Inform 2007; 76: 351=966.

22. iPath = website.=20 Available at: telemed.ipath.ch/ipath.

23. Brauchli = K,=20 Oberholzer M. The iPath telemedicine platform. J Telemed = Telecare 2005;=20 11(Suppl 2): 3=967.

10 Medical Missions for Children: A global = telemedicine and=20 teaching network

Philip O Ozuah and Marina = Reznik

Introduction

Advances in information and communication technology = (ICT)=20 have provided new ways of delivering health care.1 The = World=20 Health Organization (WHO) has recognized the role of =91health = telematics=92 in=20 improving access to medical and health care, health education, global = health=20 promotion, training of health personnel and the management of emergency=20 situations.2 This = is=20 particularly relevant in developing countries, where there are often = growing=20 health disparities, and where children are particularly affected by = inequalities=20 of access.

Telemedicine has become increasingly popular in both=20 industrialized and developing countries.1 In = developing=20 nations, telemedicine has important effects on many aspects of health = systems.3 It = has the=20 potential to improve health care by removing time and distance barriers, = providing medical education and medical care, and optimizing the use of = the=20 limited health services available in these under-served communities.4

There have been many reports suggesting the potential = advantages=20 and benefits of telemedicine as a useful technique for delivering health = care in=20 the developing world.5=968 = However, few=20 authors have described the actual clinical experience of using = telemedicine=20 there.9=9613 = The reported=20 use of telemedicine for children in developing countries is even more = limited.14=9617 = Medical=20 Missions for Children (MMC) is a US not-for-profit organization that = operates a=20 global videoconferencing network. It delivers expertise from medical = specialists=20 and technicians based in hospitals in the USA to children needing care = in=20 developing countries by using telemedicine.18

Medical Missions for Children

The goal of MMC is to improve health care for = children in=20 medically under-served communities by using telemedicine. It has the = following=20 aims:18

1. To provide medical diagnoses and treatment via = telemedicine=20 to children and mothers in under-served communities around the = world.

2. To facilitate medical knowledge transfer from those = who have=20 it to those who need it using the latest in communication = technology.

3. To support applied medical research utilizing=20 state-of-the-art communications infrastructure.

MMC works with a network of 27 American hospitals, = who mentor=20 participating hospitals in under-served countries.18 It provides videoconferencing = equipment for the=20 hospitals in the developing world, as well as satellite time for the=20 communication. Videoconferencing equipment (donated by Polycom) includes = ViewStation HXD 9000, ViewStation VSX 7000 and HDX equipment, which = communicates=20 at band-widths from 384 kbit/s to 4 Mbit/s. Physicians from the = mentoring=20 hospitals volunteer their time and expertise to participate via = videoconference=20 in remote examinations of patients, consultations about diagnosis and = treatment,=20 and education about new procedures, drugs and medical equipment.

History

MMC was founded in March 1999 by Peg and Frank Brady = at St=20 Joseph=92s Children=92s Hospital in Paterson, New Jersey, as a way of = screening ill=20 children from developing countries prior to doctors travelling to treat = them.=20 After eight years of operation, MMC serves children in over 100 = countries=20 throughout Latin America, the Caribbean, Europe, Africa, Asia, the = Pacific and=20 the Middle East. At least three patient consultations or diagnostic = sessions are=20 held by videoconference each day, with 1000=961200 direct consultations = conducted=20 every year. Since its inception, MMC has provided diagnostic = consultations to=20 almost 25 000 children, using the expertise of more than 600 physicians = from 27=20 mentoring hospitals via telemedical support.

Programmes

MMC=92s work is accomplished through five = programmes.

1. Telemedicine Outreach = Programme

MMC operates a distance medicine network in more = than 100=20 countries, called the Telemedicine Outreach Programme. This programme, a = partnership with the World Bank, allows physicians to be electronically = linked=20 to patients in remote locations. MMC maintains a network of 27 mentoring = hospitals in the USA and Europe that participate in the programme.18

2. Medical Broadcasting = Channel

The Medical Broadcasting Channel (MBC) was launched = in=20 November 2005. It was developed as a means of helping physicians and = other=20 health care professionals to stay abreast of the latest developments in = the=20 medical field. High-quality, up-to-date medical education is delivered = to=20 physicians and allied health care workers around the world by satellite=20 broadcasting and Internet streaming. The Intelsat 903 satellite is used = to=20 broadcast medical content to an area that encompasses 9 million = physicians, 14=20 million nurses, 5 million health care workers, 89 000 hospitals, and 16 = 000=20 universities and medical schools.18

MBC is also available via the Internet2, the = high-speed research=20 version of the Internet. This network can support the transmission of = TV-quality=20 video and is available in 88 countries around the world.19 = The network=20 is available to more than 300 000 institutions, including universities,=20 government agencies, hospitals, medical schools, corporations and = research=20 facilities.

Eight daily seminars on different medical topics = ranging from=20 paediatrics to geriatrics are transmitted three times a day via = satellite and=20 the Internet. By providing and disseminating this latest medical = information,=20 MMC helps to increase the level of expertise in each participating = hospital, as=20 well as alleviating the disparity of care between industrialized nations = and the=20 developing world.

3. Global Video Library of = Medicine

The Global Video Library of Medicine (GVLM) provides = health=20 care workers around the world with free access to an archive of more 25 = 000=20 hours of medical video. GVLM is the digital repository of thousands of=20 video-based medical lectures, news programmes, symposia and training = sessions,=20 all of which are available to health care providers throughout the = world. It=20 provides a reliable source of clinical and medical research content via = the=20 public Internet.18 It is available to health care = professionals as=20 well as the general public. Its Video-on-Demand capability allows = researchers to=20 search for and retrieve medical content. GVLM also serves as the content = source=20 for MBC.

4. Giggles Children=92s = Theatre

The Giggles Children=92s Theatre performs three = times each week=20 to bring the healing powers of laughter and entertainment to = hospitalized=20 children in the city of Paterson, New Jersey (Figure 10.1). = From the=20 comfort of the Giggles Theatre, children are able to travel the globe on = interactive virtual field trips that include swimming with sharks, = visiting zoos=20 and museums, and exploring rainforests.

The theatre provides a short escape from the fear and = monotony=20 that often accompany a hospital stay. Giggles presentations are also = delivered=20 via closed circuit television to the bedside of children too ill to come = to the=20 theatre and are broadcast via satellite and Internet2 to other = children=92s=20 hospitals around the world.18

5. MMC-produced television = shows

The belief in creating knowledgeable patients who = can work as=20 a team with the physician to manage their illnesses led MMC to produce = three=20 television programmes for the Public Broadcasting System and MBC. The = programmes=20 educate individuals about health problems that could affect them and = their=20 families. The programmes are:18

Plain = Talk about=20 Health, which was designed to take the medical jargon out of = important=20 conversations about health.

= Tomorrow=92s=20 Medicine Today, which includes interviews with the directors of the = 27=20 institutes of the US National Institutes of Health (NIH) and researchers = from=20 around the world.

3DImage=20

Figure 10.1 A Giggles Children=92s = Theatre=20 presentation of Aesop=92s Fables

Take = Care,=20 which presents a patient describing his symptoms and the subsequent = review and=20 diagnosis by specialists.

Case report

The first child helped by MMC, Yordano, was an = 11-year-old boy=20 from rural Panama who was born with a cranial deformity resulting in the = absence=20 of one eye, difficulty in swallowing and learning difficulties. Yordano = comes=20 from a family of six. His father is a painter and his mother is a = seamstress. He=20 has an 18-year-old brother, a 5-year-old brother and a healthy twin = brother.=20 Yordano was the first child to use the MMC telemedicine network. He was = examined=20 by the physicians at St Joseph=92s Children=92s Hospital in New Jersey, = and it was=20 decided that he could be helped. A computer model of his head was = created with=20 the help of interactive telemedicine to collect the measurements. Then, = using a=20 computer, physicians designed titanium implants to correct his = deformity. A=20 physical model was made to confirm that all the parts fitted properly. = Yordano=92s=20 doctors in Panama were involved with the preparation. However, it was = decided=20 that his surgery should be performed at St Joseph=92s. Yordano and his = mother=20 arrived in the USA in November 2001 for the initial surgery. = Subsequently,=20 Yordano had 11 surgical procedures performed at St Joseph=92s to = reconstruct his=20 skull and jaw, to create an eye socket for a prosthetic eye and to = receive a new=20 titanium jaw (Figures=20 10.2=9610.4).=20 After this surgery was completed, educational sessions were held by the surgeons from the USA, who used the MMC network = to review=20 the procedure with 50 physicians from Panama. The plan is for Yordano to = have=20 one more operation in Panama to align his jaw. He is now 17 years old = and doing=20 well.

3DImage=20

Figure 10.2 Yordano with Dr Hillel = Ephros

3DImage=20

Figure 10.3 Yordano, post = surgery

3DImage=20

Figure 10.4 Yordano, seven years = after the=20 first operation

MMC and the Children=92s Hospital at = Montefiore

The Children=92s Hospital at Montefiore in the = Bronx, New York,=20 acts as a mentoring hospital for the University College Hospital in = Ibadan,=20 Nigeria. The object is to provide health education and better access to = medical=20 care for children in Nigeria. The International Center for Child Health = at the=20 Children=92s Hospital at Montefiore (CHAM) houses telemedicine equipment = to=20 facilitate encounters between CHAM staff and Nigerian medical = professionals,=20 providing a forum for medical information exchange in the form of = training=20 sessions, seminars, symposiums and consultations via = videoconferencing.

Working in partnership with the MMC, CHAM is = sponsoring the=20 College of Medicine at University College Hospital in Ibadan. MMC has = provided=20 the telemedicine equipment for the hospital in Nigeria. A curriculum of = the=20 hospital=92s educational needs and interests is being developed by = medical staff=20 in Nigeria in collaboration with CHAM faculty members. An agreement = between MMC=20 and the World Bank allows CHAM to connect with the Medical Missions site = (via=20 three ISDN lines) and access the World Bank satellite to reach the = College of=20 Medicine via Ibadan=92s satellite dish. The World Bank pays for the = satellite=20 time.

Our Nigerian partner has responsibility only for = providing space=20 for the telemedicine equipment and administrative support to ensure the = quality=20 and sustainability of the programme. They also = provide an=20 appropriate mechanism for assessing and discussing the medical and = educational=20 needs of Nigeria, to ensure that the programme contributes to the = enhancement of=20 paediatric health care.

Conclusion

There are many potential benefits of using = telemedicine to=20 deliver health care in the developing world.7=969 = However, there=20 are few reports that describe the use of telemedicine for children in = developing=20 countries. MMC, a non-profit-making organization, has a well-established = telemedicine network between mentoring hospitals in the USA and = hospitals in=20 developing nations. Since its inception, the programme has provided = direct=20 medical consultation and services to some 25 000 children in developing=20 countries.

References

1.=20 Wootton R, Craig J, Patterson V, eds. Introduction to = Telemedicine, 2nd=20 edn. London: Royal Society of Medicine Press, 2006.

2.=20 World Health Organization. Health-for-all Policy for the = Twenty-First=20 Century (Document EB101/INF. DOC./9). Geneva: WHO, 1998.

3.=20 Edworthy SM. Telemedicine in developing countries. BMJ 2001;=20 323: 524=965.

4.=20 Zhao Y, Nakajima I, Juzoji H. On-site investigation of the early phase = of Bhutan=20 Health Telematics Project. J Med Syst 2002; = 26:=20 67=9677.

5.=20 Einterz EM. Telemedicine in Africa: potential, problems, priorities.=20 CMAJ 2001; 165: 780=961.

6.=20 Fraser HS, McGrath SJ. Information technology and telemedicine in = sub-Saharan=20 Africa. BMJ 2000; 321: 465=966.

7.=20 Groves T. SatelLife: getting relevant information to the developing = world.=20 BMJ 1996; 313: 1606=969.

8.=20 Kastania AN. Telemedicine models for primary care. Stud Health = Technol=20 Inform 2004; 104: 89=9698.

9.=20 Wootton R. The possible use of telemedicine in developing countries. = J=20 Telemed Telecare 1997; 3: 23=966.

10. Wootton = R.=20 Telemedicine and developing countries =96 successful implementation will = require a=20 shared approach. J Telemed Telecare 2001; = 7(Suppl 1):=20 1=966.

11. Vassallo = DJ,=20 Swinfen P, Swinfen R, Wootton R. Experience with a low-cost telemedicine = system=20 in three developing countries. J Telemed Telecare 2001;=20 7(Suppl 1): 56=968.

12. = Patterson V, Hoque=20 F, Vassallo D et al. Store-and-forward teleneurology in developing = countries.=20 J Telemed Telecare 2001; 7(Suppl 1): = 52=963.

13. Latifi = R, Muja S,=20 Bekteshi F, Merrell RC. The role of telemedicine and information = technology in=20 the redevelopment of medical systems: the case of Kosova. Telemed J = E=20 Health 2006; 12: 332=9640.

14. Lee S, = Broderick=20 TJ, Haynes J et al. The role of low-bandwidth telemedicine in surgical=20 prescreening. J Pediatr Surg 2003; 38: = 1281=963.

15. Person = DA, Hedson=20 JS, Gunawardane KJ. Telemedicine success in the United States Associated = Pacific=20 Islands (USAPI): two illustrative cases. Telemed J E Health = 2003;=20 9: 95=96101.

16. Graham = LE,=20 Zimmerman M, Vassallo DJ et al. Telemedicine =96 the way ahead for = medicine in the=20 developing world. Trop Doct 2003; 33: = 36=968.

17. Qaddoumi = I,=20 Mansour A, Musharbash A et al. Impact of telemedicine on pediatric=20 neuro-oncology in a developing country: the Jordanian=96Canadian = experience.=20 Pediatr Blood Cancer 2007; 48: 39=9643.

18. Medical = Missions=20 for Children. Global Telemedicine and Teaching Network. = Available at:=20 www.mmissions.org/index.html.

19. Medical = Missions=20 for Children. List of Countries Aided by MMC=92s Telemedicine Outreach = Program.=20 Available at: www.mmissions.org/top/countries.html.

11 Telementoring in India: Experience with = endocrine=20 surgery

Saroj K Mishra, Puthen V Pradeep and Anjali=20 Mishra

Introduction

Telementoring =96 mentoring through the use of = telecommunication=20 =96 provides access to more experienced staff. This is an application of = tele-education in general. In surgery, telementoring allows a remotely = located=20 surgeon to obtain the help of centrally located, more experienced = surgeons in=20 performing complicated procedures. This may occur before, or even = during,=20 surgery, when expert advice can improve intraoperative decision = making.

Intraoperative assistance has been described by = several=20 authors.1,2 At = the Sanjay=20 Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS) in Lucknow, = we have=20 developed telementoring further, so that a mentor=92s input is = continuously=20 provided for the overall clinical care of the patient, to assist in = diagnosis,=20 preoperative treatment planning and postoperative care.3 = Telementoring=20 has been incorporated into the training and teaching programme of the = Department=20 of Endocrine Surgery at the SGPGIMS. This department is one of only two = in India=20 that provide curriculum-based training in this relatively new = subspecialty.=20 Hence, the short-course training given in house to general surgeons is = further=20 consolidated with telementoring. This model may be relevant to other = developing=20 countries where there is a shortage of staff in certain = subspecialties.4,5

Telemedicine in India

Public health care in India is primarily a = responsibility of=20 the state or province. The health system has a three-tiered structure: = the=20 primary health care centres cover a group of villages, secondary level = health=20 centres are at district level and medical colleges, located in big = cities,=20 provide tertiary care. Private sector hospitals account for almost 60% = of health=20 care.

Both government and private agencies have begun = telemedicine=20 projects. Government agencies that support these activities are the = Indian Space=20 Research Organization (ISRO), the Department of Information Technology, = the=20 Ministry of Communications and IT, the Department = of Science=20 and Technology, and the Ministry of Defence. In addition, self-funded = activities=20 are being carried out by various corporate hospitals. A few mobile = telemedicine=20 units using satellite connectivity provided by ISRO have been introduced = for=20 community ophthalmology care. At present, ISRO=92s telemedicine network = consists=20 of about 200 nodes spread across the country.

The Department of Information Technology has produced = guidelines=20 and standards for the practice of telemedicine in India, which are aimed = at=20 enhancing interoperability among the various telemedicine systems being = set up=20 in the country.6 This = document=20 aims to streamline the establishment of telemedicine centres and to = standardize=20 services available from different telemedicine centres. In addition to=20 suggesting standards for various equipments needed for setting up = telemedicine=20 centre, it also provides guidelines for conducting telemedicine=20 interactions.

The Ministry of Health and Family Welfare has recently = launched=20 two national projects. The first is oncoNET India, which will connect 25 = regional cancer centres with four peripheral medical colleges/hospitals = each,=20 creating a network of about 100 telemedicine nodes exclusively for = cancer care.=20 The second is the Integrated Disease Surveillance Project, in which all = the=20 district hospitals in India will be networked with regional medical = colleges.=20 The object is to improve surveillance of diseases of public health = importance=20 and to deliver continuous professional education of peripheral health = care=20 staff. A national task force on telemedicine has been working under this = ministry for over two years in formulating policies to facilitate the = growth and=20 integration of telemedicine into health care.7 = During the=20 government=92s next five-year plan, it is expected that new telemedicine = projects=20 will be introduced based on an evaluation of existing telemedicine = projects.

SGPGIMS infrastructure

In 1999, the Department of Endocrine Surgery at the = SGPGIMS=20 started experimenting with the use of videoconferencing to deliver = education to=20 a remote medical college. This followed a successful trial of multisite=20 videoconferencing of a four-day postgraduate course in endocrine surgery = and a=20 workshop on minimally invasive endocrine surgery. Endocrine surgery, as = a=20 subspecialty of surgery, is not well developed in India. To facilitate = knowledge=20 exchange across the country, the department carried out a technical = trial.=20 Gradually, the educational interest expanded to include remote health = care=20 delivery. More projects began, and the telemedicine infrastructure grew. = Currently, the infrastructure at the SGPGIMS telemedicine centre = consists of=20 several telemedicine workstations, equipped with teleradiology, = pathology and=20 videoconferencing units with large display devices. It can carry out = medical=20 data transfer and videoconferencing with six remote locations=20 simultaneously.

The equipment used for telemedicine includes = multimedia PCs with=20 43 cm monitors, as well as studio-type videoconference systems with = flat-panel=20 74 cm television screens. Peripherals include an X-ray digitizer and a=20 trinocular microscope with digital camera attachment. Initially, the=20 connectivity was through a 128 kbit/s ISDN line. Subsequently, = satellite-based=20 connectivity with a 384 kbit/s bandwidth was obtained from=20 ISRO. There is one Ku-band demand = assigned multiple=20 access (DAMA) and an extended C-band very small aperture terminal = (VSAT).

The telemedicine centre at the SGPGIMS uses various = modules in=20 telemedicine care (teleconsultation, tele-follow-up, pre-referral = screening,=20 treatment planning and telementoring), distant medical education and = remote=20 assistance in skill development of health care professionals, as well as = research and development in the field of tele-medicine.8 All=20 telemedicine sessions are real-time.

Partners

The SGPGIMS telemedicine network partners are both = national=20 and international. National partners are listed in Table = 11.1.

The international partners are Ranguil University, = Toulouse,=20 France and the Holy Family Hospital, Rawalpindi, Pakistan. Both of the = overseas=20 centres are connected with 384 kbit/s ISDN.

The technical partners are ISRO, the Centre for = Development of=20 Advanced Computing (CDAC), Pune and Mohali, and the Online Telemedicine = Research=20 Institute (OTRI), Ahmedabad.

Currently, the Orissa Telemedicine Network project is=20 operational and the Uttaranchal network is in the implementation phase. = A=20 network involving eight medical colleges in Uttar Pradesh is being = designed.

Telementoring and tele-education at the=20 SGPGIMS

The first successful telementoring session was = conducted in=20 2004, when a parathyroid tumour removal was performed at the Amrita = Institute of=20 Medical Sciences under expert guidance from the SGPGIMS. There had been = two=20 previous unsuccessful attempts at tumour removal by the same surgeon in = 2001.=20 This experiment was the

Table 11.1 National = telemedicine=20 partners of the SGPGIMS
Institution	Location	Distance from Lucknow = (km)
All three medical colleges of the state of = Orissa	Cuttack, Berhampur and Burla	1500
Two district hospitals of Uttaranchal = State	Almora and Srinagar	500
All India Institute of Medical = Sciences	New Delhi	700
Postgraduate Institute of Medical Sciences and = Research	Chandigarh	500
Amrita Institute of Medical Sciences	Kochi, Kerala	2500
Christian Medical College	Vellore, Tamil Nadu	2000
Rohtak Medical College	Rohtak, Haryana	550

first of its kind reported from India.5,9 The = patient=20 benefited, since he had the operation performed locally, without having = to=20 travel to a distant specialist centre. In fact, the general condition of = this=20 patient was so poor that he could not have travelled to the specialist = endocrine=20 surgical unit. For the telementoring session, both institutions were = provided=20 with dedicated 512 kbit/s VSAT connectivity. Video and audio quality was = good=20 enough for the expert at the SGPGIMS to guide the remote team=20 satisfactorily.

We have also used telementoring as a tool in = subspecialty growth=20 in general4 and = in=20 reinforcing endocrine surgical training.5 This has been done to meet local = requirements,=20 since there is a lack of specialist endocrine surgical centres in India. = As far=20 as structured endocrine surgical training is concerned, only two centres = in=20 India provide the MCh (Master of Surgery) degree. They have an annual = intake of=20 three candidates. In addition to the MCh training, short-course training = (1=963=20 months) is also provided by the department at the SGPGIMS. The = short-course=20 training is reinforced by the use of telemedicine. During a short = training post=20 of three months, the trainees rotate through clinical and laboratory = services=20 and attend all the academic sessions conducted by the department. = Following=20 their return to their parent institute, telementoring is used to monitor = their=20 endocrine surgical practice and to guide them in solving diagnostic = problems, in=20 treatment planning and postoperative care.5 The trainees also receive mentoring = from experts=20 in associated specialties such as nuclear medicine, endocrine pathology = and=20 interventional radiology.5

The tele-CME (continuing medical education) programmes = conducted=20 by the Department of Endocrine Surgery at the SGPGIMS are regularly = transmitted=20 to these trainee locations so that they receive updates on recent=20 developments.10 Table 11.2 = shows the=20 details of the tele-CME transmitted to the medical college in Cuttack, = where two=20 of the short-term trainees are currently located.

The trainees also consult their mentors at the SGPGIMS = in=20 discussing complex endocrine surgical problems, treatment planning,=20 intraoperative and postoperative consultation, and follow-up plan. Figure 11.1 = shows the=20 numbers of such sessions held from 2001 to 2007. Figure 11.2 = shows a=20 tele-CME and a tele-education session in progress.

The benefit of telementoring and tele-education is = that the=20 trainees are able to manage many of the common endocrine surgical = diseases=20 without referring them to the SGPGIMS.5 The added confidence due to the = continuous=20 presence of the mentor

Table 11.2 Conferences, CME = and=20 workshops held
	Year	No. of hours=20 of transmission
5th Postgraduate Course in Endocrine Surgery = (5=20 days)	2001	37
6th Postgraduate Course in Endocrine Surgery = (5=20 days)	2003	40
Indian Thyroid Society Conference	2004	9
7th Postgraduate Course in Endocrine Surgery = (5=20 days)	2005	36
8th Postgraduate Course in Endocrine Surgery = (5=20 days)	2007	34

3DImage=20

Figure 11.1 Number of telemedicine = sessions=20 held per year for reinforcement of training

3DImage=20

Figure 11.2 (a) Tele-CME session in=20 progress

3DImage=20

Figure 11.2 (b) Tele-education = session in=20 progress

increases their output in terms of the range of = endocrine=20 surgical procedures performed and reduces the complication rates.5

Although our initial experience has been successful, = there is a=20 need to develop standards and an accreditation system to facilitate = general=20 adoption of the techniques. The government has now set up a national = task force=20 for telemedicine that is going to address these matters.

Other telementoring and tele-education in=20 India

There are few reports of telementoring in medicine = from other=20 centres in India. However, some institutions, such as the All India = Institute of=20 Medical Sciences and the Apollo Telemedicine Centre, are involved in=20 telementoring experiments (personal communications). The 50-bed hospital = at=20 Aragonda, Andhra Pradesh (in the southern part of India) receives = guidance for=20 managing its patients from the specialists at the Apollo hospitals in = Chennai or=20 Hyderabad. Under expert guidance from specialists at Chennai, the Apollo = Telemedicine Centre at Aragonda has also helped primary care physicians = in=20 making decisions about complex neurosurgical cases and treating certain = minor=20 problems locally without referring them to the tertiary centre at = Chennai.11

Telementoring and tele-education in = other
developing=20 countries

Telemedicine has increasingly been used to solve = certain=20 health care problems faced by the developing world, but there is a = paucity of=20 published reports. This is especially true regarding telementoring. = Until the=20 number of publications increases, it will be difficult to=20 judge the true extent of telemedicine applications being carried out in = the=20 developing world.12

Publications in the field of telementoring in = endocrine surgery=20 from the developing world are very few in number. Even though there is = paucity=20 of telementoring applications in the field of endocrine surgery in = developing=20 countries, there are reports in other specialties. Lee et al13 = reported=20 telementored laparoscopic varicocelectomy and nephrectomy in Bangkok, = Thailand,=20 which was 17 500 km from the mentoring location at the Johns Hopkins = Hospital in=20 Baltimore, USA. This experiment was conducted using ISDN lines at a = bandwidth of=20 384 kbit/s. The authors concluded that transfer of knowledge and=20 teaching=96learning were achieved and that the video pictures = transmitted had=20 acceptable resolution and clarity. Similarly, transcontinental = telementored=20 procedures (laparoscopic bilateral varicocelectomy and a percutaneous = renal=20 access for a percutaneous nephrolithotomy) were carried out in = collaboration=20 between surgeons in Baltimore and Sao Paulo and Recife in Brazil.14

Telementoring has been conducted using low-bandwidth = mobile=20 telemedicine applications to support a mobile surgery programme in rural = Ecuador.15 = This=20 involved a mobile operating room, which was taken to a remote region of = Ecuador=20 (see Chapter = 18). Using=20 a laptop computer equipped with telemedicine software, a = videoconferencing=20 system and a digital camera, surgical patients were evaluated and = operative=20 decisions were made via ordinary telephone lines. The surgeons in the = mobile=20 unit in Ecuador were telementored by an experienced surgeon located at = Yale=20 University in the USA. Apart from five preoperative evaluations, a = laparoscopic=20 cholecystectomy was successfully telementored from the Department of = Surgery at=20 Yale University School of Medicine to the mobile surgery unit in = Ecuador. The=20 use of real-time surgical telementoring to teach complex = ophthalmological=20 procedures was successfully performed in real time via an ISDN line at a = bandwidth of 128 kbit/s from the Saint Francis Medical Centre in = Honolulu,=20 Hawaii, to ophthalmologists at the Makati Medical Center in Manila, = Philippines,=20 more than 8000 km away.16

Telemedicine has also been used asynchronously=20 (store-and-forward) for consultations and patient management by = practitioners at=20 remote location. Vassallo et al17 = reported the=20 establishment of a telemedicine link by the Swinfen Charitable Trust in = July=20 1999, to support a lone orthopaedic surgeon practising in Savar, near = Dhaka,=20 Bangladesh. Evaluation of the telemedicine-based advice for 27 referrals = revealed it to be useful and cost-effective (see Chapter 19).

A trial telemedicine system to facilitate consultation = between=20 medical students pursuing elective study at a remote location in the = developing=20 world and specialists at a central location was established between Gizo = Hospital in the Solomon Islands and Emory University Hospital in = Atlanta, USA. A=20 visiting medical student used this facility to relay images and = investigation=20 reports to specialists in Atlanta. This was used for telemedicine-aided=20 learning, thus providing expert support to medical students in remote=20 locations.18 A = pilot=20 study at the Patan Hospital, Kathmandu, Nepal by the Swinfen Charitable = Trust=20 has shown that a low-cost telemedicine link is technically feasible and = can be=20 of significant benefit for diagnosis, management and telemedicine based=20 education in a developing world setting.19 = Remote=20 monitoring of paediatric patients at the Children=92s Field Hospital in = Gudermes,=20 Chechnya, not only allowed significant number of = patients to=20 be treated locally but also enabled the doctors at the peripheral = location to=20 receive advice about operative techniques20 = (see Chapter 25).

Problems concerning telementoring and = tele-education
in=20 developing countries

Common health care delivery problems faced by = developing=20 countries are infrastructural and organizational in nature. = Infrastructural=20 problems include unreliable electricity supplies, poor telephone = services, lack=20 of transport and lack of medical supplies. Organizational problems = include a=20 lack of CME for health staff, poor training and supervision of health = care=20 workers, shortage of doctors and health care workers, and too many = patients.=20 Telemedicine may be useful in assisting with many of these difficulties. = The=20 major challenges with telemedicine in developing countries are = unrealistic=20 expectations, unsustainable funding models, lack of trials and = evaluation data,=20 and lack of published results and sharing of expertise.

During the audit of the telemedicine programmes at the = SGPGIMS=20 (2001=962005), it was found that only 61% of the scheduled sessions were = held=20 successfully, i.e. 39% of sessions could not be conducted owing to = technical or=20 human resource problems. Technical problems (23%) included power failure = at the=20 remote end, disconnection of the VSAT link and shifting of the VSAT = service=20 (Indian National Satellite System) to a new transponder. Human resource = problems=20 (77%) included non-availability of doctors at the expert end (36%) or at = the=20 remote end (35%), non-availability of technical staff at the remote end = (7%) and=20 others.21

The legal and ethical barriers that are commonly cited = in=20 telemedicine generally are also relevant in developing countries. These = include=20 questions about medicolegal liability and recommendations for good = clinical=20 practice, for which guidelines and protocols are still evolving. This is = especially true for cross-border practice.22 = Other=20 concerns include standards, interoperability, product liability, = intellectual=20 property rights and sharing of health information. Ethical and political = matters=20 need to be addressed.23

At present, professional boundaries are definitely = barriers to=20 the practice of telementoring both within and between countries. This = may be=20 assisted by national health care regulatory bodies or by international = agencies=20 such as the World Health Organization, which in consultation with its = member=20 countries has the potential to develop a global regulatory framework. In = the=20 meantime, accreditation of telementoring-based programmes needs to be = carried=20 out by appropriate agencies in each country or at a global level.=20 Standardization of equipment, networks, technique, professional = competence and=20 process needs to be worked out. Legal questions regarding the sharing of = responsibility as a result of the consequences of actions taken during=20 telementoring must be addressed. There are as yet no guidelines on these = matters. The health care regulatory body within each country needs to = develop=20 legislation for safe practice via telemedicine.

Conclusion

Telemedicine has the potential to improve the = utilization of=20 available resources for health care in developing countries. Our = experience in=20 the specialty of endocrine surgery in India has demonstrated the = effectiveness=20 of telemedicine applications in training, education and skills = development. We=20 have successfully used telementoring for continuous reinforcement of = endocrine=20 surgical training and also in the operating theatre for guided tumour = removal.=20 Even though telemedicine-enabled applications are being explored in = India and=20 other developing countries, few published reports have yet appeared. = Deploying=20 and sustaining telemedicine and telementoring requires the commitment = and=20 support of all those involved if success is to be achieved.

References

1.=20 Rosser JC, Wood M, Payne JH et al. Telementoring. A practical option in = surgical=20 training. Surg Endosc 1997; 11: 852=965.

2.=20 Bruschi M, Micali S, Porpiglia F et al. Laparoscopic telementored = adrenalectomy:=20 the Italian experience. Surg Endosc 2005; 19:=20 836=9640.

3.=20 Mishra SK, Mishra A, Pradeep PV. Telementoring in endocrine surgery. In: = Kumar=20 S, Marescaux J,eds. Telesurgery. Heidelberg: Springer-Verlag,=20 2008.

4.=20 Pradeep PV, Mishra A, Kapoor L et al. Surgical sub-specialty growth in=20 developing country: impact of telemedicine technology; a case study with = endocrine surgery. In: Proceedings of the 8th International = Conference on=20 E-Health Networking, Application and Services (Healthcom 2006), New = Delhi:=20 34=969.

5.=20 Pradeep PV, Mishra A, Mohanty BN et al. Reinforcement of endocrine = surgery=20 training: impact of tele-medicine technology in a developing country = context.=20 World J Surg 2007; 31: 1665=9671.

6.=20 Ministry of Communications and Information Technology. Recommended=20 Guidelines & Standards for Practice of Telemedicine in India. = Available=20 at:=20 www.mit.gov.in/telemedicine/Report%20of%20TWG%20on%20Telemed%20Standardis= ation.pdf.

7.=20 Mishra SK, Gupta SD, Kaur J. Telemedicine in India: initiatives and = vision. In:=20 Proceedings of the 9th International Conference on E-Health = Networking,=20 Application and Services (Healthcom 2007), 19=9622 June, Taipei, = Taiwan:=20 81=963.

8.=20 SGPGI. Telemedicine. Available at: www.sgpgi-telemedicine.org.

9.=20 Pradeep PV, Mishra SK, Vaidyanathan S et al. Telementoring in endocrine = surgery:=20 preliminary Indian experience. Telemed J E Health 2006;=20 12: 73=967.

10. Pradeep = PV, Mishra=20 A, Kapoor L et al. Applications of tele-health technology in endocrine = surgery:=20 Indian experience. In: Proceedings of the Telemedicine 2007 = Conference,=20 31 May=961 June 2007, Montreal, Canada.

11. = Ganapathy K.=20 Telemedicine and neurosciences in developing countries. Surg = Neurol=20 2002; 58: 388=9694.

12. Wootton = R.=20 Telemedicine and developing countries =96 successful implementation will = require a=20 shared approach. J Telemed Telecare 2001; = 7(Suppl 1):=20 1=966.

13. Lee BR, = Bishoff J=20 T, Janetschek G et al. A novel method of surgical instruction: = international=20 telementoring. World J Urol 1998; 16: = 367=9670.

14. = Rodrigues Netto N=20 Jr, Mitre AI, Lima SV et al. Telementoring between Brazil and the United = States:=20 initial experience. J Endourol 2003; 17: = 217=9620.

15. Rosser = JC Jr, Bell=20 RL, Harnett B et al. Use of mobile low-bandwith telemedical techniques = for=20 extreme telemedicine applications. J Am Coll Surg 1999;=20 189: 397=96404.

16. Camara = JG,=20 Rodriguez RE. Real-time telementoring in ophthalmology. Telemed = J 1998;=20 4: 375=967.

17. Vassallo = DJ,=20 Swinfen P, Swinfen R, Wootton R. Experience with a low-cost telemedicine = system=20 in three developing countries. J Telemed Telecare 2001;=20 7(Suppl 1): 56=968.

18. Mukundan = S Jr,=20 Vydareny K, Vassallo DJ et al. Trial telemedicine system for supporting = medical=20 students on elective in the developing world. Acad Radiol 2003; = 10: 794=967.

19. Graham = LE,=20 Zimmerman M, Vassallo DJ et al. Telemedicine =96 the way ahead for = medicine in the=20 developing world. Trop Doct 2003; 33: = 36=968.

20. Ehrlich = AI,=20 Kobrinsky BA, Petlakh VI et al. Telemedicine for a children=92s field = hospital in=20 Chechnya. J Telemed Telecare 2007; 13: = 4=966.

21. Kapoor = L, Basnet=20 R, Chand RD et al. An audit of problems in implementation of = telemedicine=20 programme. In: Proceedings of the 9th International Conference on = E-health=20 Networking, Application and Services, 19=9622 June 2007, Taipei, = Taiwan:=20 87=969.

22. = Stanberry B. Legal=20 and ethical aspects of telemedicine. J Telemed Telecare 2006;=20 12: 166=9675.

23. Kapoor = L, Basnet=20 R, Pradeep PV et al. Integrating telemedicine in surgical applications.=20 Comput Soc India Commun 2007; 30: = 17=9620.

SECTION 4
CLINICAL

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12 Teledermatology in developing = countries

Steven Kaddu, Carrie Kovarik, Gerald Gabler = and H Peter=20 Soyer

Introduction

The inherent visual nature of dermatology makes it = suitable=20 for telemedicine. Several teledermatology projects have recently been = initiated=20 in developing countries, and the number is gradually increasing.1=967 = Preliminary=20 results underline a number of potential benefits to patients, remote = health care=20 workers and health care systems of host countries. These benefits (Box 12.1) = include easy=20 extension of specialized dermatological services to geographically = remote areas=20 with few dermatologists, reduction of patients=92 waiting time for = appointments,=20 faster screening for skin diseases, promotion and coordination of = scientific=20 health projects, and education of health workers and lay people.1=966,8 = Local=20 physicians benefit from the mentoring and educational aspects of the=20 consultations, as well as the access to improved research facilities and = professional

Box 12.1 Potential benefits = of=20 teledermatology

Benefits to = patients

= Enhanced=20 access to a trained dermatologist

= Prompt=20 specialist opinion, leading to more accurate diagnosis and = treatment=20 outcomes

= Reduction of=20 patient=92s waiting time

= Reduction of=20 travel expenses

Benefits to local health care=20 workers

= Improved and=20 efficient access to specialized dermatology care

= Improved=20 management of patients with skin problems

New=20 opportunities for continued medical education

= Enhanced=20 professional collaboration

= Enhanced=20 collaboration in research

= Access to=20 online atlases and databases

More = efficient=20 screening of patients with skin problems

= Better=20 follow-up of patients with selected skin problems

Benefits to local health care=20 system

= Reduction in=20 health care costs

= Reduction in=20 patient=92s and physician=92s travel costs

= Reduction in=20 total number of hospital admissions, as well as faster=20 discharges

= Increase=20 efficiency in the use of human resources

= Increased and=20 effective support for local health professionals

= Compilation of=20 online databases

interactions. Consulting experts also get special=20 opportunities to review rare or unusual dermatological cases.

As in other telemedicine systems, teledermatology = employs both=20 store-and-forward methods (asynchronous) and real-time approaches=20 (synchronous).9 Both = modalities have previously been shown to be quite reliable and accurate = when=20 compared with traditional face-to-face consultation.9=9613=20 Store-and-forward systems are more widely used, owing to their lesser=20 technological requirements and affordability. Images are submitted by = email or=20 presented on a web-based system. Although the real-time approach = represents a=20 reasonable substitute for in-person consultation and has the advantage = of=20 enhancing patient=96doctor interaction, it is more time-consuming and=20 expensive.

Teledermatology may involve providing assistance, = follow-up or=20 teaching. Tele-assistance models aim at teleconsultation, telescreening = and/or=20 second opinion.7,14 = The majority=20 of teledermatology projects in developing countries deal with = dermatology=20 consultations. Telescreening projects have been used to manage waiting = lists for=20 treatment of dermatoses with different healing times or to support = prevention=20 programmes such as those surveying skin tumours.15=20 Telefollow-up systems deal with transmission of medical information = regarding=20 follow-up and treatment progression of patients from remote centres = (e.g. to=20 follow up patients treated for certain chronic skin conditions such as = leg=20 ulcers and leprosy) and for postoperative evaluation.5,16=20 Tele-education is proving to be a versatile model, helpful in staff = development=20 such as by tutoring and assessing medical and paramedical workers.7 Most = teledermatology collaborative projects also involve some degree of=20 tele-education in addition to tele-assistance. Thus, in addition to=20 long-distance consultation, they also provide continuing medical = education (CME)=20 for physicians who submit cases. Applications for tele-education mainly=20 integrate text and images (static or dynamic) and/or virtual reality = models to=20 achieve health education.

The use of web applications for discussion forums = represents=20 another application of teledermatology. The main objective of such = applications=20 is to create a quick and easy method for teleconsultation from a pool of = expert=20 consultants. The philosophy behind these =91DermOnline=92 communities is = open access=20 teleconsultation in dermatology, which means that these platforms are = free to=20 all users and that the users themselves generate the content by sending = and=20 answering the teleconsultations. These communities have moderators who = check=20 both the subscribers and the content of the requests in order to = guarantee=20 friendly and orderly virtual interaction.

Teledermatology in developing = countries

There are several teledermatology networks and = projects in=20 developing countries.

The telederm.org application and=20 networks

The telederm.org application was = initiated by=20 the Department of Dermatology of the Medical University of Graz, = Austria, in=20 2002. The primary goal was to develop a software = application=20 that would facilitate worldwide exchange of knowledge and expertise in=20 dermatology and dermatopathology. The application is now used by several = teledermatology networks, some of which are active in developing = countries,=20 including the telederm.org project and the = Africa=20 Teledermatology Project.7,17=9619 = Versions of=20 the application are available in German, Italian, Chinese, Turkish = languages,=20 Serbian and Hebrew.

The program provides the functionality to store and = forward=20 medical cases with attached images. Within a particular network, users = are=20 categorized as either clients or experts. Clients can only submit cases = to=20 selected experts, whereas experts have the right to review cases, write = comments=20 and suggest a diagnosis, or further forward cases to other selected = experts=20 within the system (Figure 12.1). = All users=20 can subscribe for notifications so that they get an automatic email if, = for=20 example, a new comment is added to one of their cases or if a new case = is=20 entered on the site. Every network has at least one administrator who is = able to=20 register users and/or reassign consultations to preferred experts.

3DImage=20

Figure 12.1 Africa Teledermatology = project=20 data flow

All requests are archived in a database with a = personal archive=20 for each user. A client can choose to send a request for consultation = only to a=20 selected expert, or he or she can submit a request to an open forum as a = =91discussion case=92. In the former situation, the user receives a = personal answer=20 and interactions remain private. Cases submitted as =91discussion = cases=92 are=20 visible to all users, who can review the cases and submit on-line = opinions.

The telederm.org = project

This teledermatology network was initiated in April = 2002 with=20 the aim of creating an easy-to-use platform for teleconsultation = services where=20 physicians could seek diagnostic advice in dermatology from a pool of = expert=20 consultants and discuss challenging cases.18 An = online=20 discussion forum was included in October 2003. At present, more than = 1300=20 physicians are subscribed to the telederm.org project from over = 90=20 countries worldwide. Through this application, participants from = different=20 medical specialties are matched with dermatologists with a range of = experience=20 in diagnosis and management of various skin diseases. By providing a = platform=20 for interactive discussion between physicians at the point of care and = experts=20 from different countries, the telederm.org project seeks to = raise the=20 level of competence of physicians and dermatologists at the point of = care on a=20 worldwide level.

The telederm.org project is a = non-profit=20 venture under the auspices of the International Society of = Teledermatology. The=20 main academic institutions involved are the Department of Dermatology, = Medical=20 University of Graz, Graz (Austria) and the Dermatology Group, School of=20 Medicine, University of Queensland, Brisbane (Australia). Moderators of = the=20 telederm.org=20 community come from a range of different countries, including Turkey, = Croatia,=20 Romania, China, Pakistan, USA and India. The telederm. org project has = 1024=20 users, with an average of 38 new users per month. It handles about 27 = new cases=20 per month.

The Africa Teledermatology project

The Africa Teledermatology project20 = was=20 initially conceived as the =91Uganda Tele-Dermatology- and = E-Learning-Project=92 in=20 February 2007, with sponsorship from the Kommission f=FCr = Entwicklungsfragen (KEF)=20 der =D6sterreichischen Akademie der Wissenschaften. Its main objective = was to=20 facilitate improvement of the treatment of skin diseases in Uganda by=20 establishing an Internet channel for long-distance dermatological = consultation=20 between the medical Universities of Makerere and Mbarara in Uganda and = the=20 Department of Dermatology, University of Graz. In collaboration with the = Department of Dermatology at the University of Pennsylvania, USA, the = scope of=20 the project was expanded, with the eventual inclusion of a number of = other=20 medical centres in eastern, central and southern Africa, which led to = the=20 formation of the Africa Teledermatology project. The main purpose of = this work=20 is to support African health workers in the diagnosis and management of = patients=20 with skin diseases, especially those having skin conditions related to=20 HIV/AIDS.

The Africa Teledermatology project uses the telederm.org = application=20 (Figure = 12.2). There=20 are links on the application homepage to educational resources and a = dermatology=20 curriculum. An online archive of tropical skin conditions should = emerge

3DImage=20

Figure 12.2 Dematologists and = medical staff at=20 Mbarara university hospital, Uganda selecting and processing difficult = cases of=20 skin diseases for teleconsultation

that will serve as an Internet source of educational = material=20 for training and updating of medical specialists and health personnel. A = secondary goal of the project is to establish a platform for dermatology = research collaboration. The ultimate objective is the integration of the = various=20 aspects of teledermatology and teledermatopathology into health care = systems of=20 developing countries.

In the first 12 months, 160 teledermatology-supported = patient=20 encounters have been processed. Of these, 35% of cases were children and = 25%=20 represented HIV-associated skin conditions. A number of Internet = learning=20 facilities for medical personnel have been set up on the project = website,=20 including an online case presentation with discussion, dermatology = lectures and=20 an international forum of physicians with an interest in tropical = dermatology.=20 Through this initiative, scientific cooperation has been established = with a=20 number of specialists from well-known medical/dermatology centres = worldwide, who=20 have contributed their experience in management of difficult skin = conditions=20 submitted by colleagues in Africa.

iPath application and = networks

The iPath software was developed by the Department = of=20 Pathology of the University Hospital Basel as an open source framework = for=20 building web- and email-based tele-medicine applications.21=9623 = iPath=20 provides the functionality to store medical cases with attached images = and other=20 documents in closed user groups. Within these groups, users can review = cases,=20 suggest diagnoses and submit comments. In addition, users can subscribe = for=20 notifications so that they receive an automatic email message if, for = example, a=20 new comment is added to one of their cases or if a new case is entered = in a=20 group. All users are organized into one or more discussion groups. Every = discussion group has at least one moderator who can assign other users = to the=20 group and who can delete erroneous data.

At present, iPath hosts several telemedicine networks = active in=20 developing countries, several of which involve teledermatology. These = include=20 the following.

Solomon Islands National Telemedicine = Network

This is a joint project of the National Referral = Hospital in=20 Honiara, South Pacific Medical Projects and the University of Basel.24 It = aims to=20 use telemedicine to improve health care delivery in provincial hospitals = in the=20 Solomon Islands. There is special emphasis on the fields of dermatology, = radiology, orthopaedics and paediatrics.

LT Telepatologija

This is regional network of pathologists and other = medical=20 specialists in the Baltics, based on the iPath platform.25 = Its purpose=20 is to support clinicopathological case discussions, consultations and = CME.

RAFT-Forum (telemedicine platform of the R=E9seau = de=20 T=E9l=E9-enseignement et de T=E9l=E9m=E9decine en Afrique = Francophone)

The main activity of this forum is the webcasting of = interactive courses for physicians and other health care workers in=20 French-speaking countries of Africa, including Mali, Mauritania, = Senegal,=20 Morocco, Tunisia and Madagascar.26 = The main=20 goal is to encourage knowledge sharing across = medical=20 institutions in the various participating countries. Topics for = discussion are=20 proposed by the partners of the network. The technology used for the = webcasting=20 works with an Internet connection, a Java-enabled web browser (e.g. = Internet=20 Explorer or Mozilla) and the free software RealPlayer.

Telemedicine Sur

This is a telemedicine platform for medical = discussions, CME=20 and consultations for medical specialists and health practitioners in = Latin=20 America.27 = Specialties=20 involved include mainly pathology, dermatology and venereology, as well = as=20 paediatrics.

West Africa Doctors and Healthcare Professionals=20 Network

This is a West African telemedicine network, again = based on=20 the iPath software.28 = Its goal is=20 to enhance the communication capabilities of doctors, particularly in = the areas=20 of information access, distance learning (CME), telemedicine- and=20 knowledge-based support of diagnosis, and management of patients in = various=20 specialties.

HealthNet Nepal

This is a health information and communication = network in=20 Nepal that provides low-cost email, Internet access and a wide range of = medical=20 and public health resources to the Nepalese health community.29 = The network=20 began in 1994, and is subscribed to by over 230 health institutions and=20 organizations, including hospitals, clinics, university departments, = research=20 sites and non-governmental organizations (NGOs) in both urban and rural = areas.=20 The network enables health professionals throughout Nepal to communicate = and=20 exchange knowledge.

Teledermatology project in Port St Johns, South=20 Africa

This project was initiated in 1999 at Port St Johns, = a small=20 and poor provincial town on the east coast of South Africa, with the aim = of=20 improving access to dermatological care for patients and family = practitioner=20 clinical skills.30,31 = The scope of=20 the project was to connect general practitioners from Port St Johns to a = network=20 with dermatology specialists. The project started with email-based=20 store-and-forward teledermatology, but, since 2002, it has been using = the iPath=20 software. In the first year, the server in Basel was used, but, since = 2003, the=20 project has been connected to a telemedicine network run by the = Telemedicine=20 Unit of the University of Transkei (UNITRA) in Umtata.

ITG telemedicine =96 the Institute of = Tropical Medicine=20 website

The project was begun in 2003 by the Department of = Clinical=20 Sciences at the Institute of Tropical Medicine, Antwerp, Belgium.32 = Its aim was=20 to facilitate the introduction of antiretroviral therapy (ART) for = patients=20 affected by HIV/AIDS in developing countries by providing training, = distance=20 support and education to health care providers working in these = settings. Advice=20 is given through email messages from a server list, and afterwards = through a=20 discussion forum on a telemedicine website. Details of the patient=92s = history,=20 physical examination, images, laboratory findings and questions to be = answered=20 have been received from a number of different countries.

Swinfen Charitable Trust

The Swinfen Charitable Trust was set up in 1998 by = Lord and=20 Lady Swinfen to =91assist poor, sick and disabled people in the = developing world=92=20 by providing access to expert medical advice from consultants all around = the=20 world.33 It = offers=20 provincial hospitals in developing countries the opportunity to submit = cases to=20 specialists worldwide. Communication is via a simple email telemedicine = system=20 using an automatic email messaging service developed by the Centre for = Online=20 Health at the University of Queensland, Brisbane, Australia. The core of = the=20 network is an automatic email routing system that directs the messages = about=20 each case to the parties concerned (i.e. the referring doctor and the=20 specialists being consulted). The Swinfen Charitable Trust has been able = to=20 establish telemedicine links between remote hospitals in the developing = world=20 with international medical consultants in order to receive advice free = of=20 charge. The remote hospitals and clinics are supplied with = high-resolution=20 digital cameras and tripods, and medical staff are taught how to use the = equipment. The Swinfen Charitable Trust operates in over 30 countries, = including=20 Afghanistan, Cambodia, East Timor, Iraq, Nepal, Papua New Guinea and Sri = Lanka,=20 and offers specialist advice in a wide range of fields including = dermatology,=20 dentistry, paediatrics, obstetrics and gynaecology, oncology, = orthopaedics,=20 ophthalmology, neurology, plastic surgery and trauma (see Chapter 19).

Teledermatology outcomes

There have been few previous studies focusing on=20 teledermatology outcomes, and these have mainly involved projects in=20 industrialized countries.34=9636 = Generally,=20 diagnostic accuracy and clinical effectiveness represent the most = popular=20 clinical outcome measures. The possible explanation for their repetitive = evaluation is the rapidly changing technology, especially that of the = digital=20 cameras used in teledermatology.

As far as developing countries are concerned, there = have not yet=20 been any large studies focusing on the clinical outcomes of = teledermatology,=20 despite general consensus supporting the increased diagnostic accuracy = and=20 clinical effectiveness possible using the technique. Problems in = assessment of=20 clinical outcomes in projects in developing countries include mainly = patient=20 loss to follow up and inadequate medical record systems, although = similar=20 problems may also apply to traditional face-to-face consultations in = this=20 setting.

The economic value, clinical benefits and = sustainability of=20 teledermatology in developing countries remain to be formally proved. = This is=20 primarily because evaluations of these economic outcomes require complex = analysis of the direct and indirect costs to national health providers = and=20 patients, as well as assessment of the impact of teledermatology = services on=20 earlier diagnosis and expert management.

Quality

A number of factors may lower diagnostic accuracy in = teledermatology. These include poor-quality images, insufficient = clinical=20 information supplied, intrinsic difficulties of cases=20 submitted, interference of technology in the perception of = three-dimensional=20 images, lack of ability to palpate or physically examine the patient, = and lack=20 of proper training of physicians who submit cases or who give opinions, = among=20 others. Poor-quality images may be of low resolution or may have a high = level of=20 compression. Clinical information may be confusing owing to image files = from=20 similar patients being separately sent or inconsistently coded. It is = necessary=20 that medical workers be adequately trained to take good images and = instructed=20 how to properly send cases before being involved in teledermatology = projects. It=20 is also advisable to include a link to working instructions on the = homepage of=20 teledermatology web applications; for example, see the Africa = Teledermatology=20 project website.20

Legal problems

The increasing availability of health information = about=20 individuals in electronic databases and through online networks has = offered=20 tremendous benefits to physicians, health care workers and patients. = However, it=20 has also created new legal challenges. There are presently extensive = discussions=20 concerning the potential risks and complex legal problems associated = with=20 telemedicine health care services provided to patients from remote = locations=20 using telecommunication. Legal problems relate generally to problems = concerning=20 the privacy of identifiable health information, and the reliability and = quality=20 of health data, as well as medical liability. Since telemedicine in = developing=20 countries is mainly practised across state borders, providers must be = aware of=20 the potential risks concerning medical liability in the respective = countries=20 where the patients are located. There is a need for developing countries = to=20 adopt rules and regulations to address legal aspects involved in the use = of=20 telemedicine in order to safeguard the rights of patients. Matters that = need to=20 be considered include mainly safeguards about data forwarding, security = of the=20 patient=92s data (including images), confidentiality and the = responsibilities of=20 health workers involved in telemedicine.

Generally speaking, local physicians are directly = responsible=20 for treatments deriving from teleconsultations in dermatology. The = medico-legal=20 position of remote expert dermatologists is similar to that when the = telephone,=20 fax, email or letter is used for consultation, since all these methods = amount to=20 the provision of advice from a distance, and normal standards of care = and skill=20 should therefore apply. In teledermatology, there is an obligation to = practise=20 to a reasonable level of skill. The referring doctor must give accurate = clinical=20 information and submit representative images of reasonable quality. = Complicated=20 treatment procedures recommended by remote experts need the patient=92s = permission=20 before being carried out.

Integration and intercultural = context

Preliminary studies have confirmed the feasibility = and=20 benefits of integrating teledermatology into the medical care systems of = developing countries. However, there are major challenges to = sustainability,=20 including political, economic, technical as well as cultural barriers. = Many=20 governments in developing countries are gradually recognizing=20 the potential of telemedicine to improve health care delivery and reduce = national health care budgets. Obviously, dermatology is not a main focus = of=20 government and NGO health policies in developing countries, since = available=20 resources are normally allocated to medical conditions with more serious = consequences, such as malaria, tuberculosis and HIV/AIDS rather than to=20 non-lethal skin disorders.

As a basis for introducing and sustaining = teledermatology=20 services in developing countries, it is crucial that the relevant = national=20 governments modernize internal communication in hospitals and remote = medical=20 centres. Internet services need to be widely accessible, even in rural = parts of=20 the developing world. The availability of email services in remote areas = has=20 potential benefits for poor countries. It is cheap, requires relatively = simple=20 hardware and software, and can easily deliver stored information. The = deployment=20 of fixed or mobile telecentres promises to be valuable in bringing = telemedicine=20 services to remote areas.

Cultural barriers may play a negative role in the = sustainability=20 of teledermatology programmes, and may be based on individual, = institutional or=20 societal attitudes. Individual patients may feel uncomfortable or refuse = to be=20 involved in teledermatology owing to a lack of trust in the ability of = the=20 technology to improve their health. This attitude may be based on = inadequate=20 information as a result of political and economic differences, cultural=20 attitudes, language barriers and differences in perceptions of =91health = and=20 wellness=92. Studies have shown that patients who are well acquainted = with=20 computers and the Internet tend to be more open to the use of = telemedicine.37 = There is a=20 need for proper explanation in advance, together with information for = patients=20 about teledermatology, such as what it is and what its benefits are, = before=20 patients are offered teledermatology.

Local physicians and health workers may also adopt a = negative=20 attitude to the use of teledermatology services for a number of reasons. = They=20 may be uncomfortable about sending consultations in English, feel that=20 teledermatology cannot improve the health of their patients, distrust = the safety=20 and privacy of the systems used, prefer the option of transferring = patients, or=20 feel that teledermatology services cannot lower their health care costs. = Moreover, because of the limited number of doctors in developing = countries,=20 local physicians and health workers may be concerned that = teledermatology=20 systems will be time-consuming and generate unnecessary extra work. It = is=20 therefore crucial that leaders at local hospitals and medical centres be = engaged=20 early enough in the process of introducing teledermatology services and = be made=20 aware of the potential and relative advantages of the technique. = Participating=20 local physicians and health workers should also receive comprehensive = education=20 and training packages, as well as support to improve their technical and = media=20 skills, prior to their involvement in teledermatology projects. It is an = advantage to add formal guidelines and protocols of instructions on the=20 homepages of web applications. In order to facilitate faster adoption, = local=20 health workers selected to participate in teledermatology projects = should=20 preferably have prior experience in the use of the Internet.

In summary, consideration of a range of economic, = political and=20 technical factors in the host country or institution during the planning = and=20 early stages of implementation of teledermatology projects should help = to ensure=20 the viability and sustainability, as well as the integration, of = teledermatology=20 programmes (Box=20 12.2).

Box 12.2 Practical steps in setting up = a=20 teledermatology project

1 Review prior telemedicine and = teledermatology=20 activities in the region of interest.

2 Assess current technologies and = telecommunications, as=20 well as human resources available.

3 Assess clinical, educational and = administrative needs=20 and priorities.

4 Assess the ability of teledermatology to = meet the=20 needs and willingness of health professionals to use the=20 technology.

5 Review the current policies (or lack of = policies) that=20 may affect the practice of teledermatology in both the remote = sites and=20 the referral centres.

6 Plan and distribute information and = educational=20 packages to all individuals potentially involved.

7 Find out about available technology and=20 telecommunications links at all potential sites, and make sure = that the=20 technology is available at remote sites.

8 Identify teledermatology technology that = best meets=20 the needs of the communities, technical requirements and security, = and is=20 compatible with the referral centres.

9 Establish contacts with potential remote=20 centres.

10 Establish a team of individual to help in = strategic=20 planning, implementation and evaluation of the initial phases of = the=20 project.

11 Contract and choose a vendor to install the = required=20 IT infrastructure at each of the remote sites.

12 Identify the telecommunications options and = work with=20 the vendor(s) to test and implement the preferred = option.

13 Educate and train potential users about the = teledermatology system and how to use it.

14 Educate and train potential technicians how = to repair=20 the technology

15 Educate the administrators/managers at the=20 teledermatology sites about how it may affect current = workflow.

16 Initiate and conduct a preliminary = evaluation of=20 design, implementation and technical performance, as well as = clinical=20 staff and patient satisfaction

17 Develop an ongoing education and training = programme=20 focused on individuals who are not part of the original=20 rollout.

Financial aspects

Most teledermatology activity in developing = countries=20 represents pilot projects receiving subsidized funding from external = governments=20 and NGOs, or from foreign universities and hospitals. There is very = little=20 available information concerning the cost-effectiveness and = sustainability of=20 these services. Economic analyses of the viability of teledermatology = projects=20 are also complicated owing to the rapidly declining cost of hardware and = telecommunications, and the presence of a number of hidden costs and = benefits,=20 such as the opportunity cost of a patient=92s time and the intangible = benefit of=20 an earlier correct diagnosis, which are hard to quantify. Nevertheless, = for the=20 adoption of teledermatology services in countries with low resources, it = is=20 necessary to obtain reasonable estimates of the financial consequences,=20 including the costs of implementation and subsequent operation. Proper = prior=20 financial planning will help to ensure success and sustainability.

Implementation expenses in teledermatology projects = mainly=20 comprise the costs for equipment (in a store-and-forward system, these = include=20 digital camera and accessories, computers, image editing programs, a = back-up=20 system and a printer), equipment maintenance, telecommunication and = staff=20 training. Sustainability expenses tend not to = depend on the=20 number of users/patients served. They include costs related to the = operation and=20 running of the project, acquiring the physical space, supplies and = travel.

Future developments

The number of medical centres using teledermatology = in=20 developing countries is increasing, and the technique could soon become = an=20 integral part of the health care system in some countries. Future = technical=20 developments may improve the delivery of teledermatology consultations = in=20 developing countries. For instance, the use of mobile phones with = built-in=20 cameras represents a potential alternative to bulky digital cameras and=20 computers in more remote areas.16,38,39=20 Teledermatopathology, a related field to teledermatology, could refine=20 dermatology teleconsultation by providing a channel for confirming = diagnoses as=20 well as for training and supervision and collaborative research. Until = now,=20 establishing teledermatopathology services has been mainly hampered by = the high=20 implementation costs.

There is an urgent need for physicians and health = policy makers=20 in the developing world to establish standards and regulations = concerning the=20 practice of telemedicine and teledermatology. Future studies should = define the=20 ethical, legal, economic and technical standards required of telemedical = referrals in individual countries that would ensure acceptance, economic = viability and effectiveness, as well as security, privacy and = confidentiality of=20 patients. Studies focusing on teledermatology outcomes should be = conducted to=20 confirm its clinical benefits and cost-effectiveness.

Finally, the global increase in the number of = teledermatology=20 networks implies a need to establish a common international = teledermatology=20 forum. Such a forum could serve to educate and assist users and policy = makers in=20 different parts of the developing and industrialized world on how to = optimize=20 teledermatology services, especially through identification of proven = low-cost=20 technology approaches.

References

1.=20 Schmid-Grendelmeier P, Masenga EJ, Haeffner A, Burg G. Teledermatology = as a new=20 tool in sub-saharan Africa: an experience from Tanzania. J Am Acad=20 Dermatol 2000; 42: 833=965.

2.=20 Schmid-Grendelmeier P, Doe P, Pakenham-Walsh N. Teledermatology in = sub-Saharan=20 Africa. Curr Probl Dermatol 2003; 32: = 233=9646.

3.=20 Caumes E, Le Bris V, Couzigou C et al. Dermatoses associated with travel = to=20 Burkina Faso and diagnosed by means of teledermatology. Br J = Dermatol=20 2004; 150: 312=9616.

4.=20 Fraser HSF, McGrath St JD. Information technology and telemedicine in = sub=20 Saharan Africa. BMJ 2000: 321; 465=966.

5.=20 Miot HA, Paix=E3o MP, Wen CL. Teledermatology =96 past, present and = future. An=20 Bras Dermatol 2005; 80: 523=9632

6.=20 House M, Keough E, Hillman D et al. Into Africa: the telemedicine links = between=20 Canada, Kenya and Uganda. CMAJ 1987 15; 136:=20 398=96400.

7.=20 First World Congress of Teledermatology and Annual Meeting of the = Austrian=20 Scientific Society of Tele-medicine, 9=9611 November 2006, Graz, = Austria.=20 Available at: www.teledermatology-society.org/worldcongress.

8.=20 Kristiansen IS, Poulsen PB, Jensen KU. Economic aspects =96 saving = billions with=20 telemedicine: fact or fiction? Curr Probl Dermatol 2003;=20 32: 62=9670.

9.=20 Eedy DJ, Wootton R. Teledermatology: a review. Br J Dermatol = 2001;=20 144: 696=96707.

10. Du = Moulin MF,=20 Bullens-Goessens YI, Henquet CJ et al. The reliability of diagnosis = using=20 store-and-forward teledermatology. J Telemed Telecare 2003;=20 9: 249=9652.

11. Pak HS, = Harden D,=20 Cruess D et al. Teledermatology: an intraobserver diagnostic correlation = study,=20 Part II. Cutis 2003; 71: 476=9680.

12. Piccolo = D, Smolle=20 J, Wolf IH et al. Face-to-face diagnosis versus telediagnosis of = pigmented skin=20 tumors: a teledermoscopic study. Arch Dermatol 1999;=20 135: 1467=9671.

13. Granlund = H.=20 Aspects of quality: face-to-face versus teleconsulting. Curr Probl=20 Dermatol 2003; 32: 158=9666.

14. Taylor = P,=20 Goldsmith P, Murray K et al. Evaluating a telemedicine system to assist = in the=20 management of dermatology referrals. Br J Dermatol 2001;=20 144: 328=9633.

15. Oliveira = MR, Wen=20 CL, Neto CF et al. Web site for training nonmedical health-care workers = to=20 identify potentially malignant skin lesions and for teledermatology. = Telemed=20 J E Health 2002; 8: 323=9632.

16. Braun = RP,=20 Vecchietti JL, Thomas L et al. Telemedical wound care using a new = generation of=20 mobile telephones: a feasibility study. Arch Dermatol 2005;=20 141: 254=968.

17. Soyer = HP,=20 Hofmann-Wellenhof R, Massone C et al. Telederm.org: freely available = online=20 consultations in dermatology. PLoS Med 2005; = 2:=20 e87.

18. Massone = C,=20 Hofmann-Wellenhof R, Gabler G et al. Global teledermatology: a specific = web=20 application for dermatological consultation. Internet Health = 2004;=20 3: e3. Available at:=20 www.Internet-health.org/ih200431e03.html.

19. Massone = C, Soyer=20 HP, Hofmann-Wellenhof R et al. Two years experience with Web-based=20 teleconsulting in dermatology. J Telemed Telecare 2006;=20 12: 83=967.

20. Africa=20 Teledermatology Project. Available at: telederm.org/africa.

21. iPath. = Available=20 at: ipath.ch.

22. Brauchli = K,=20 O=92Mahony D, Banach L, Oberholzer M. iPath =96 a telemedicine platform = to support=20 health providers in low resource settings. Stud Health Technol = Inform=20 2005; 114: 11=9617.

23. Brauchli = K,=20 Christen H, Haroske G et al. Telemicroscopy by the Internet revisited. = J=20 Pathol 2002; 196: 238=9643.

24. Solomon = Islands=20 Telemedicine Network. Available at: telemed.ipath.ch/solomons.

25. LT = Telepatologija=20 =96 Lithuania. Available at: ipath.ch/site/node/441. Also, in = Lithuanian, at:=20 telemed.ipath.ch/lithuania.

26. RAFT. = Available=20 at: raft.hcuge.ch.

27. = Telemedecina Sur.=20 Available at: telemed.ipath.ch/tmsur.

28. West = Africa=20 Doctors and Healthcare Professionals Network. Available at: = www.wadn.org.

29. = HealthNet Nepal.=20 Available at: www.healthnet.org.np.

30. = Teledermatology in=20 Port St Johns, South Africa. Available at: ipath.ch/site/node/22.

31. = O=92Mahony D, Banach=20 L, Mahapa DH et al. Teledermatology in a rural family practice. SA = Fam=20 Pract 2002; 25: 4=968.

32. = Telemedicine:=20 Online Support for HIV/AIDS Care. Available at:=20 telemedicine.itg.be/telemedicine/site/Default.asp.

33. Swinfen = Charitable=20 Trust Website. www.swinfencharitabletrust.org.

34. Wootton = R, Bloomer=20 SE, Corbett R et al. Multicentre randomised control trial comparing real = time=20 tele-dermatology with conventional outpatient dermatological care: = societal=20 cost-benefit analysis. BMJ 2000; 320: = 1252=966.

35. = Heinzelmann PJ,=20 Williams CM, Lugn NE, Kvedar JC. Clinical outcomes associated with=20 telemedicine/telehealth. Telemed J E Health 2005; = 11:=20 329=9647.

36. Aoki N, = Dunn K,=20 Johnson-Throop KA, Turley JP. Outcomes and methods in telemedicine = evaluation.=20 Telemed J E Health 2003; 9: 393=96401.

37. Qureshi = AA, Kvedar=20 JC. Patient knowledge and attitude toward information technology and=20 teledermatology: some tentative findings. Telemed J E Health = 2003;=20 9: 259=9664.

38. Massone = C, Lozzi=20 GP, Wurm E et al. Cellular phones in clinical teledermatology. Arch=20 Dermatol 2006; 141: 1319=9620.

39. Massone = C, Lozzi=20 GP, Wurm E et al. Personal digital assistants in teledermatology. Br = J=20 Dermatol 2006; 154: 801=962.

13 Cross-cultural telemedicine via email: = Experience in=20 Cambodia and the USA

Paul Heinzelmann, Rithy Chau, Daniel Liu and = Joseph=20 Kvedar

Introduction

The Khmer empire was once the largest and most = powerful in=20 South-East Asia. The descendant country of Cambodia is now home to over = 14=20 million people. The Vietnam War and the violent reign of the Khmer Rouge = in the=20 1970s left millions dead or traumatized. The collapsed health system was = left=20 with an enormous burden of infectious diseases, malnutrition and = psychological=20 trauma. In 1979, there were thought to be fewer than 50 doctors left in = the=20 entire country.1

The average annual rate of 0.3 medical contacts per = person=20 remains the lowest in the region. This may be primarily due to a lack of = access,=20 as Cambodia has the lowest ratio of physicians to population in the = region.2 = Despite the=20 fact that 85% of Cambodians live in rural areas, only 13% of government = health=20 workers work there.2 The = problems=20 associated with the lack of access are compounded by frequent misuse of=20 prescription drugs and indigenous health practices that are at times=20 dangerous.3 For = example,=20 animist healers may sometimes treat open fractures with a splint and a = topical=20 application called =91ma=92lou=92. This compound is made from chewed = betel nut and=20 lime paste, and has been known to result in serious infection or even=20 death.

Poor health system performance has led to poor health = outcomes.=20 One out of 12 children never lives to reach the age of five years,4 and = among=20 antenatal clinic attendees, HIV is estimated at 2.2%, the highest = reported for=20 any country in Asia.5 The=20 tuberculosis case rate (508 per 100 000 persons) is approximately 100 = times that=20 of the USA and is the highest rate in Asia.6 = Malaria=20 remains endemic, and has a prevalence of 5 per 1000 persons.7 = Meanwhile,=20 there is a growing prevalence of chronic non-communicable disease, and = traumatic=20 injuries and deaths from landmines and road traffic accidents continue=20 steadily.

Cambodia ranks among the lowest countries on the = United Nations=20 Human Development Index (it was ranked 129 of 177 countries in = 2006)8 and = among the=20 highest in poverty. Forty percent of Cambodians live on less than US$10 = per=20 month, and some 45% of the population has to borrow money to pay for = health care=20 services, which in turn has become the main cause of indebtedness and = loss of=20 land ownership.9 Table 13.1 = compares=20 Cambodia=92s health indicators and resources with those of the = USA.

Table = 13.1 Health=20 indicators and resources: the USA versus Cambodia19 =
	USA	Cambodia	Year
Health indicators
Life expectancy at birth (years) males	75	51	2005
Life expectancy at birth (years) = females	80	57	2005
Under-5 mortality rate (per 1000 live = births)	8	143	2005
Infant mortality rate (per 1000 live = births)	7	98	2005
Deaths due to HIV/AIDS (per 100 000 population = per=20 year)	5	114	2005
Mortality rate for non-communicable diseases = (per 100 000=20 population per year)	460	853	2002
Mortality rate for cardiovascular diseases (per = 100 000=20 population per year)	188	392	2002
Health care resources
Physicians (density per 1000 = inhabitants)	2.6	0.2	2000
Nurses (density per 1000 inhabitants)	9.4	0.6	2000
Pharmacists (density per 1000 = inhabitants)	0.9	0.04	2000
Total expenditure on health (% of GDP)	15.4	6.7	2004
General government expenditure on health (% of = total=20 expenditure on health)	44.7	25.8	2004
Private expenditure on health (% of total = expenditure on=20 health)	55.3	74.2	2004
Out-of-pocket expenditure (% of total private = expenditure=20 on health)	23.8	85.4	2004
Per capita total expenditure on health = (US$)	6096	23.6	2004
Gross national income per = capita=20 (purchasing power paritya)=20 (US$)	41950	2490	2005
aPurchasing power parity is a = currency=20 conversion rate that both converts a common currency and equalizes = the=20 purchasing power of different currencies. It eliminates the = differences in=20 price levels between countries in the process of=20 conversion.

Telecommunications

During the 1990s, the advent of the Internet and the = growth of=20 mobile phone technology dramatically changed the way that people = communicate and=20 share information on a global scale. Disparities in access to these = networks=20 inadvertently left Cambodia and many other regions isolated by a = =91digital=20 divide=92. None the less, broad public access to the Internet within = Cambodia was=20 boosted by foreign investment in the late 1990s from countries such as = Canada=20 and Australia via a link through Singapore.10 = Like many=20 developing countries, diffusion has been slow, with only 2 of every 1000 = citizens becoming Internet users by 2002.11

Early investment in mobile phone networks gave = Cambodia the=20 distinction of being the first country in the world where mobile phone=20 subscribers outnumbered fixed line subscribers. By 2000, four out of = five=20 telephone subscribers were using a mobile

Table = 13.2=20 Information and communication technology (ICT) indicators20 =
	USA	Cambodia	Year
ICT diffusiona	0.81	0.21	2004
ICT connectivitya	0.75	0.01	2004
ICT accessa	0.87	0.41	2004
ICT policya	1.0	0.38	2004
Mobile phone subscribers per 1000 = inhabitants	49	3	2002
Personal computers per 1000 = inhabitants	659	2	2002
Internet users per 1000 inhabitants	551	2	2002
aDiffusion is the = average of=20 three factors: connectivity, which is based on the number = of=20 Internet hosts, PCs, telephone main lines, mobile subscribers per = capita;=20 access, which is based on the estimated number of = Internet=20 subscribers, adult literacy rate, cost of a local call and GDP; = and=20 policy, which is based on the presence of Internet = exchanges,=20 level of competition in telecommunications, level of competition = in the=20 Internet service provider market.

phone =96 the highest ratio in the world.10 = Various=20 information and communication technology (ICT) indicators in Cambodia = and the=20 USA are compared in Table = 13.2.

Humanitarian non-profit organizations and social = entrepreneurs=20 have begun to recognize the opportunity to use these growing = communications=20 networks for social change. The non-profit organization American = Assistance for=20 Cambodia (AAfC) and its founder provide one example. Bernard Krisher = formed the=20 AAfC in 1993 with the aim of rehabilitating Cambodia. Since that time, = the AAfC=20 has built over 300 elementary schools throughout rural Cambodia and has = provided=20 approximately one-third of them with access to the Internet.12 = This growing=20 Internet infrastructure established by AAfC has become the backbone for = a=20 cross-cultural, multi-organizational telemedicine project that allows = physicians=20 at the Harvard Medical School in Boston and clinicians at the Sihanouk = Hospital=20 Centre of HOPE in Phnom Penh to support patient care in under-served = regions of=20 Cambodia.

Telemedicine programme

The telemedicine programme is a collaboration = between the=20 AAfC, Operation Village Health (a project of the Center for Connected = Health of=20 the Partners HealthCare system in Boston) and the Sihanouk Hospital = Centre of=20 HOPE in Phnom Penh. The aim is to provide remote consultation and = supporting=20 tools to build capacity and improve local care for those living in rural = Cambodia.

The local health care providers (Cambodian nurses and = doctors)=20 play a central role in the work. After assessing the patient (i.e. = history and=20 physical and diagnostic tests), they transcribe a document of their = findings=20 into English and transmit this, together with attached images, via email = to the=20 consulting clinicians in Boston and Phnom Penh for review. Coordinators = at each=20 facility direct the cases to the appropriate medical specialist. After = reviewing=20 the medical cases, the offsite clinicians return their recommendations. = The=20 supportive guidance delivered in this way not only enhances the quality = of care,=20 but also provides a unique educational opportunity.

3DImage=20

Figure 13.1 Sites of operation of = the=20 telemedicine clinics in Cambodia

The programme currently operates at two sites in = northern=20 Cambodia (Figure=20 13.1). In the first seven years, approximately 1000 = telemedicine-supported=20 patient encounters were completed at the two sites.

Site 1: Rovieng Health = Centre

The Rovieng district is located in the Preah Vihear = province,=20 and is home to 6493 families (approximately 32 000 people). The region = is served=20 by two health centres, which are located 15 km apart. The region is = primarily an=20 agricultural community, and the estimated average annual income is less = than=20 US$50. Indigenous medical practices are still commonly used, and include = techniques that involve direct skin contact (i.e. cupping, pinching and=20 coining), animistic healing practices and the use of various herbal=20 remedies.13 = Most=20 visitors to the health centre have never met a Western-trained physician = in=20 person.

The pilot telemedicine programme began in February = 2001 at one=20 of the health centres in Rovieng. Each month, 25=9640 people gather = there to have=20 their medical conditions assessed and, if appropriate, triaged for = telemedicine=20 consultation. Typically, 15=9620 of these cases are documented in = English and sent=20 via email to Western-trained clinicians located in Phnom Penh and = Boston. To=20 date, telemedicine patients have come from 35 of the 57 villages in the=20 district. On many occasions, those living near the health centre provide = accommodation for people who have travelled longer distances by allowing = them to=20 stay for several days in their homes.

This site is 235 km and about 6 hours by road from the = major=20 hospitals in the capital city of Phnom Penh. It is also about 4 hours = from the=20 nearest referral hospital. Despite the existence of = these=20 more sophisticated facilities, cost, uncertainty and time constraints = prevent=20 most village inhabitants from seeking care outside the village.

To facilitate improved local care, a nurse from = Sihanouk=20 Hospital Centre of HOPE travels by road from Phnom Penh to Rovieng each = month.=20 Those patients who cannot be easily diagnosed and treated by the nurse = have=20 their cases sent by email to consulting physicians using the satellite = Internet=20 connection at the adjacent elementary school. The local nurse must = assess each=20 patient and transcribe the details of the encounter before these = recommendations=20 are provided. Once received by the relevant consultant, recommendations = for=20 patient management are generally returned to the nurse within 12 = hours.

The telemedicine clinic operates as follows:

Day 1:	Nurse and driver travel from Phnom Penh to=20 Rovieng.
Day 2:	Nurse assesses patients, performs local = laboratory=20 tests, photographs patients and sends transcribed cases in English = to=20 consultants for review via email. Consulting clinicians in the USA = and=20 Phnom Penh review cases and return their recommendations within 12 = hours.
Day 3:	Same activities as Day 2.
Day 4:	Nurse reviews and implements consultant=20 recommendations.
Day 5:	Blood samples for any off-site testing are = collected;=20 nurse and driver return to Phnom Penh with blood samples in a=20 cooler.

To enhance local diagnostic capacity, five = point-of-care=20 laboratory tests were introduced in October 2004. The availability of = these=20 tests has decreased the need for more expensive off-site laboratory = testing,=20 allowing quicker and more accurate diagnosis. The five tests were:

(1)	blood glucose
(2)	haemoglobin
(3)	urine analysis (glucose, ketones, pH, specific = gravity,=20 protein, leucocyte esterase, nitrites)
(4)	urine chorionic gonadotrophin (pregnancy = test)
(5)	faecal occult = blood.

The choice of these tests was based on several = factors,=20 including the prevalence of local disease, ease of use, storage = requirements,=20 low cost, and the ability to use them without reliance on running water = or=20 electricity. Simple algorithms for using these tests were also created = so that=20 the nurse could use them independently. Several manufacturers kindly = donated=20 test kits to launch the service.

Site 2: Rattanakiri Referral=20 Hospital

Based on the success of telemedicine in Rovieng, a = second site=20 opened in April 2003 at the Rattanakiri Referral Hospital (RRH) in = Banlung, the=20 capital of the Rattanakiri province. This province is home to a mixture = of 13=20 ethnic and tribal groups, and is generally considered to be the poorest = of the=20 provinces. Non-Western indigenous health practices are widely practised. = Unlike=20 the cases from Rovieng, these referrals are = initiated by=20 Cambodian physicians working at the RRH, who have greater access to = local=20 resources, including ECG measurement, laboratory tests and basic X-ray = imaging.=20 Accordingly, the cases tend to be more complex, although there is = usually more=20 information for consulting physicians to consider in formulating their=20 recommendations. As with the Rovieng site, the cases are sent each month = as=20 email messages using a satellite connection to the Internet. Turnaround = time for=20 receipt of consultant recommendations is also less than 12 hours. The=20 telemedicine clinic operates as follows:

Day 1:	Patients in need of teleconsultation are = selected by=20 local physicians.
Day 2:	Cases are transcribed into English; relevant = images=20 (e.g. skin, ECG, X-ray or ultrasound) are attached and sent via = email to=20 consulting clinicians; consulting clinicians in USA and Phnom Penh = review=20 cases and return their recommendations within 12 = hours.
Day 3:	Local physicians review and implement the=20 recommendations
Day 4:	Any remaining arrangements for off-site = testing or=20 referral are made.

This site received its initial financial support = from the=20 Markle Foundation and is now largely supported by private individual = donations,=20 most notably from Edward and Laurie Bacharach.

Effects on local care

Retrospective reviews of the telemedicine work have = been=20 completed by staff at the Center for Connected Health and the Harvard = Medical=20 School. These studies have examined the types of patients participating = in the=20 telemedicine programme, the clinical impact on the community, and the = utility=20 and cost savings associated with the portable point-of-care laboratory. = To date,=20 the majority of these formal evaluations and reviews have focused on = operations=20 at the Rovieng site. The results are summarized below.

Demographics and case mix

A retrospective review evaluated all cases completed = at the=20 Rovieng site from January 2005 to May 2006.13 = There were=20 196 teleconsultations for 106 patients. The majority of patients were = female,=20 and two-thirds of all patients sought telemedicine care on more than one = occasion (Table=20 13.3). Most visits for new patients were for non-communicable = chronic=20 diseases (Table=20 13.4). The most frequent diagnosis among all patients was dyspepsia = (Table = 13.5).

Clinical impact

In a previous study, the first 214 cases of the = programme=20 were reviewed.14 = The mean=20 duration of the chief complaint among first-time clinic visitors was 37 = months=20 for the first 6 months of the study period. By the last six months of = the study=20 period, this had dropped to 8 months (Figure 13.2). = The=20 proportion of patients referred for care at offsite = facilities decreased by 51% per year of clinic operation (95% confidence = interval 27=9675%; p < 0.001) (Figure 13.3). = These=20 data suggest that longstanding chronic conditions among villagers are = now being=20 addressed and that appropriate care can be delivered locally.

Table 13.3 Patient = utilization and=20 demographics: Rovieng, January 2005=96May 2006
	Number	%
Total number of visits	196	100
Follow-up visits	132	67
New patient visits	64	33
Total patients	86	100
Female	64	74
Male	22	26
Age (years): 0=9614	7	8
15=9664	65	76
≥65	14	16

Table 13.4 Most frequent = complaints=20 among new patients: Rovieng, January 2005=96May 2006 (n = =3D=20 64)
	Number	%
Epigastric pain	9	14
Cough	6	9
Neck mass	5	8
Joint pain	5	8
Shortness of breath	5	8
Palpitations	5	8
Dizziness	5	8
Polydipsia / polyuria	4	6
Oedema	4	6

Table 13.5 Most frequent = diagnoses:=20 Rovieng, January 2005=96May 2006. There were 196 consultations for = 106=20 patients, some of whom had multiple diagnoses.
Diagnosis	Visits, including=20 this diagnosis	Patients
Dyspepsia	45	30
Hypertension	73	27
Anaemia	40	22
Diabetes (type 2)	48	15
Thyroid disease	23	12
Total	229	106

3DImage=20

Figure 13.2 Duration of patients=92 = primary=20 chief complaint at initial visit, during three phases of the study = period.=20 (Reproduced with permission from Telemed J E Health 2005;=20 11(1), published by Mary Ann Liebert, Inc.)

3DImage=20

Figure 13.3 Proportion of patients = referred=20 off-site for care during the study period. (Reproduced with permission = from=20 Telemed J E Health 2005; 11(1), published by = Mary Ann=20 Liebert, Inc.)

Point-of-care testing

Comparisons were made between the 57 patient = encounters=20 occurring after the introduction of the laboratory tests and 119 = encounters=20 occurring in the year before, which served as historical controls. = Overall, the=20 proportion of patient cases receiving laboratory testing did not = increase=20 (Fisher=92s exact test, p =3D 0.71). Meanwhile, the proportion = of cases=20 requiring off-site referral for the completion of laboratory testing = decreased=20 significantly from an average of 69% to 35% (p < 0.001). The = costs=20 associated with laboratory testing also decreased, from an estimated = average of=20 US$41 to US$17 per month.15

Lessons learned

Several valuable lessons have been learned during = seven years=20 of operation. The project has demonstrated the feasibility of using=20 store-and-forward telemedicine across time zones, socioeconomic strata = and=20 cultures. More specific observations have also been made, and can be = categorized=20 as human, economic or technology factors (Table = 13.6).

Human factors

Human factors are arguably the most important for = success.=20 This requires not only commitment at the organization level, but also = adoption=20 by the users: the patients, local care providers and consulting = physicians.

Patients

Demand by patients for telemedicine services at the = Rovieng=20 Health Centre has remained high, particularly among women aged 15=9664 = years. The=20 sustained patient volume and rate of return visits suggest that = cross-cultural=20 telemedicine can compete successfully with conventional and local = indigenous=20 practices. This is probably due to several factors.

The willingness of families to accommodate one = another during=20 the monthly tele-medicine clinics signals a high degree of =91social = capital=92=20 within this community. The monthly schedule of the clinics encourages = adherence=20 among patients through frequent opportunities to educate, inform and = reinforce=20 the benefits of the prescribed medication. The social nature of these = monthly=20 gatherings brings community members together, and may also play a role = in=20 adherence =96 much like that of a support group or

Table 13.6 Proposed = characteristics of=20 programme success
Factor	Characteristics
Human	Willingness to participate/collaborate, = adoption,=20 satisfaction, cultural competence, supportive political=20 environment
Economic	Sustainability, affordability, marketability,=20 profitability
Technological	Usability, interoperability, scalability,=20 transferability

=91group visit=92 (a model of chronic care = management gaining=20 popularity among US primary care physicians). The significance of this = is most=20 evident in instances where patients are asked to begin long-term = medication=20 regimens that may have little effect on their sense of wellbeing =96 or = even=20 produce undesirable side effects. For example, antihypertensive = medications are=20 now frequently prescribed to treat the surprisingly high prevalence of = high=20 blood pressure in this community. The high return rate among villagers = and the=20 apparent adherence to modern drug regimens suggests that the concept of = chronic=20 disease management is being incorporated into the local culture.

It is important to note that, at present, there is no = direct=20 cost to patients for telemedicine visits or for the prescribed = medications=20 recommended in the consultations, which undoubtedly encourages a high = return=20 rate. To better understand patient expectations, their satisfaction and=20 willingness-to-pay were assessed in 2003 using a verbally administered=20 survey.7 All = patients=20 surveyed (n =3D 63) were either =91satisfied=92 or =91very = satisfied=92 with the=20 use of telemedicine as an alternative to the seeking of care within the=20 traditional Cambodian health system. Of those surveyed, 78% were willing = to pay=20 for these services. Of those willing to pay, the mean amount was US$0.63 = per=20 visit.

Local providers

Initially the dialogue between local and consulting = clinicians=20 was a fairly unstructured exchange, akin to an instant messaging = Internet=20 =91chat=92. However, as the telemedicine programme has matured, this has = evolved=20 into a structured format using a standardized template for history and = physical=20 examination (Box=20 13.1).

The visiting telemedicine nurse in Rovieng is part of = the SHCH=20 staff, and participation is mandated in the job description. In = contrast,=20 telemedicine at the RRH depends on the interest and willingness of the = local=20 physicians to participate. Patients that are managed using telemedicine = require=20 more local physician time, although there is no additional physician=20 remuneration. It could be argued that the inherent opportunity cost to=20 physicians who participate under this arrangement might ultimately = become a=20 barrier to sustainability. Possible methods of maintaining the = participation of=20 local Cambodian physicians include reducing lengthy = translation/transcription=20 times and improving cultural competence among US consultants to ensure = that=20 their recommendations are relevant to the local context and available=20 resources.

Consulting physicians

Informal inquiries of consulting clinicians in the = USA and=20 Phnom Penh have revealed several potential areas for quality = improvement. To=20 maximize the value of the consulting physician=92s recommendations and = avoid a=20 =91garbage-in=96garbage-out=92 situation, measures should be taken to = ensure the=20 completeness of the initial clinical data collected and documented by = the local=20 provider. Convenient and reliable web access to patient medical records = could=20 enhance continuity of care for those with recurring or chronic = conditions.

Overall, a high degree of cultural competence among = consulting=20 and local clinicians has been important to the successful introduction = of=20 Western-based medical concepts such as chronic disease (i.e. diabetes = and=20 hypertension) and prevention.

Box 13.1 Standardized template = for=20 history and physical examination
Patient:
Chief complaint:
History of present illness:
Past medical/surgical history:
Social history:
Allergies:
Family history:
Review of systems:
Physical examination:
Vital signs: (blood pressure, pulse, = respiration,=20 temperature, weight)
General:
Head, eyes, ears, nose, throat:
Chest:
Abdomen:
Musculoskeletal:
Neurological:
Genitourinary:
Rectal:
Previous laboratory studies:
Laboratory studies requested:
Assessment:
Plan:
Comments/notes:
Examined by:	Date:

Economic factors

Grants, foundations and private donations from = organizations=20 such as the Asia Development Bank and Japanese corporate sponsors have = funded=20 the efforts of AAfC. Satellite services (estimated cost US$285 per site = per=20 month) have been secured as corporate gift-in-kind donations from a Thai = telecommunications company. By =91piggy-backing=92 the telemedicine = programme onto=20 this existing Internet infrastructure, large capital investments have = been=20 avoided.

None the less, certain problems remain, such as the = cost=20 implications of telemedicine. As mentioned above, the local physician = time=20 required per patient is greater than for traditional care in cases = originating=20 at the RRH. Furthermore, strict adherence by local clinicians to the=20 recommendations of US consulting physicians who are uninformed about = local=20 resource constraints could result in increased utilization and, = therefore,=20 cost.

At present, the programme continues to rely on = volunteers and=20 donations from charitable organizations. As a result, alternative = economic=20 schemes (i.e. fee-for-service or a pooled payment = model) may=20 eventually need to be introduced if this model of care is to be = transferred to=20 other regions or implemented on a broader scale. Some revenue has been = generated=20 via the online sales of locally produced products such as coffee, = scarves and=20 other handicrafts, but, to date, this has contributed little to the = overall=20 operating budget.

Technological factors

Reliable electrical power and Internet connectivity = are=20 central to the operation of the programme. The use of solar panels = supplemented=20 by portable generators has proven to be feasible for the operation of = computers=20 and satellite communications equipment. Telecommunication employs a=20 low-to-moderate range of bandwidth and uses a store-and-forward, = asynchronous=20 email mode of communication. These characteristics contribute to the = potential=20 for scalability, especially as the use of email and familiarity with = computers=20 among Cambodians grow. Expansion of Internet connectivity, however, has = been=20 restricted by poverty, the lack of a rigorous academic community to = nurture=20 networking, the complexity of using the Khmer language with computing = and=20 application development, a shortage of dial-up telephone lines and = restrictive=20 government regulations.10

In terms of laboratory technologies to support remote=20 consultations, the point-of-care laboratory tests appear to be feasible, = clinically useful and likely to reduce the need for slower, more = expensive=20 offsite testing.

Future directions

The data from the retrospective reviews and lessons = learned=20 have helped to plan a strategy for the future.

Human factors

As there is a high level of demand for management of = chronic=20 illnesses such as diabetes and hypertension, an increased emphasis on = continuity=20 of care is planned for patients at the Rovieng site.

Recently, the non-governmental organization HealthNet=20 International has been contracted by the Cambodia Ministry of Health to = reform=20 health care delivery in several provinces, including Rattanakiri. As a = result,=20 the telemedicine component at the RRH is also being restructured. = Expected=20 benefits include greater local ownership and accountability of the = programme=20 through stronger administrative oversight and physician participation. = This=20 change is expected to integrate telemedicine more formally into the = hospital=92s=20 service and enable a greater measure of evaluation and quality control. = In=20 addition, it is hoped that this new arrangement will facilitate a = stronger=20 relationship with the Ministry of Health and potentially enable broader = use of=20 tele-medicine to support government-sponsored public health = initiatives.

To build local capacity, an increased emphasis on = clinician=20 education is anticipated. Linking educational content directly to = patient care=20 recommendations is being considered as one way to enhance the = experiential=20 learning that already occurs. Skills training in = the use of=20 computers, project management and administration would also enable = greater local=20 ownership of the programme.

Economic factors

To date, the programme has successfully enlisted the = voluntary=20 participation of highly skilled medical specialists and clinicians whose = time=20 would otherwise not be affordable. This approach will continue to be = crucial for=20 the future sustainability of the programme, as will philanthropic and=20 gift-in-kind contributions from socially minded individuals and=20 corporations.

Technology factors

A more sophisticated clinical information management = system is=20 required. This would facilitate continuity of care through web access to = patient=20 records and enable more robust data analysis for population tracking and = research. Several web-based platforms or electronic medical records are = being=20 explored. Examples include the system created by the Swinfen Charitable = Trust=20 (see Chapter = 19) and=20 open-source formats (i.e. OpenMRS and OpenVista).

To improve the efficiency and completeness of local = clinician=20 assessment and transcription, digital pen technology combined with = standardized=20 clinical forms is being explored. This may be an improvement over = keyboard data=20 entry.

Conclusion

Cambodia=92s health system faces a significant = disease burden,=20 as well as provider shortages and limited resources. The low-bandwidth,=20 store-and-forward telemedicine programme that began in 2001 has expanded = to a=20 second site. Experience suggests that this model of care is not only = feasible,=20 but also acceptable to patients and care providers, and has positive = clinical=20 effects. Continued challenges to its operational efficiency and = effectiveness=20 remain, as do methods of data collection to assess the clinical effects. = With=20 stakeholders in the USA and Cambodia, this collaborative project seeks = to become=20 a sustainable, scalable and transferable model of cross-cultural = telemedicine=20 for low-resource settings.

From a broad perspective, the process of globalization = will=20 undoubtedly have an impact on the health of populations in both the=20 industrialized and the developing world.16 = Telemedicine=20 and telehealth applications are likely to emerge as future tools to = transform=20 the way care is delivered across cultures, geography and time zones. It = is clear=20 that utilizing communication technologies to decrease health disparities = is=20 possible in places such as rural Cambodia, but large-scale deployment of = telehealth in the developing world will depend on the positive = convergence of=20 human, economic and technological factors.17

Acknowledgements

We thank Kathy Fiamma, Dr Kavitha Reddy, Dr Sherene = Idriss,=20 Heather Bello, Nedialka Douptcheva and Marco Senelly.

References

1.=20 Ricciardi L. A Model for Remote Health Care in the Developing World: = The=20 Markle Foundation Telemedicine Clinic in Cambodia. Available at:=20 www.markle.org/markle_programs/healthcare/projects/cambodia_telemedicine.= php#report1.

2.=20 Kvedar J, Heinzelmann PJ, Jacques G. Cancer diagnosis and telemedicine: = a case=20 study from Cambodia. Ann Oncol 2006; 17(Suppl = 8):=20 37=9642.

3.=20 Kemp C. Cambodian refugee health beliefs and practices. J Community = Health=20 Nurs 1985; 2: 41=9652

4.=20 World Health Organization. The World Health Report 2000 =96 Health = Systems:=20 Improving Performance. Geneva: WHO, 2000. Available at:=20 www.who.int/whr/2000/en/index.html.

5.=20 Centers for Disease Control. Screening HIV-infected persons for = tuberculosis =96=20 Cambodia, January 2004=96February 2005. MMWR Morb Mortal Wkly = Rep 2005;=20 54(46): 1177=961180.

6.=20 World Health Organization. Global Tuberculosis Control =96 = Surveillance,=20 Planning, Financing. Geneva: WHO, 2005. Available at:=20 www.who.int/tb/publications/global_report/en.

7.=20 World Health Organization Regional Office for the Western Pacific. = Malaria=20 Annual Data. Available at: = www.wpro.who.int/sites/mvp/data/malaria.

8.=20 United Nations Development Programme. Human Development Report = 2006.=20 Available at: hdr.undp.org/hdr2006/statistics.

9.=20 World Health Organization. Country Cooperation Strategy: = Cambodia.=20 Available at: = who.int/countries/en/cooperation_strategy_khm_en.pdf.

10. Wright = D. The=20 International Telecommunication Union=92s report on Telemedicine and = Developing=20 Countries. J Telemed Telecare 1998; 4(Suppl = 1):=20 75=969.

11. World = Health=20 Organization. Core Health Indicators. Available at:=20 www.who.int/whosis/database/core/core_select.cfm.

12. American = Assistance for Cambodia. Available at: www.cambodiaschools.com.

13. Reddy = KK, Idriss=20 SZ, Chau R et al. Cross-cultural telemedicine approach to epidemic = diabetes:=20 model for developing nations. Telemed J E Health 2007,=20 13: 198 (Abst T5C1).

14. = Brandling-Bennett=20 HA, Kedar I, Pallin DJ et al. Delivering health care in rural Cambodia = via=20 store-and-forward telemedicine: a pilot study. Telemed J E = Health 2005;=20 11: 56=9662.

15. = Heinzelmann PJ,=20 Jacques G, Kvedar J. Telemedicine by email in remote Cambodia. J = Telemed=20 Telecare 2005; 11(Suppl 2): 44=967.

16. Huynen = MM, Martens=20 P, Hilderink HB. The health impacts of globalization: a conceptual = framework.=20 Global Health 2005; 1: 14.

17. Graham = LE,=20 Zimmerman M, Vassallo DJ et al. Telemedicine =96 the way ahead for = medicine in the=20 developing world. Trop Doct 2003; 33: = 36=968.

18. Heinzelmann PJ, Lugn NE, Kvedar JC. = Telemedicine in the=20 future. J Telemed Telecare 2005; 11: = 384=9690.

19. World = Health=20 Organization. WHO Statistical Information System (WHOSIS). = Available=20 at: www.who.int/whosis.

20. World = Health=20 Organization. The Digital Divide: ICT Development Indices 2004. = New=20 York and Geneva: United Nations, 2005.

14 Telepathology and telecytology in developing=20 countries

Sangeeta Desai

Introduction

The field of surgical pathology and cytology = involves a=20 cascade of operator-dependent technical, scientific and medical = processes. The=20 preparation and interpretation of surgical pathology and cytology = material=20 requires trained technical personnel, excellent technical support, = skill,=20 experience and some basic infrastructure. Developing nations such as = India are=20 typically flawed by vast socioeconomic differences. In India, there is a = truly=20 heterogeneous and uneven development of health care facilities, which = results in=20 major disparities: some medically privileged areas have expertise on par = with=20 the industrialized world, while other remotely located, rural, = under-served=20 populations are almost totally deprived of any medical facilities. = Telemedicine=20 provides a method of bridging this gap.1=965

Telepathology for the developing = world

Telepathology is the practice of pathology at a = distance using=20 telecommunications. It involves viewing images on a video monitor rather = than=20 directly through a microscope. The minimum requirements for = telepathology=20 are:

a light = microscope=20 (motorized for dynamic telepathology);

a = high-resolution=20 camera (either a digital camera or a video camera with a frame grabber=20 card);

a = workstation for=20 the telepathologist;

access to = a=20 telecommunications network.

Telepathology can be performed using a static, or=20 =91store-and-forward=92, approach; it can also be conducted using a = dynamic, or=20 real-time, approach; or it may employ a hybrid of the two.1,2 = There are=20 obvious disadvantages associated with static telepathology, the major = one being=20 sampling error, which reflects the passive nature of this exercise. In = contrast,=20 dynamic telepathology overcomes the basic drawback of static = telepathology,=20 although techniques such as ultra-rapid virtual slide processing6 are=20 prohibitively expensive in a developing country setting. Sampling error = in=20 static telepathology consultation could be reduced by the referring = pathologist=20 sending a set of images covering both ambiguous and = unambiguous areas. There is general agreement that a reasonably accurate = histopathological diagnosis is possible on the basis of the examination = of=20 judiciously selected digital images. It has been our observation that = mutual=20 trust, rapport and close interaction between referring pathologist and=20 telepathologist, and adequate training of the referring pathologist, are = very=20 important to achieve successful teleconsultations.2

The quality of the images is largely dependent on the = quality of=20 the basic starting material, which is the stained slide. The mode of=20 transmission and the image compression will not compromise the quality = of images=20 if chosen carefully. It has been suggested that successful telepathology = diagnoses can be achieved using adaptive colour reduction algorithms to = reduce=20 image file size, thus facilitating transmission without sacrificing=20 quality.7

The single most important factor that influences = selection of=20 the system in the developing world is the cost. The potential customer, = in=20 addition, also faces the problem of commercial pressure by the vendors. = Dealing=20 with single-vendor proprietary systems, i.e. buying the camera, software = and=20 microscope in a package, implies an inability to negotiate costs. = However, it is=20 heartening to note that the costs of most of the components of = telepathology=20 system are declining.

Constraints

There are a number of constraints that limit the = introduction=20 of telepathology in the developing world. These include the = following.

Inadequate = infrastructure

The essential components of any telepathology = system, i.e. the=20 microscope, a camera with software and a computer, may not available in = rural=20 areas of developing countries. Procurement of these items may be = difficult.=20 Telecommunication facilities may not be developed at all, or they may be = so=20 poorly developed that it may be difficult or impossible to transmit = cases.=20 Moreover, the development and availability of telecommunication = facilities may=20 be non-uniform.3,4,8,9

Non-uniform processing of pathology=20 material

The limiting step in telepathology is availability = of a=20 well-processed histology or cytology glass slide. In the developing = world, the=20 lack of infrastructure, equipment and uniform standards makes for poor = pathology=20 material or suboptimal technical material.

Lack of accreditation

Telepathology is a combination of surgical = pathology,=20 information technology and imaging. All three processes lack defined = standards.=20 A few centres conduct accreditation for histopathology, but there are no = standards laid down for telepathology in particular.

Low level of training

A well-processed stained slide is the most important = factor=20 for success in telepathology. Lack of trained manpower for = histopathology=20 processing has a very negative effect on the subsequent quality of a=20 telepathology consultation. As training is required for surgical = pathology and=20 cytology specimen processing, it is also required for information = technology and=20 handling of camera and computer. The natural tendency of the staff to = initially=20 resist any new technology may also need to be managed carefully.

Lack of dedicated = personnel

It is often difficult to find dedicated personnel to = carry out=20 telepathology or to staff a telemedicine department. The staff are = expected to=20 perform multitasking, especially in a low-volume centre.

Applications of telepathology

Intraoperative consultation between pathologist and = surgeon=20 requires rapid and accurate diagnosis, which is rendered on a frozen = section and=20 provides the necessary guidance to the operating surgeon. For = interpretation of=20 intraoperative frozen sections, transmission of live images is required = using=20 dynamic telepathology. The same also holds true for primary diagnosis of = routine=20 surgical pathology. Although this technique is well developed in certain = parts=20 of Europe and the USA,5,10 in = developing countries, the constraints of cost mean that intraoperative=20 consultation is rare.

However, telepathology has proven its merit in = developing=20 countries where dynamic teleconsultation is not required, for example to = obtain=20 second opinions,3,4,8,9=20 expert-to-expert consultations, quality assurance, distance education, = consensus=20 diagnosis for pathology review in clinical trials and proficiency = testing. In=20 the USA, ultra-rapid turnaround time in surgical pathology has recently = been=20 demonstrated in breast cancer clinics. These combine digital mammography = imaging=20 and interpretations, the latest advances in rapid specimen processing = (microwave=20 and automated immunostaining), and biopsy diagnosis by telepathology, = producing=20 a =91one-stop shop=92 for patients being investigated.6 = Although this=20 is attractive, promising and useful for the industrialized world, it is = not=20 practical in the developing world because of the high costs.

Another potential use of telepathology is for = consultations=20 generated in the industrialized world to be outsourced to experts in = developing=20 countries. This is currently practised in the field of radiology at some = centres. However, credentialing requirements, issues related to = licensure and=20 malpractice coverage need to be resolved for this approach.11 If = these=20 factors are dealt with appropriately then this model of tele-pathology = may have=20 potential.

Telepathology is not yet validated in the field of = exfoliative=20 cytology, which involves microscopic examination of cells that are shed = from the=20 lesion. Most cytologists would agree that telecytology is not a = preferred mode=20 for reporting exfoliative cytology. However, it is worth noting that = there have=20 been a few studies of telecytology involving fine-needle aspiration = cytology=20 (FNAC).9

Tele-surgical pathology and = telecytology

The distinction between tele-surgical pathology and=20 telecytology is based on the inherent differences between the cytology = and=20 surgical pathology material. Surgical pathology material consists of = cells and=20 tissue architecture. Hence, the telepathologist and referring = pathologist can=20 make use of the tissue architecture as a reference point to discuss the = case=20 and/or obtain additional images from any suspicious areas. Cytology = smears=20 mainly consist of cells with a few stromal fragments and are spread over = a large=20 area. The whole smear needs to be scanned. Hence, telecytology requires = more=20 comprehensive and optimized initial sampling of the smears, which = increases the=20 number of images produced. Telecytology largely depends on the images = chosen by=20 the referring pathologist. Hence, it is desirable to have the = problematic areas=20 adequately represented in the initial images in telecytology.9

Experience of telepathology in = Mumbai

The Tata Memorial Hospital in Mumbai, India is a = tertiary=20 cancer referral centre, delivering comprehensive care to cancer patients = in the=20 Indian subcontinent. The hospital has a static telepathology link with = two rural=20 cancer centres located 500 km from Mumbai (Figure 14.1). = The=20 process to establish a static telepathology link with one of

3DImage=20

Figure 14.1 Static telepathology = workstation=20 at the referring pathologist=92s end in Barshi, Solapur, India

the rural cancer centres, the Nargis Dutt Memorial = Cancer=20 Hospital, began in October 2000 and came to fruition in January 2002. = The delays=20 were mainly due to hurdles related to the communication link. However, = once it=20 became fully operational, tele-pathology was able to sustain = itself.3,5,8,9 The=20 communication medium employed is the ordinary telephone system, with the = 56=20 kbit/s dial-up modem providing access to the Internet. A set of = compressed=20 images in conjunction with clinical data are sent as email = attachments.

The performance of static telepathology was assessed = by=20 comparing the diagnoses rendered on telepathology and glass slides,=20 respectively. The comparison was categorized as follows:

(1)	complete concordance
(2)	minor discrepancy (clinically = unimportant)
(3)	major discrepancy (clinically = important)
(4)	qualified diagnosis
(5)	deferred = diagnosis.

Analysis of tele-surgical pathology=20 consultations

In a study of 299 static telepathology consultations = accrued=20 over a period of 3 years to December 2004, there were 251 surgical = pathology, 2=20 international consultations and 46 cytology cases.3,4,8,12 = Concordance=20 (absolute concordance, qualified diagnosis or minor, clinically = unimportant=20 discrepancies) for tele-surgical pathology was 96% (199 of 207 cases). = The=20 diagnosis was deferred in 30 cases.

Our experience of deferred diagnoses on telepathology = indicates=20 that the =91probable=92 diagnosis rendered in complex cases such as = lymphoid=20 neoplasia, sarcoma and round cell tumours matched the final glass slide=20 diagnosis in 47% of cases. The =91probable=92 telepathology diagnosis = rendered on=20 potentially difficult cases does give the referring pathologist a = direction or=20 impart a different thought process during decision making.12

We believe that static telepathology consultation = helps the=20 referring pathologist to unravel the diagnosis while dealing with = potentially=20 complex cases, even in the event of deferral. Static telepathology has = the=20 potential to provide specialist support in the clinical management of = such=20 cases.

Analysis of telecytology=20 consultations

A total of 46 cases accrued over period of 3 years = were=20 analyzed.9 The = cases=20 included 44 FNAC and 2 exfoliative cytology smears. The concordance = (absolute=20 concordance, qualified diagnosis or minor, clinically unimportant = discrepancies)=20 for telecytology was 91% (39 of 43 cases). The diagnosis was deferred in = 5=20 cases.

The reasons for major discrepancies for both = telesurgical=20 pathology and telecytology were interpretative errors, inadequate = sampling,=20 poor-quality sections and images, and inadequate clinical data. We = believe that=20 effective use of static telepathology can be achieved by thorough = sampling by=20 the referring pathologist, expertise in surgical pathology at the=20 telepathologist=92s end and effective interaction between the two = ends.3,4,8,9,12

Conclusion

Telepathology is a powerful technique. To make best = use of it,=20 the raw material, i.e. the stained glass slide, must be of optimum = quality. We=20 have found that telepathology is valuable in bridging the gap between=20 under-served areas and specialty centres, and can build confidence and = capacity=20 in the professionals working in under-served areas. This also reduces=20 professional isolation, as expressed by referring pathologists. Patients = from=20 under-served areas receive better professional advice, while saving = their travel=20 costs to tertiary centres. Another major advantage of teleconsultation = is=20 effective management of turnaround time. In our study, 48% of cases were = reported within 8 hours (a single working day) and 91% of cases within 3 = days.

It is obvious that telepathology is potentially useful = in the=20 developing world. A decision to implement a diagnostic telepathology = system in=20 developing countries will be based on numerous factors, but the pivotal = factor=20 will be the need for telepathology. A strong impetus to establish = communication=20 between distantly located centres can help to establish successful, = inexpensive=20 and effective teleconsultation and to transfer knowledge and expertise = to=20 medically underprivileged areas and bridge the gap of knowledge and = expertise at=20 low cost. I believe that once the advantages of tele-pathology are = visible to=20 pathologists generally, the technique will rapidly gain in = popularity.

Acknowledgements

I am grateful to Dr KA Dinshaw, Dr Ashok Mohan, Dr = BM Nene, Mr=20 MK Chauhan, Mr TK Ghosh, Mr Manoj Chavan, Mr Amit Satvekar and Mr Bipin = Gadhave.=20 I thank Dr Roshni Chinoy, Dr Shubhada Kane, Dr Tanuja Shet and Dr Mukta = Ramadwar=20 for reporting telepathology cases and Dr Rajasa Patil and Dr Sanica = Bhele for=20 providing logistical support.

References

1.=20 Wootton R. Recent advances: telemedicine. BMJ 2001;=20 323: 557=9660.

2.=20 Weinstein RS, Descour MR, Liang C et al. Telepathology overview: from = concept to=20 implementation. Hum Pathol 2001; 32: = 1283=9699.

3.=20 Desai S, Ghosh TK, Chinoy R et al. Telepathology at Tata Memorial = Hospital,=20 Mumbai and Barshi, a rural centre in Maharashtra. Natl Med J = India=20 2002; 15: 363=964.

4.=20 Desai S, Patil R, Chinoy R et al. Experience with telepathology at a = tertiary=20 cancer centre and a rural cancer hospital. Natl Med J India = 2004;=20 17: 17=9619.

5.=20 Cross SS, Dennis T, Start RD. Telepathology: current status and future = prospects=20 in diagnostic histopathology. Histopathology 2002; = 41:=20 91=96109.

6.=20 Weinstein R, Descour MR, Liang C et al. An array microscope for = ultrarapid=20 virtual slide processing and telepathology. Design, fabrication, and = validation=20 study. Hum Pathol 2004; 35: 1303=9614.

7.=20 Doolittle MH, Doolittle KW, Winkelman Z, Weinberg DS. Color images in=20 telepathology: How many colors do we need? Hum Pathol 1997;=20 28: 36=9641.

8.=20 Desai S, Patil R, Kothari A et al. Static telepathology consultation = service=20 between Tata Memorial Centre, Mumbai and Nargis Dutt Memorial Charitable = Hospital, Barshi, Solapur, Maharashtra: an analysis of the first 100 = cases.=20 Indian J Pathol Microbiol 2004; 47: = 480=965.

9.=20 Jialdasani R, Desai S, Gupta M et al. An analysis of 46 static = telecytology=20 cases over a period of two years. J Telemed Telecare 2006;=20 12: 311=9614.

10. Frierson = HF Jr,=20 Galgano MT. Frozen-section diagnosis by wireless telepathology and ultra = portable computer: use in pathology resident/faculty consultation. = Hum=20 Pathol 2007; 38: 1330=964.

11. = Kalyanpur A,=20 Neklesa VP, Pham DT et al. Implementation of an international = teleradiology=20 staffing model. Radiology 2004; 232: = 415=9619.

12. Bhele S, = Jialdasani R, Kothari A et al. Analysis of deferrals on static = telepathology=20 consultation service. Ind J Pathol Microbiol 2007; = 50:=20 749=9653.

15 Internet-based store-and-forward telemedicine = for=20 subspecialty consultations in the Pacific region

C Becket Mahnke, Charles W Callahan and = Donald A=20 Person

Introduction

An early form of telemedicine communication in the = developing=20 world was the radiotelephone. A series of ham radio operators would = establish a=20 schedule of time available for the long-distance communication between = remote=20 locations and more centralized locations. During the early 1960s, one of = us=20 (DAP) managed distant medical consultations between US military staff in = Panama=20 and distant military groups, missions and embassies from Mexico to South = America=20 using the Military Affiliate Radio System. At a prearranged weekly time, = a radio=20 operator would connect the various organizations together. Medical = questions=20 were discussed, which facilitated decisions regarding local medical care = versus=20 evacuation. However, radiotelephony was susceptible to problems caused = by the=20 weather and sunspot activity, resulting in loss of bandwidth and = sometimes loss=20 of signal. During the same period of the 1950s and 1960s, communications = within=20 the far-flung US-associated Pacific Trust Territories were handled in a = similar=20 manner.1

Early telemedicine work at Tripler Army Medical=20 Center

Tripler Army Medical Center (TAMC) was the test site = for the=20 Composite Health Care System, a database of the US Department of = Defense. It was=20 deployed in the late 1980s, and included modules for order entry, = retrieval of=20 radiology and laboratory results, pharmacy, patient administration and = coding=20 information. An email function was added in 1995, and this provided the = basis=20 for teleconsultations and referrals within the military health care = system in=20 Hawaii and ultimately military medical facilities in the Pacific. File=20 attachments, however, were not allowed in the secure Composite Health Care System, which limited = telemedicine to the=20 written word only.

In 1993, telemedicine consultations with TAMC were = begun from=20 the US Army Kwajalein Atoll Missile Range in the Marshall Islands. There = was an=20 existing AT&T videoconference system at Kwajalein Atoll. About 150=20 consultations were conducted over 5 years, and a few unnecessary = referrals to=20 Honolulu were avoided.2 The = process,=20 however, was difficult to schedule. Expensive computer and video = hardware and=20 costly maintenance with special technical support were required. By = virtue of=20 the proximity of the Ebeye Island to Kwajalein, a few Marshallese = patients=20 benefited from this demonstration project, but it was obvious that such = a=20 technology-dependent system was not practicable in the rest of the=20 Pacific.

In 1995, at the inaugural meeting of the Pacific Basin = Medical=20 Association held in Pohnpei, the utility of the Picasso still-image = telephone=20 was demonstrated by a consultation on a patient in Palau, some 2400 km = away.=20 That consultation avoided the evacuation of the patient from Palau to = Hawaii=20 (saving at least US$20 000).1 Four = Picasso=20 telephones were donated by AT&T to jurisdictions in the Western = Pacific, and=20 over 30 telemedicine demonstration projects were successfully carried = out on the=20 island of Pohnpei, between islands in Pohnpei State, and internationally = between=20 Alaska, Hawaii, Pohnpei, New Caledonia, Kosrae State and Palau. Several = patients=20 were transferred using this process. However, the cost of long-distance = calls=20 became prohibitive, and local health budgets could not continue paying = such=20 costs (US$5=9610 per minute).3

Pacific Island Healthcare Project

At about the same time (1989=961990), a programme to = benefit the=20 graduate medical education needs of TAMC=92s residents in training was = developed.=20 The Pacific Island Healthcare Project (PIHCP) was developed to = facilitate the=20 referral and treatment of indigenous peoples of the former Pacific Trust = Territories, now referred to as the US-associated Pacific Islands = (USAPIs). The=20 USAPIs include three US territories (American Samoa, Guam and the = Commonwealth=20 of the Northern Mariana Islands) and three independent, freely = associated states=20 (the Republic of the Marshall Islands, the Federated state of Micronesia = and the=20 Republic of Palau) (Figure 15.1 = and Table 15.1). = The=20 peoples of the USAPIs suffer from diseases such as tuberculosis, = rheumatic heart=20 disease, leptospirosis, dengue fever, pyomyositis and leprosy, as well = as=20 chronic diseases such as diabetes mellitus, obesity, hypertension,=20 hyperuricaemia and cancer. In addition, there are surgically correctable = congenital lesions, such as cleft lip/palate, congenital diaphragmatic = hernia,=20 Hirschprung disease and hypospadius.

The challenges of managing consultations with the time = differences (five time zones and an International Date Line) and great = distances=20 (8000 km between Honolulu in Hawaii and the Republic of Palau) are = formidable.=20 The region is extremely remote (Figure 15.1). = Some=20 distant islands and atolls are 600=961300 km from the jurisdiction=92s = capital,=20 reachable only by sailing canoe. Prior to the development of the = web-based=20 referral system, consultations from the jurisdictions came in the form = of

3DImage=20

Figure 15.1 US-associated Pacific = Islands,=20 with an overlay of the continental USA (to scale) to demonstrate the = distances=20 invlolved

Table 15.1 Pacific Island = Healthcare=20 Project jurisdictions
Jurisdiction	Populationa (000s)	Area (km2)	Islands	US Association
Guam	152	1400	1	Territory
American Samoa	64	515	7	Territory
Commonwealth of Northern Marianas	69	1235	21	Commonwealth
Republic of Marshall Islands	66	470	1225	Free association
Federated States of Micronesia	132	1820	607	Free association
Republic of Palau	18	1190	350	Free association
Total	500
aBased on 2000=20 estimates

letters, long-distance telephone calls, faxes and = even the=20 diplomatic pouch. From 1988 to 1997, the PIHCP provided definitive care = at TAMC=20 for about 2500 patients from the USAPIs. The web-based system was = established in=20 1997, and in 1998 we were able to demonstrate asynchronous consultations = with=20 TAMC.4

Since that time, email with attached images has been = shown to be=20 an acceptable medium for consultation for almost all patients. Several = steps=20 were needed to implement four test sites in Micronesia. First, a = consultation=20 web page was created with a request form to ensure that there was = sufficient=20 information to allow TAMC specialists to comment. Second, a web page was = created=20 to display all current or recent consultations received from the USAPIs. = Third,=20 a group of TAMC specialists was trained in the use = of a web=20 browser to access the consultations and comment on cases where = appropriate. The=20 use of a web-based system provided a flexible approach to patient = management=20 discussions. Four sites within Micronesia were selected as test sites: = Chuuk,=20 Pohnpei, Palau and Majuro in the Marshall Islands. Each location had = relatively=20 inexpensive Internet service providers (ISPs) and 24-hour access to the=20 Internet. Each site was provided with:

a desktop=20 computer

a digital = camera=20 (D-600L, Olympus)

a flatbed = scanner=20 with transparency adapter (Scanmaker E6 Professional, Microtek)

a digital = video=20 camera (DCR VX-1000, Sony)

a = printer.

In addition, two sites were provided with a digital = otoscope=20 and ophthalmoscope (American Medical Devices).

Training was conducted in two phases. First, a group = of all=20 interested clinicians at the annual Pacific Basin Medical Association = meeting in=20 Chuuk were allowed to test the equipment. Once the equipment had been = installed=20 at each site, small groups were trained. For many of the medical = officers, this=20 was the first opportunity that they had had to see or use a computer. It = should=20 be noted that five senior physicians in Yap, Pohnpei and Palau had = access to the=20 web page using their personal computers. Their involvement was important = to the=20 success of the programme.4

Clinical procedure

The first step in creating an electronic = consultation is to=20 gather digital images where appropriate. Even in cases where images do = not=20 support the consultation, an image of the patient helps to humanize the=20 electronic process. Images are acquired using a digital still camera, = digital=20 video camera or digital medical device camera. Additional images can be = acquired=20 using the flatbed scanner (e.g. laboratory results, ECG recordings, = photographs=20 and X-ray films). Initially, it proved difficult to produce images of = acceptable=20 quality from X-ray films. However, in most cases, careful use of the = digital=20 camera to acquire an image on a light box proved satisfactory.5 = Images are=20 annotated using simple image editing software, with date, comments on = area of=20 concern and an identifying code as applicable.

Next, the history of the patient must be typed into = the=20 computer. This step is often completed before the connection to the = Internet is=20 made. The clinicians use a common word-processing program to type the = medical=20 history, and then copy and paste it into the website form; we do not use = a rigid=20 format for the history. Once complete, the clinician connects to the = Internet=20 and submits the case. Depending on the number and size of attached = images, this=20 process can take several minutes. The resulting electronic patient = record is=20 archived and can be retrieved via the website.

Once a new case is received, an automatic email = notification is=20 sent to the PIHCP Director. The Director queries the database to find = the case.=20 The information is protected by secure socket layer (SSL) encryption, = which=20 meets the current Health Care Financing = Administration=20 guidelines for secure clinical use of the Internet. The consultation is=20 displayed as the provider types it in, with attached images displayed if = included. The Director then comments on the case and forwards it to = appropriate=20 specialists as required. All comments are stored in the database, = complete with=20 time/date stamp and user information.

Specialists are notified of a new case via email. The = email=20 message contains a working diagnosis, a case number and a link to the = PIHCP=20 website. After reviewing the clinical data and images, the specialist = can=20 comment on the case or ask for further information or testing to be = done. The=20 remote provider is notified by email of the new comments, and reviews = these on=20 the website. If further information is required, he or

3DImage=20

Figure 15.2 Numbers of PIHCP cases = (n=20 =3D 3039): (a) origin; (b) type. CNMI, Commonwealth of the Northern = Mariana=20 Islands

she can enter the response on the web page. In this = manner, a=20 difficult case can be discussed using the website as a discussion group = for a=20 specific patient.

Results

By the end of 1999, we had installed 10 workstations = in all of=20 the jurisdictions of the USAPIs. More than 3000 consultations and = referrals have=20 been submitted in the nearly 10-year history of the telemedicine = programme (Figure 15.2). = The=20 majority of the cases have come from the Marshall Islands, the Republic = of Palau=20 and Chuuk State. The US Congress provides US$2.5=965 million per year to = the PIHCP=20 for patient travel and medical care. After an initial investment of=20 approximately US$300 000 to install the workstations and train the local = providers, the PIHCP programme has been self-sustaining. The leadership = of TAMC=20 has supported the programme and integrated its administration into the=20 hospital=92s business plan. Administrative support is provided by = TAMC=92s Patient=20 Administration Division and technical support is provided by TAMC=92s = Information=20 Management Division. The Medical Director has provided the direction, = leadership=20 and oversight of the PIHCP as a labour of love.

We do not provide a list of indications for = telemedicine. The=20 decision to initiate a teleconsultation is left to the referring doctor. = The=20 numbers of patients accepted to TAMC for further evaluation and = treatment are=20 shown in Table = 15.2.=20 With the implementation of the web-based system in the late 1990s, there = has=20 been a drop in the

Table 15.2 Pacific Island = Healthcare=20 Project: number of patient referrals accepted at TAMC for further=20 evaluation and treatment
Financial year	No. of referrals
1991	326
1992	401
1993	335
1994	462
1995	413
1996	160
1997	228
1998	189
1999	222
2000	225
2001	201
2002	142
2003	154
2004	132
2005	171
2006	139

number of patients brought to TAMC for evaluation = and=20 treatment. This has not been due to a decrease in the number of cases = submitted=20 to the PIHCP. It has been due to more accurate triage of those who would = benefit=20 from transfer to TAMC using the web system. In addition, the web-based = system=20 allows many patients to be treated locally with telemedical support from = TAMC=20 specialists. Both factors lead to improved health care for a greater = number of=20 patients. The costs associated with the care of those patients brought = to TAMC=20 are shown in Figures=20 15.3 and 15.4.

The PIHCP telemedicine system has had a significant = effect on=20 medical practice as reflected by the length of stay (Figure 15.5). = Prior to=20 the development of the web-based PIHCP system, the average length of = stay for=20 Pacific Island patients approached 30 days. Since implementation of the=20 teleconsultation process, the length of stay has fallen, and is = currently just=20 over 5 days. This is a consequence of more appropriate triage of = patients prior=20 to transfer to TAMC, as well as improved coordination of care once the = patient=20 arrives.

Implementation of the web-based consultation system = has had=20 other advantages. It has allowed isolated practitioners to stay = connected with=20 their colleagues throughout the Pacific and be kept up to date with = modern=20 medicine. There has also been educational value for the residents in = training at=20 TAMC. Numerous publications have resulted from patient referrals.5=9610 = Pacific=20 Islanders have been restored to health, and have returned home to lead = normal=20 and productive lives.

3DImage=20

Figure 15.3 Number of PIHCP cases = and total=20 costs

3DImage=20

Figure 15.4 PIHCP: total expenditure = for all=20 islands. FY, financial year

3DImage=20

Figure 15.5 PIHCP: number of cases = accepted=20 and length of stay

Pacific Asynchronous TeleHealth = system

TAMC is the tertiary military medical treatment = facility for=20 the US military (active duty staff, retirees and dependants) in the = Pacific=20 region. TAMC=92s area of responsibility includes US military bases in = Korea,=20 mainland Japan, Okinawa and Guam (Figure 15.6). = These=20 remote military health care facilities are often staffed by relatively = junior=20 physicians and have limited access to subspecialty care. Even if = subspecialty=20 care is available in the host nation, language and cultural limitations=20 represent significant impediments to providing safe and effective care. = A=20 teleconsultation system capable of providing subspecialty services had = the=20 potential to improve both access to and quality of health care = delivered.

TAMC=92s asynchronous telemedicine for US military = beneficiaries=20 started in 2000, with the Electronic Children=92s Hospital of the = Pacific=20 (ECHO-Pac) asthma intervention. Children with asthma were enrolled from = military=20 facilities in Guam, Okinawa, mainland Japan and Korea. Each child was = cared for=20 utilizing an asthma clinical pathway with advice from a paediatric = pulmonary=20 specialist via the website. All patients experienced an improvement in = their=20 asthma. There were fewer emergency room visits and fewer unscheduled = acute=20 clinic visits. At the same time, the primary care provider=92s practice = in caring=20 for children also improved as a result of increased use of asthma = education and=20 planning.11

In addition to the asthma intervention, ECHO-Pac = included a=20 general consultation capability modelled on the PIHCP. This feature was = far more=20 popular with remote

3DImage=20

Figure 15.6 US military health care = facilities=20 in the Pacific region, with overlay of the continental USA (to scale) to = demonstrate the distances involved: Honolulu is closer to Atlanta (7230 = km) than=20 it is to Seoul (7320 km) or Okinawa (7480 km)

health care providers than the asthma intervention. = From=20 October 2000 until April 2004, a total of 875 teleconsultations were = submitted=20 to the ECHO-Pac system from 14 different US military hospitals and = clinics=20 throughout the Western Pacific. These consultations included over 1700 = images=20 and more than 7000 clinical comments from numerous specialists.

One of the difficulties with technology research is = the lack of=20 =91measures of effectiveness=92 for new initiatives. Technology is often = pursued=20 because it can be done, without asking whether it should be done and = with no=20 plan to measure whether the technology makes a difference. In 2004, the = PacRim=20 Teleconsultation Effectiveness Trial evaluated ECHO-Pac=92s impact on = access to=20 specialty care, the quality of the care provided and the cost savings. A = panel=20 of 5 physicians evaluated 267 consultations over a 1-year period. The = average=20 time for the consultation to be reviewed and forwarded by the consult = manager=20 was 5 hours (SD 3), with a reply from a consultant in an average of 32 = hours (SD=20 14). The diagnosis was modified in 15% of cases, the diagnostic plan was = modified in 21% and the treatment plan was modified in 24%. Air = evacuation to=20 TAMC for further evaluation was reduced by 30%. Given the significant = cost of=20 moving patients (approximately US$5800 per case), use of the ECHO-Pac=20 teleconsultation system demonstrated significant cost avoidance.12

As a result of the success of the ECHO-Pac = teleconsultation=20 system, TAMC launched the Pacific Asynchronous TeleHealth (PATH) system = in 2004.=20 PATH was created with a modular design to expand the capabilities to the = care of=20 both paediatric and adult patients. Subsequent modules have included = Lightning=20 Med (used by military health care providers in Afghanistan and Iraq) and = a=20 module for tele-auscultation development and testing.13 = The secure=20 website allows health care providers at medical treatment facilities = throughout=20 the Pacific region to submit cases for subspecialist input. Referring = physicians=20 provide clinical information, along with images, video and sound as = necessary.=20 At the TAMC, physician managers forward the case to the appropriate = subspecialty=20 for comment, and email messages notify all involved in a case when new=20 information or comments have been added.

Differences from the Pacific Island = Healthcare=20 Project

Although PATH was modelled on the PIHCP website, it = became=20 apparent that the different patient and referring provider populations = served=20 would require some modifications to the teleconsultation process. For = example,=20 US military beneficiaries have both increased health care options and=20 expectations compared with patients served by the PIHCP. Since use of = PATH is=20 not mandatory, referring providers can simply refer the patient for = local=20 specialty care (if available) or for air evacuation to TAMC or another = tertiary=20 military treatment facility. Our philosophy has been to simplify the=20 teleconsultation process where possible, knowing that many health care = providers=20 will opt for the least time-consuming option when sending a patient for=20 subspecialty care. As a result, the processes of teleconsultation = submission,=20 administration and multimedia handling have continued to change with = technology=20 innovations and provider needs.

Documentation and privacy requirements are demanding = in PATH,=20 which must comply with all US regulations. The results of = teleconsultation must=20 ultimately reside in the patient record, so we = developed a=20 system that allows the consultation notes to be printed onto standard US = military health care forms for inclusion in the patient=92s record. The = security=20 is sufficient to comply with the Health Information Portability and=20 Accountability Act of 1996. The password encryption protocols are = rigorous so as=20 to ensure security. Although email is used to inform providers of new=20 information regarding a specific case, no individually identifiable = health=20 information is included in the messages.

Documentation of services provided in PATH is = important.=20 Although few US insurance companies offer reimbursement for asynchronous = telehealth, the Surgeon General of the Army grants appropriate workload = credits=20 for telemedicine. For this purpose, a billing module was created in PATH = allowing for workload capture on the part of the subspecialist. Once a=20 teleconsultation is entered into the PATH system, the patient = administrators=20 receive an email message informing them of a new patient requiring = registration=20 into the local hospital system. Once a subspecialty provider completes=20 teleconsultation services in PATH, the billing module allows for easy = coding of=20 diagnosis. On completion, departmental coders are alerted of the billing = form=20 via email and can enter the data into the system. This streamlined = approach=20 reduces the extra work required of the consultant (approximately 10=9615 = seconds=20 to complete and email the workload credit form) while documenting the = workload=20 provided by PATH. Accurate documentation is essential to continued = funding of=20 the PATH system.

Experience with PATH

Since its launch in October 2004, the number of = consultations=20 submitted to the PATH system has increased (Table 15.3). = There has=20 also been a 20% increase in the number of images submitted per = teleconsultation=20 in just over two years. Since the opening of the adult telemedicine = module,=20 nearly one-third of all consultations submitted have been for adult = patients.=20 This rapid growth verifies the demand for adult subspecialty = teleconsultation=20 services in the region.

The system is designed to accept all types of = referrals. When a=20 physician is registered in PATH, and during the consultation process = itself,=20 referring providers are reminded that it is not intended to be used for = medical=20 emergencies. Currently, there are over 600 registered users from 30 = military=20 hospitals and clinics throughout the Pacific. All of this activity has = occurred=20 despite the fact that PATH=92s use is optional,

Table 15.3 PATH = teleconsultation=20 workload
	2004	2005	2006
Paediatric consultations	181	259	290
Adult consultations	97	167	117
Total	278	426	407
Number of images	248	353	457
Number of comments	2370	3793	2745

and no formal system training occurs. Since most US = military=20 physicians serve for only one to two years in the Western Pacific, there = is high=20 turnover among PATH users.

As described above, the PATH system improves = subspecialist=20 access and quality of care while reducing health care expenditures from = air=20 evacuation or referral to host-nation specialists. Even for patients who = are=20 transferred to TAMC for further evaluation, PATH minimizes health care=20 expenditures by reducing test duplication and coordination of efficient=20 diagnostic and therapeutic options, resulting in a more rapid return to=20 duty.

Challenges

Like many telemedicine systems, PATH was initially = funded by=20 research and development funds without a clear plan for financial=20 sustainability. Once initial funding had been obtained, we sought funds = from=20 referring institutions based on the cost savings from avoided air = evacuations.=20 We chose this avenue because of the high cost of air evacuation = (US$3000=966000=20 per patient), believing that the 30% reduction demonstrated in the = PacRim=20 Teleconsultation Effectiveness Trial12 = would make=20 the system sustainable. Owing to the financial structure of the US = military=20 health care system, however, no single institution was responsible for = these=20 expenditures and, although each potential organization felt that PATH = was a=20 useful service, none was willing to contribute to its costs. = Fortunately, the=20 Army Surgeon General recognized PATH=92s value and provided funds = (approximately=20 US$100 000 per year). Since the initiation of the workload capture = function in=20 late 2006, we anticipate that the revenue generated from PATH=92s = teleconsultation=20 services will provide the necessary financial resources for future=20 sustainability.

The US military=92s transition to an electronic = medical record=20 (EMR) has resulted in further challenges for the PATH system. Since the = clinical=20 information needed for teleconsultation is already stored in a digital = format in=20 one of several computer systems, remote US health care providers have = requested=20 system interoperability to streamline the consultation process. In = addition, the=20 results of a PATH teleconsultation must find their way back to the = patient=92s EMR=20 so that future caregivers have access to the information. At present, = this is a=20 manual process, albeit one under review.

The introduction of telemedicine has provided = opportunities to=20 expand PATH=92s capabilities. We are currently experimenting with a = variety of=20 tele-auscultation devices for telecardiology. Although there was initial = enthusiasm about using these devices, once the novelty wore off most = were=20 abandoned because of the time required and the lack of technical support = available. We have learned that, although transmission of useful = telehealth=20 information may be possible with these devices, they must first be = tested and=20 integrated into PATH for seamless use prior to deployment. This is a = challenging=20 task, owing to the range of proprietary software and hardware, and the = few=20 interoperability standards.

Improved communications in the Western Pacific, by = non-secure=20 email, telephone or fax, has resulted in frequent consultations by = health care=20 providers outside the PATH system. Since these = routes allow=20 for easy, rapid consultation, some health care providers prefer this to=20 utilizing the PATH system. However, such consultation routes do not meet = privacy=20 requirements, result in little, if any, clinical documentation, and fail = to=20 generate workload credit for the physicians involved.

Future work

We continue to develop the PATH system. For example, = the=20 tele-auscultation module allows remote digital stethoscopy. This = includes a=20 digital heart sounds recording system, which can be operated via a = graphical=20 user interface. Using this system, paediatric cardiologists can = differentiate=20 normal from abnormal heart sounds with a high degree of accuracy.13 We = are also=20 beginning to use the PATH system for tele-education. This will provide=20 continuing medical education to staff distributed throughout the Pacific = region.

Acknowledgements

The views expressed here are those of the authors = and do not=20 reflect the official policy of the Department of the Army, Department of = Defense=20 or the US Government.

References

1.=20 Yano V, Finau SA, Dever G et al. The PBMA and telemedicine in the = Pacific: the=20 first steps. Pac Health Dialog 1997; 4: = 81=964.

2.=20 Delaplain CB, Lindborg CE, Norton SA, Hastings JE. Tripler pioneers = telemedicine=20 across the Pacific. Hawaii Med J 1993; 52:=20 338=969.

3.=20 Person DA, Whitton RK. An Internet based consultation and referral = network=20 between Tripler Army Medical Center and hospitals in the Western = Pacific. In:=20 Proceedings of Pacific Medical Technology Symposium, 1998: = 132=968.

4.=20 Person DA. Pacific Island Health Care Project: early experiences with a=20 web-based consultation and referral network. Pac Health Dialog = 2000;=20 7: 29=9635.

5.=20 Ruess L, Uyehara CF, Shields KC et al. Digitizing pediatric chest = radiographs:=20 comparison of low-cost, commercial off-the-shelf technologies. = Pediatr=20 Radiol 2001; 31: 841=967.

6.=20 Person DA. The Pacific Island Health Care Project: easing the cancer = burden in=20 the United States associated Pacific Islands. Pac Health Dialog = 2004;=20 11: 243=967.

7.=20 Person DA. The Republic of Palau and the Pacific Island Health Care = Project=20 (PIHCP). Pac Health Dialog 2005; 12: = 132=9640.

8.=20 Hensel KS, Person DA, Schaefer RA, Burkhalter WE. An internet-based=20 referral/consultation system for the US-associated Pacific Islands: its=20 contribution to orthopedic graduate medical education at Tripler Army = Medical=20 Center. Mil Med 2005; 170: 214=9618.

9.=20 Belnap CP, Freeman JH, Hudson DA, Person DA. A versatile and economical = method=20 of image capture for telepathology. J Telemed Telecare 2002;=20 8: 117=9620.

10. = Meza-Valencia BE,=20 de Lorimier AJ, Person DA. Hirschsprung disease in the US associated = Pacific=20 Islands: more common than expected. Hawaii Med J 2005;=20 64: 96=96101.

11. Malone = F, Callahan=20 CW, Chan DA et al. Caring for children with asthma through = teleconsultation:=20 =91ECHO-Pac: The Electronic Children=92s Hospital of the Pacific=92. = Telemed J E=20 Health 2004; 10: 138=9646.

12. Callahan = CW,=20 Malone F, Estroff D, Person DA. Effectiveness of an Internet-based=20 store-and-forward telemedicine system for pediatric subspecialty = consultation.=20 Arch Pediatr Adolesc Med 2005; 159: = 389=9693.

13. Mahnke = CB, Abbas=20 M, Mulreany MP. PacRim Pediatric Heartsounds Trial: asynchronous = pediatric=20 cardiology evaluation via tele-auscultation. Presented at the 2nd Annual = Pediatric Telehealth Colloquium, San Francisco, CA, 6=968 September = 2007.

16 Telemedicine support for a global network of = Italian=20 hospitals

Gianfranco Costanzo and Paola = Monari

Introduction

In 2002, the Italian Ministry of Health began a = project to=20 support Italian hospitals around the world. This was driven by an ad hoc = governing body, the Alliance of Italian Hospitals Worldwide. The IPOCM=20 (Integration and Promotion of Italian Hospitals and Health Care Centres=20 Worldwide) project originated from a census of Italian hospitals abroad=20 conducted by the Ministry of Foreign Affairs. By using an elastic = definition of=20 the term =91Italian=92, hospitals were identified in most developing = countries. The=20 hospitals included those with Italian ownership, Italian management or = Italian=20 physicians and health staff, and also those managed or owned by Catholic = religious orders.

In the initial census, there were 41 Italian hospitals = or other=20 health care centres. Almost immediately, another hospital was added to = the list=20 (Table = 16.1), and=20 after the First Conference on Italian Hospitals Worldwide, which was = held in=20 Rome, other Italian health care centres applied to be included. At = present,=20 there are 79, and the number is expected to increase in the future.

The project=92s vision was of a new kind of = international health=20 cooperation that was able to keep results locally, for use by health = providers=20 who are committed to improving the health status of the population. In = other=20 words, the intention was not to adopt a spot approach to health = cooperation,=20 which might alleviate the specific health needs of certain population = groups,=20 but rather to share with local staff the most appropriate methodologies = for=20 attaining ambitious and sustainable targets.

Within this framework, telemedicine was considered as = one=20 strategic factor in the structure and organization of the health care = network.=20 Since telemedicine facilitates diagnosis, medical consultation and = assistance=20 using the resources of centres of excellence, it could therefore improve = both=20 medical and administrative support for Italian hospitals abroad. A model = based=20 on the use of the Internet 1=969 = which is=20 autonomous and cooperative at the same time would conform with the = principle of=20 subsidiarity, i.e. decisions would be taken at the nearest level of=20 responsibility.

At the 2003 conference in Rome, Italian hospitals = abroad made=20 the request to be part of a democratic organization. The Alliance of = Italian=20 Hospitals Worldwide was

Table 16.1 Italian = hospitals
Country	Hospital
Albania	Poliambulatorio Padre Luigi Monti, = Tirana
Angola	Hospital da Divina Providencia, = Luanda
Argentina	Ospedale Italiano di Buenos Aires
	Ospedale Italiano Garibaldi, = Rosario
	Ospedale Italiano Monte Buey Ospedale Italiano = di=20 Cordoba
	Associacion Hospital Italiano Regional Del = Sur
	Ospedale Italiano De La Plata
Armenia	Ospedale Redemptoris Mater, = Ashotsk
Brazil	Poliambulatorio Nossa Senhora Aparecida, Foz do = igua=E7u
	Hospital Italiano di Rio de = Janeiro
Burkina Faso	Centro di Accoglienza Notre Dame de Fatima =96 = CANDAF,=20 Ouagadougou
	Centre M=E9dical avec Antenne Chirurgicale St = Camille,=20 Nanoro
	Centro di Salute e Promozione Sociale Suore = Figlie di San=20 Camillo, Ouagadougou
	Centro Medico St Camillo, Koupela
	Centro Medico St Camillo, = Ouagadougou
Canada	Ospedale Italiano Santa Cabrini = Montr=E9al
C=F4te d=92Ivoire	Centro Don Orione, Bonoua
Democratic Republic of the Congo	H=F4pital G=E9n=E9ral Conventionn=E9 = Catholique, Kimbau
	H=F4pital de Mokala, Kinshasa
	H=F4pital Txingudi, MC Lumbi
Egypt	Ospedale Italiano Umberto I, = Cairo
Ethiopia	HEWO Hospital =96 Quih=E0, Mekele
	Italian Dermatological Centre IISMAS, = Mekele
Jordan	Ospedale Italiano =96 ANSMI, = Amman
	Ospedale Italiano =96 ANSMI, = Kerak
India	Indian Spinal Injuries Centre, New = Delhi
	Israel Ospedale Italiano =96 ANSMI, = Haifa
	Holy Family Hospital, Nazareth
Kenya	Piccola Casa della Divina Provvidenza, = Chaaria
	Tabaka Mission Hospital, Tabaka
	St Camillus Mission Hospital, = Karungu
	Consolata Hospital Nkubu, Meru
Morocco	Ospedale Italiano =96 ANSMI, = Tangier
Paraguay	Sociedad Italiana de Socorro Mutuo, = Asuncion
Syria	Ospedale Italiano =96 ANSMI, = Damascus
Sudan	Mary Immaculate Hospital. = Mapourdit
Tanzania	Mbweni Hospital =91Santa Maria = Nascente=92
Uganda	St Mary=92s Hospital di Lacor
Uruguay	Ospedale Italiano Umberto I, = Montevideo
Venezuela	Policlinico Santa Ana, Ciudad = Bolivar
Zambia	Italian Orthopaedic Hospital, = Lusaka
	Ospedale Mtendere Mission, = Chirundu
Zimbabwe	St Michael=92s Mission Hospital, = Ngezi
	Luisa Guidotti Hospital, = Mutoko

then formally established. The founding partners = were a=20 number of government ministries. Immediately afterwards, certain centres = of=20 excellence in Italy were invited to join the Alliance. It was agreed = that all=20 partner hospitals in Italy and abroad would cooperate on health by = supporting=20 the network. The strategic objective was to contribute expertise from = Italy to=20 increase the quality of health care in Italian hospitals abroad.

Policy-making process

Under normal circumstances, a distinction can be = made between=20 the different phases in the policy-making process.10 = Accordingly,=20 the Italian Ministry of Health began a public policy cycle. The phases = were=20 agenda setting, policy formulation, policy implementation and policy = evaluation,=20 i.e. those of classical public policy research.

The agenda setting was established on the basis of the = wishes of=20 the Italian hospitals abroad, which expressed a need for diagnostic = support and=20 organizational assistance. Within the Ministry of Health, a group of = experts who=20 later on would be working for the IPOCM project started studying the = problem,=20 using systematic methodologies and tools. Five objectives resulted:

1. To connect the Italian hospitals abroad with = centres of=20 excellence in Italy and the Secretariat for Technical Assistance (STA) = in=20 Rome

2. To reduce diagnostic and organizational = shortcomings among=20 doctors working in Italian hospitals abroad, through a teleconsultation=20 service

3. To increase the individual and collective skills of = the=20 health personnel through an e-learning service

4. To facilitate twinning arrangements between = hospitals and=20 facilitate government agreements with the countries hosting Italian = hospitals=20 abroad

5. To find out more about the health needs of Italian = hospitals=20 abroad in order to provide better cooperation and sustain the = acquisition of=20 medical equipment.

Task environment

Since the IPOCM participants and activities were = functionally=20 interconnected, actions of any one could potentially affect the = others.11 = Given this=20 complex framework for

3DImage=20

Figure 16.1 The Alliance=92s = power-interest=20 grid

action, an assessment of stakeholders and their = relevance was=20 undertaken. The relevant internal stakeholders were the founding = ministries and=20 the associated hospitals in Italy and abroad. The relevant external = stakeholders=20 were the hospitals in the developing countries, the scientific = community,=20 citizens=92 associations and the press.

Observation of the policy arena requires accurate = management of=20 all stakeholders. They can be prioritized using the power versus = interest=20 grid.12 Figure 16.1 = shows the=20 power=96interest grid of the project stakeholders.

The task environment of the Alliance describes the = ideal area=20 occupied by its stake-holders, such as clients, providers, competitors, = unions,=20 employees, financiers, institutions and scientific organizations. It is = also a=20 place in which the Alliance operates intense and continuous = relationships.13

In order to pursue the project=92s objectives, = telemedicine=20 instruments and political levers were identified, all of them designed = to=20 empower health professionals abroad. Medical teleconsultation and = e-learning=20 services were designed. In addition, an inventory of health equipment = was set up=20 in order to allow hospitals abroad to benefit from health equipment = donated by=20 institutions in Italy. (A complete description of the Alliance=92s = services and=20 user manuals is available at the Ministry of Labour=92s website.14)

Teleconsultation

Various telemedicine approaches have been used over = the last=20 few years.15=9617 In = particular, those of medium or low cost that use customized computer=20 applications have been found to be best for developing countries. This = is=20 confirmed by the extensive use of the Internet18,19 = and email in=20 low-resource settings,20 on = the basis=20 of cost=96benefit considerations, high availability = of=20 connection services and common knowledge about their use.

The methodology adopted for the network was to assess = first the=20 technological need expressed by each Italian hospital abroad. As a = consequence=20 of this, all information from the different countries was collected and = studied=20 by the Secretariat in order to identify those that were viable. The = availability=20 of local Internet connectivity was examined, and standard contracts to = be signed=20 by hospitals with Internet service providers (ISPs) were developed. All = this=20 work was designed to allow all hospitals to have similar connectivity. = The best=20 approach for about 30% of the hospitals, most of them in the sub-Saharan = area,=20 was a satellite connection through individual contracts with a = non-profit-making=20 provider. To improve interoperability, the hospitals were equipped with = similar=20 workstations. Finally, software specifications were produced.

The Alliance=92s network is based on access to the = Internet via=20 ADSL, HDSL (high-bit-rate digital subscriber line) or full-duplex 256 = kbit/s=20 Ku-band satellite communication. The = satellite=20 connections are mainly used by hospitals in sub-Saharan Africa. = Workstations are=20 PCs equipped with peripheral devices such as a digital cameras, printers = and A4=20 scanners. The teleconsultation architecture is based on a Management = Centre (MC)=20 located at the Secretariat in Rome. The client software allows either an = asynchronous telemedicine interaction or a real-time = videoconference.

Two different types of users are involved. The = referring doctors=20 are located in 45 hospitals abroad and the specialists are located in 34 = hospitals in Italy. The choice of specialist for a given = teleconsultation is not=20 made at the referring site. Instead, the teleconsultation allocation is=20 performed by the MC. This guarantees the same quality to all referring = doctors.=20 The MC allocates the request to the most appropriate specialist based on = a=20 routing matrix. The MC can monitor the process until the = teleconsultation is=20 completed (the target is to complete consultations within 72 hours). The = Alliance=92s database contains 86 disease code groups, according to the=20 International Classification of Diseases, 9th revision, = Clinical=20 Modification (ICD9-CM),21 = which expand=20 into 8500 single disease codes. Each specialist centre is responsible = for=20 negotiated code groups, and organizes itself to satisfy the service = workload=20 within the established targets for reply time and performance quality. = Most=20 specialist centres decided to concentrate the incoming referral traffic = on a=20 single workstation.

The referring doctor uses the client software to = generate an=20 email message containing clinical case data, or to access a = videoconsultation if=20 necessary. When compiling the fields on the electronic form, structured = XML=20 messages are created. Since both enquiry and reply are managed by the = same=20 client software, any health centre is able to act as a referral or a = specialist=20 site. The referring doctor, in addition, can invite a close examination = of a=20 clinical case by sending a videoconsultation invitation to the = specialist.

International standard medical terminology is = supported by the=20 system, as well as five different languages (Italian, English, French,=20 Portuguese and Spanish). Diseases are codified according to ICD9-CM and = drug=20 names are taken from a standard reference work.22 = The=20 interface collects all relevant data for the teleconsultation request or = reply=20 into encoded fields, in order to allow later textual retrieval and = statistical=20 analysis. ICD9-CM codes and the patient=92s gender and age are the = relevant pieces=20 of information for the routing function performed = at the MC,=20 and they are put into the form by the referring doctor through = multi-option=20 lists. Most attached files are captured by digital cameras, and are = usually sent=20 after compression (i.e. with a .zip extension). Some attached files are = taken=20 directly from diagnostic equipment where feasible.

The database does not store any patient identity = information,=20 and therefore the system complies with Italian privacy law. The message = reaching=20 the MC contains a teleconsultation identification number, which is = automatically=20 generated by the software, as well as the hospital and workstation = identifiers.=20 Request and reply data are stored in a teleconsultation record in the = database=20 (Microsoft Access), which also holds diagnostic attachments and other=20 information, such as the time of the request delivery at the MC and the = time of=20 the reply being forwarded to the referring doctor. Attachments are = classified by=20 content (e.g. patient pictures, reports, images or chart recordings). = The=20 attachment extension is automatically captured by the system, allowing = the MC to=20 detect possible mismatches between the number of attachments that are = sent and=20 those actually received. Transfer protocols between the PC and mail = server are=20 SMTP and POP.

In addition, a videoconsultation can be requested by a = referring=20 doctor in relation to a clinical case where a reply has already been = delivered.=20 It can also be requested by a specialist when sending the reply. The MC = manages=20 the videoconsultation requests until the referring doctor and the = specialist=20 reach an agreement about the date and time. The MC=92s main functions = allow=20 clinicians to contact hospitals in different time zones while they are = not=20 online and allow clinicians to handle requests for videoconsultation. = Once the=20 meeting has been agreed, the MC notifies the caller, and those involved = are sent=20 an invitation message that contains a link to the web portal. Finally = the system=20 sends an alert message some minutes before the scheduled time to ensure = that=20 both doctors are available in front of their PCs. Doctors can therefore = launch=20 the session from any workstation with a browser that accepts ActiveX = controls=20 and discuss the case with the help of the relevant documentation.

E-learning

Global support to health personnel includes the = provision of=20 an e-learning service oriented to the needs of doctors and health staff = abroad.=20 This facility is provided in addition to training events on specific = topics of=20 common interest.

Assessment of training = needs

One main problem was to understand as accurately as = possible=20 the scale and quality of the training required. The Secretariat reviewed = various=20 information sources. The first was the declaration given by the hospital = at the=20 time of application to the Alliance. They are required to complete a = health=20 personnel training requirement form for each of their health staff. This = information is then stored in a database ready for analysis.

A second source was the registration of doctors and = health staff=20 with the Alliance e-learning platform. Potential users are asked to give = information about their professional and training = profile,=20 curriculum and career expectations. They are also requested to state = their=20 training need in terms of medical disciplines. This information is also = stored=20 in the database and used for subsequent analysis.

A third source, although an indirect one, is the = medical=20 teleconsultation service itself, with a database that provides = statistics about=20 the most commonly used ICD9-CM codes. The teleconsultation data = therefore=20 identifies disease areas that deserve particular attention and thus = training=20 support.

Other aspects that are taken into consideration are = the hospital=20 resources and the sociopolitical framework. Developing countries, = especially the=20 least developed countries, have their own agenda on health topics.

Production of learning = content

Most of the learning materials that have been = produced are the=20 result of an assessment of the training needs expressed by the = hospitals. Each=20 centre of excellence selected its own production materials and made them = available to the Secretariat. These materials were optimized for = uploading and=20 organized by training area and by an assigned ICD9-CM code.

Other important data accessible via the platform come = from the=20 medical teleconsultation reports. In fact all teleconsultations result = in=20 reports that are classified by ICD9-CM code, and therefore a referring = doctor=20 can consult this archive before making a new teleconsultation request. = The=20 teleconsultation service therefore has substantial training = benefits.

In addition to all this, the Secretariat has produced = 18 new=20 learning courses in response to identified training needs:

1. Oral urgent treatment protocol

2. Infectious disease prevention

3. Disorders of growth

4. Periodic fevers in the child

5. Chronic diarrhoeas

6. HIV/TB comorbidity

7. Clinical and biochemical ART monitoring

8. Hypertension in pregnancy

9. Post-partum haemorrhage and puerperal = infections

10. Ectopic pregnancy

11. Ovarian tumours and their complications

12. Menorrhagia

13. Lung TB radiological diagnosis

14. Hospital infections

15. Biological risk and vaccine prevention for health=20 personnel

16. Low economic impact reconstructive prosthesis = techniques

17. Pharmacological and surgical therapy in acute oral = infections

18. Infectious diseases in pregnancy.

The courses were produced by teams that are = facilitated and=20 monitored by the Secretariat for Technical = Assistance. The MC=20 looks after the whole production process with an expert who manages = relations=20 with the external producer company. The role of the MC=92s expert is = essential in=20 monitoring the timing, given the complexity of the multiple production=20 processes.

Health equipment inventory

In response to requests for new equipment coming = from doctors=20 working abroad, the Secretariat produced a web-based inventory for = health=20 equipment that was being donated. In 2005, Italian law provided the = legal=20 framework for public health centres to give notice to the inventory of = the=20 planned disposal of functioning health equipment. Thus, the inventory = allows a=20 centre to make the equipment available for an interested hospital = abroad.=20 Hospitals can see all equipment on the inventory and reserve items = according to=20 their need. This system, which matches offer and demand, improves the = efficiency=20 of the donation process and provides a picture of the entire donation = cycle,=20 which is useful for a better cooperation policy.

An ontology for the Alliance

Classification of diagnoses and other statistical = data is=20 fundamental to the work of the Alliance. This led to an ontological = definition=20 of the Alliance=92s services.23,24 = ICD9-CM=20 codes are ontology agents of the teleconsultation routing matrix. = Doctors can=20 scroll through the list of training materials and cross-link the = interservice=20 ontology agent, taking advantage of different databases. The same thing = is=20 possible when using the web-based inventory of donated medical equipment = (which=20 is the third service of the Alliance), where the agent is hospital = structure, as=20 well as when talking of teleconsultation, where both ICD9-CM and = hospital=20 structure are considered (Figure = 16.2).

Quality control

Customer satisfaction

In 2005, a survey of service satisfaction was = carried out=20 among teleconsultation users. The areas investigated were technology,=20 communication and organization. The results of the survey showed that = 89% of=20 specialists expressed positive judgements, and 86% of referring doctors. = There=20 were only a small number of negative judgements (about 9%). Criticisms = were=20 discussed subsequently with specialist and referring centres in order to = improve=20 service quality.

The Secretariat urged the MC to intervene on a few = points=20 related to technological and organizational matters. In about 10% of the = hospitals, the MC detected trans-coding actions on teleconsultation = messages=20 operated by some Microsoft Exchange mail servers, as well as = difficulties=20 related to internal security policies. These

3DImage=20

Figure 16.2 The first implementation = of the=20 Alliance=92s reference ontology. (Adapted from Top Level Concepts of = the=20 Reference Ontology of Medicine. Laboratory of Applied Ontology of = Rome,=20 National Research Council.)

problems were overcome by helping the hospital IT = departments=20 to properly configure their internal mail servers and security systems. = The=20 automatic alarm facilities at the MC helped to identify the problem of = lost=20 attachments and to solve it.

As far as the service organization at the health = centres is=20 concerned, after experiencing some mismanagement of time and allocation = of=20 requests, hospitals were advised by the Secretariat to install the=20 teleconsultation workstation in the health directorate in order to = manage the=20 incoming flow of enquiries centrally. Some teleconsultation forms were = not=20 properly filled in by the referring centres in terms of completeness of = medical=20 data for diagnosis, so the Secretariat intervened in order to improve = the=20 request quality and speed up the processing. This represents a global = process of=20 optimization.

In 2006, a second survey on satisfaction was carried = out. The=20 results were positive in relation to the national health centres and to = the=20 Italian hospitals worldwide. For the latter, a slight decrease of = service=20 satisfaction was recorded in comparison with the previous survey. The = reasons=20 are essentially due to the =91distance=92 of some physicians who in = Italy are far=20 from the day-to-day problems of hospitals in other countries. As far as = the=20 specialists are concerned, communication can sometimes be difficult = (mostly=20 because of the use of the English and Spanish languages on the form, = rather than=20 Italian, and the lack of clinical data).

Manual of procedures

The total quality management approach adopted by the = Alliance=20 includes a manual of procedures. Procedures are planned for each of the=20 Alliance=92s services with the help of the relevant people in the = operational=20 management. This is an attempt to standardize actions in a = conceptualized=20 framework. It helps operators to manage routine and unexpected events.=20 Procedures are revised either periodically or when needed.

Insights

Common difficulties experienced during the first = years of the=20 project included a shortage of local infrastructure and a lack of = financial=20 resources. War conditions in some of the countries hosting the = Alliance=92s=20 hospitals provided additional problems. Planning and implementation = activities=20 were therefore very important, and the Secretariat accomplished these = tasks=20 successfully. We concentrated on finding technical solutions tailored to = the=20 micro dimension of each problem, since it was impossible to act = with a=20 country-level approach. The motivation and cohesion of the hospitals = were=20 continuously supported by the Secretariat, and there was = public=96private=20 sponsorship for some technical solutions. After four years of = experience, it is=20 clear that success is mainly due to the strong organizational framework = provided=20 by the Secretariat, in terms of methodologies and procedures. This has = made it=20 possible to produce better results than are common with telemedicine = projects in=20 developing countries, where simple email is the usual medium of = communication.=20 Key factors in our success were a telecommunication network, specialized = software for teleconsultation, an organized database and ad=20 hoc ontologies.

There were other components that were also essential = for the=20 success of the initiative. The hospitals in Italy provided valuable = expertise,=20 both in teleconsultation and in distance learning. In addition, it = should be=20 mentioned that free-of-charge participation of hundreds of specialists = would be=20 simply inconceivable if done outside the public health system.

Finally, all doctors of Italian hospitals worldwide = have left=20 their own mark in strengthening the mission of the Alliance, which is = both=20 ethical and cooperative. The mixture of all these things has made the = programme=20 effective, and now partnership appears to be a main asset.

Conclusion

The IPOCM programme is rather different from other=20 telemedicine work recorded in the literature. Although it shares some = elements=20 with other telemedicine initiatives in developing countries, it has = relied on a=20 solid organizational element as well as standardized procedures. = Institutional=20 support, in terms of resources and know-how, was crucial in ensuring=20 sustainability and high service quality. Furthermore, good governance = was=20 required to keep all these elements together. Appropriate resources and = good=20 governance are therefore important components for a public policy = focused on=20 health partnership in developing countries.

References

1.=20 Vassallo DJ, Buxton PJ, Kilbey JH, Trasler M. The first telemedicine = link for=20 the British Forces. J R Army Med Corps 1998; = 144:=20 125=9630.

2.=20 Vassallo DJ. Twelve months=92 experience with telemedicine for the = British armed=20 forces. J Telemed Telecare 1999; 5(Suppl 1):=20 117=9618

3.=20 Edejer TT. Disseminating health information in developing countries: the = role of=20 the Internet. BMJ 2000; 321: 797=96800.

4.=20 Fraser HS, McGrath SJ. Information technology and telemedicine in = sub-Saharan=20 Africa. BMJ 2000; 321: 465=966.

5.=20 Vassallo DJ, Swinfen P, Swinfen R, Wootton R. Experience with a low-cost = telemedicine system in three developing countries. J Telemed = Telecare=20 2001; 7(Suppl 1): 56=968.

6.=20 Vassallo DJ, Hoque F, Roberts MF et al. An evaluation of the first = year=92s=20 experience with a low-cost tele-medicine link in Bangladesh. J = Telemed=20 Telecare 2001; 7: 125=9638.

7.=20 Graham LE, Zimmerman M, Vassallo DJ et al. Telemedicine =96 the way = ahead for=20 medicine in the developing world. Trop Doct 2003; = 33:=20 36=968.

8.=20 Wootton R. Design and implementation of an automatic message-routing = system for=20 low-cost telemedicine. J Telemed Telecare 2003;=20 9(Suppl 1): 44=967.

9.=20 Cone SW, Carucci LR, Yu J et al. Acquisition and evaluation of = radiography=20 images by digital camera. Telemed J E Health 2005; = 11:=20 130=966.

10. Anderson = JE.=20 Public Policy-Making. New York: Praeger, 1972.

11. Kirsh D. = Adapting=20 the environment instead of oneself. Adaptive Behavior 1996;=20 4: 415=9652.

12. Eden C, = Ackermann=20 F. Making Strategy: the Journey of Strategic Management. = London: Sage,=20 1998.

13. Johnson = G, Scholes=20 K. Exploring Corporate Strategy. Englewood Cliffs, NJ: = Prentice-Hall,=20 1993: 75=96114.

14. = Ministero del=20 Lavoro, della Salute e della Politiche Sociale: Settore Salute. = Available (in=20 Italian) at: www.ministerosalute.it.

15. Mitka M. = Developing countries find telemedicine forges links to more care and = research.=20 JAMA 1998; 280: 1295=966.

16. Strode = SW, Gustke=20 S, Allen A. Technical and clinical progress in telemedicine. = JAMA 1999;=20 281: 1066=968.

17. Rodas = EB, Latifi=20 R, Cone S et al. Telesurgical presence and consultation for open = surgery.=20 Arch Surg 2002; 137: 1360=963.

18. Fisk NM, = Vaughan=20 JI, Wootton R, Harrison MR. Intercontinental fetal surgical consultation = with=20 image transmission via Internet. Lancet 1993; = 341:=20 1601=962.

19. Kuntalp = M, Akar O.=20 A simple and low-cost Internet-based teleconsultation system that could=20 effectively solve the health care access problems in underserved areas = of=20 developing countries. Comput Methods Programs Biomed 2004;=20 75: 117=9626.

20. Zolfo M, = Lynen L,=20 Dierckx J, Colebunders R. Remote consultations and HIV/AIDS continuing = education=20 in low-resource settings. Int J Med Inform 2006; = 75:=20 633=967.

21. National = Center=20 for Health Statistics, US Centers for Disease Control and Prevention.=20 International Classification of Diseases, 9th revision, = Clinical=20 Modification (ICD9-CM). Available at: = www.cdc.gov/nchs/icd9.htm.

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17 Telemedicine in Nepal

Mohan R Pradhan

Introduction

Telemedicine is the process of providing medical = expertise=20 remotely with the help of telecommunication. It is particularly valuable = in=20 remote areas, and is therefore useful in Nepal, where the few = specialists are=20 separated from most of the population. Nepal has one of the lowest gross = national products (GNPs) (US$300) per capita1 and = one of the=20 lowest literacy rates (50%)2 of = the South=20 Asia Region. These factors have contributed to the prevalence of = communicable,=20 respiratory and nutrition deficiency diseases, which are among the most = common=20 disorders seen in hospital outpatient departments. Telemedicine is = therefore an=20 attractive potential means of improving health services. In = industrialized=20 countries, real-time telemedicine is commonly used. However, this = modality is=20 not applicable in a developing country, like Nepal, because of the high = cost of=20 bandwidth and the poor telecommunication infrastructure.

The alternative modality, more suitable for a = developing=20 country, is store-and-forward telemedicine. In a store-and-forward = interaction,=20 the referring doctor usually enters the clinical information and digital = images=20 in a computer. The information can then be transmitted via a dial-up = Internet=20 connection as an email attachment to a central computer. The expert = doctor can=20 access the data independently at a convenient time. The size of the = images=20 attached to email messages is a potential problem with this technique, = which may=20 necessitate some degree of image compression.

HealthNet Nepal

HealthNet Nepal is a non-governmental organization = (NGO) that=20 provides affordable Internet services to the Nepalese health community, = access=20 to health information and technical support for various regional=20 information-sharing initiatives. It has developed its own software, = called Hnet=20 telemedicine.

Development of the = software

When we examined the available telemedicine = software, we found=20 that open source software was not suitable for our purpose3 and = that=20 commercial software could not be easily modified. It was therefore = decided to=20 develop software suitable for telemedicine in the context of = Nepal.

The local system collects a clinical history and = images, which=20 are then transmitted to a specialist for diagnosis. For the clinical = history,=20 both general information and discipline-specific information are = collected. The=20 general information includes the following:

patient=20 information

basic=20 information

personal = history

past = medical=20 history

family = history.

There is also discipline-specific information for = the=20 following specialties:

= pathology

= radiology

= dermatology

= cardiology.

In acquiring digital images, the following = components were=20 considered.

Pathology

Images were obtained using a digital camera (Nikon = CoolPix=20 4500). This type of camera is suitable for pathology. It has a = resolution of 4=20 megapixels (Mp), which is sufficient for telemedicine according to the=20 recommendations of the American College of Radiology.4 An = additional=20 advantage of this camera is that it can be easily mounted on a = microscope with a=20 30 mm eyepiece adapter.

Radiology and dermatology

It was found that using the same camera for = pathology was not=20 practical. The camera used for radiology and dermatology was a Nikon = CoolPix P4,=20 which has a higher resolution (8 Mp). An additional feature of this = camera is=20 its vibration-reduction ability, which makes it suitable for taking = pictures in=20 shaky conditions.

Cardiology

For cardiology, an ECG machine was used (ECG 9620L, = Cardiofax)=20 that directly transfers an ECG image to a computer. Thus, there is no = need to=20 use a digital camera to photograph ECG recordings.

Software for data transfer and=20 security

The software ensured data security during transfer = in the=20 following ways.

Image processing

Once images have been stored in the computer, they = need to be=20 cropped to reduce the file size and annotation has to be provided for = better=20 description of the clinical problem. A simple graphics package was = developed for=20 this purpose and incorporated into the client software of the Hnet = telemedicine=20 system. This graphics package allows cropping, = annotation,=20 rotation, colour balance and conversion to black and white. In addition, = the=20 free image-viewing software IrfanView was used.5

Compression

Image compression was used to reduce the quantity of = memory=20 required to store an image. For example, an image that has a resolution = of 640 =D7=20 480 pixels with 24-bit colour requires 900 kbyte of storage. If this = image can=20 be compressed at a compression ratio of 20 : 1, the quantity of storage = required=20 is reduced to about 45 kbyte. Hnet has used the camera=92s built-in JPEG = image=20 compression at a ratio of 16 : 1. It has been found that image = compression of=20 60=9680% can be achieved without significant loss of diagnostic = quality.

Security and confidentiality

Data stored in a computer must not be read or = compromised by=20 unauthorized users. The Hnet software uses password-level encryption. = The=20 passwords are stored in MD5-encrypted format for security. Without an = authorized=20 login, no one can run the application.

Receiving and reviewing cases

After logging on to the Hnet system, the two = physicians=20 concerned, typically a remote physician or health worker and a medical=20 specialist in a hospital, communicate by email. After uploading a case, = the=20 server selects a doctor on a simple round-robin basis from the names = listed in=20 the roster. The server regularly watches for a reply from the doctor. If = a=20 doctor does not reply to a case within 12 hours, then the case is = automatically=20 assigned to another doctor listed in the roster. Doctors are categorized = into=20 groups, such as dermatology, radiology, cardiology and pathology. These=20 specialists can view only their own cases.

Digital photography guides

A technical manual was developed as a basic guide = for=20 non-medical professionals and general practitioners on how to take = clinical=20 photographs in radiology, pathology and dermatology using a digital = camera.

Pilot project

The pilot telemedicine network was implemented from = July 2004=20 to December 2006. The project was financed by the PAN Asia programme of = the=20 IDRC, Canada (see Chapter=20 7). The following hospitals referred cases for telemedicine:

AMDA = Hospital, Damak=20 (eastern region)

Siddhartha = Children=92s and Women Hospital, Butwal (western region)

Siddhi = Memorial=20 Hospital, Bhaktapur (central region).

Specialist expertise was provided from the following = central-level hospitals:

Teaching = Hospital,=20 Tribhuvan University (Department of Radiology and Dermatology)

Kathmandu = Medical=20 College (Department of Pathology and Department of Dermatology)

Sahid = Ganga Lal=20 National Heart Centre.

The medical experts located at the medical colleges = and=20 special hospitals of the central level (capital city) were chosen = because the=20 doctors there had better knowledge of IT and were willing to participate = in the=20 project. The local hospitals were chosen based on the size and location = of the=20 local population.

It was found that the availability of telemedicine = increased the=20 volume of teleconsultation and provided exposure to a rural community = for the=20 medical interns of medical colleges. It also provided continuing = education and=20 reduced the professional isolation of health professionals working in = rural=20 areas. All these factors improved the quality and efficiency of the = health=20 service. With the use of telemedicine, access to the literature through = the=20 HINARI system of the World Health Organization increased. The = observations below=20 are based on informal communication with the referring physicians.

Study

A study was conducted in Nepal to assess whether = telemedicine=20 based on store-and-forward technology would be satisfactory for the = diagnosis of=20 cases sent from remote rural areas in the specialties of dermatology, = radiology,=20 pathology and cardiology. There were two components to the work: a basic = component and a clinical component.6 The = basic=20 component was to define the minimum technical specifications to ensure = that=20 diagnostically important information could be captured through a = clinical=20 history and digital image. This component also included an investigation = of the=20 medical expert=92s ability to make an accurate diagnosis based on = digital images=20 and clinical history. The second component was to evaluate whether the=20 technology would improve the process of health care delivery by = increasing=20 information flow and reducing professional isolation.

For inclusion of cases, data were collected from the = field=20 sites. These cases were entered into the computer of the client site and = uploaded to the server. On the server, the specialist doctors completed = their=20 perception of the image exposure and diagnostic quality using a binary = scale (0=20 =3D poor or 1 =3D adequate). At the second stage, the specialist doctors = recorded=20 their confidence in the presence of each diagnostic indicator on a = five-point=20 scale (1 =3D definitely absent to 5 =3D definitely present). The ratings = from these=20 scales were used for receiver operating characteristic (ROC) analysis. = The ROC=20 analysis was used to determine whether the image quality was sufficient = for=20 diagnosis.

A two-step rating method was used to plot the ROC = data. First, a=20 dichotomous variable indicating quality of image (0 =3D negative or 1 = =3D positive)=20 was used. Second, the dichotomous variable based on the quality of the = image was=20 further rated based on a five-point scale (1 =3D = definitely=20 negative to 5 =3D definitely positive. The use of five categories is a = reasonable=20 compromise between the needs of ROC analysis and the precision with = which the=20 observers can be expected to reproduce their ratings. The five-point = rating=20 scale was used to calculate predicted probability. This predicted = probability=20 along with the dichotomous variable can be used to plot an ROC curve in = order to=20 provide a visual impression of the reliability of the points. The = statistical=20 package SPSS 11.5 was used for calculating predicted probability using a = logistic regression model. Based on the dichotomous variable, a = predicted=20 probability ROC curve was plotted.

Similarly, provisional diagnosis by primary care = physicians and=20 diagnosis by clinical experts was used for comparing baseline medical = knowledge=20 of primary care physicians with clinical experts. These data were used = only in=20 dermatology.

Study findings

A total of 218 cases were observed:

= dermatology : 75=20 cases

radiology = : 90=20 cases

histology = : 34=20 cases

cytologu : = 19=20 cases.

The gold standard for any specialist referred = remains the=20 traditional method of consultation, i.e. in the case of radiology, it is = the=20 viewing of an X-ray film; in the case of pathology, it is viewing = through a=20 microscope; and in the case of dermatology, it is face-to-face=20 consultation.

We adopted an affordable system that was appropriate = to our=20 needs.7 = Compared with=20 real-time systems, store-and-forward systems are more practical and less = expensive. Store-and-forward methods allow the use of low-cost = equipment,=20 low-bandwidth connections and asynchronous consultation. This approach = has been=20 used successfully in industrialized countries where high-quality images = are=20 transmitted via tele-medicine networks for consultation.8

Digital cameras are an efficient method of obtaining = digital=20 images. Krupinski et al9,10 = evaluated=20 the effectiveness of digital photography for dermatology and bone trauma = diagnoses, and found that digital camera images were of satisfactory = quality.=20 Piccolo et al11 = found high=20 diagnostic concordance between telepathology and histopathology = diagnosis. Lim=20 et al12 = and High et=20 al13 = evaluated a=20 digital camera for teledermatology, and also found high concordance with = face-to-face diagnoses.

For determining the quality of images sufficient for = diagnosis,=20 a ROC analysis was performed. It has been suggested that qualitative = conclusions=20 can be drawn from ROC experiments performed with at least 100 = observations.14 In = our=20 example, all four tests (dermatology, radiology, histology and cytology) = had low=20 p values (p < 0.5).15 Figure 17.1 = shows the=20 ROC curve for dermatology. It can be concluded that the images had the = ability=20 to detect disease.

3DImage=20

Figure 17.1 ROC curve for = dermatology (the=20 broken line represents no discrimination, i.e. a random guess)

Willingness to participate in the = telemedicine=20 project

In Nepal, there are few doctors. There is only one = doctor for=20 6000 people (the doctor-to-population ratio is 1 : 6000). Our study = showed that=20 practising doctors usually did not use IT for knowledge updating. The = reasons=20 given for not using IT were that most of the doctors were busy = practitioners and=20 they perceived that they could manage communicable, respiratory, = tropical and=20 nutritional deficiency diseases without recent information. Another = reason was=20 the heavy patient workload.

However, the circumstances are different in medical = colleges,=20 since doctors are required to update their knowledge in order to teach = students.=20 IT has become a useful medium for updating their knowledge. So, doctors = working=20 in medical colleges and special research institutes are chosen as = experts for=20 the diagnosis of certain cases. Another reason is that doctors working = in=20 medical colleges and research institutes feel comfortable in using = IT.

Age of users

All the users were aged 31=9650 years. This included = participants from both central and local hospitals. The reason may be = that the=20 younger generation grew up with computers, witnessing developments in = computers=20 and the Internet first hand.

Gender

Only one (10%) female was involved in a telemedicine = project,=20 and she was a health professional from a central hospital. In Nepal, = medicine=20 has been and still is a male-dominated profession. = Nurses=20 were not involved in telemedicine in the local hospital. The reason is = that=20 consultations are like a second opinion, which exclude nurses=92 = participation=20 because they do not have the doctors=92 level of competence.

Organizational position

With reference to the organizational position of = participants,=20 it was found that staff involved in the telemedicine project were = doctors or=20 technicians responsible for the technical part of the project.

Users=92 attitudes to = telemedicine

The technical components of telemedicine were = related to the=20 computerization process of central and remote sites. The problems = related to the=20 computerization process were related to low computer literacy and the = absence of=20 reliable communication infrastructure. In this context, the users=92 = attitudes=20 depended on their general knowledge and familiarization with computer=20 technology. All participants in the project from local hospitals and = central=20 hospitals felt comfortable with IT as a whole and telemedicine in = particular.=20 Telemedicine gave them an opportunity to enhance their efficiency and = distance=20 learning and to minimize professional isolation. With the help of = telemedicine,=20 they were able to create databases for various diseases, their forms and = methods=20 of treatment. Doctors perceived that the databases helped to improve = their=20 efficiency.

Consultation areas

Telemedicine was used for the purpose of general = guidance,=20 assessment of diagnosis, treatment and examinations. It was also found = that=20 confidence between local and remote hospitals was crucial to achieve and = maintain a fruitful dialogue. Often it is difficult to state the = diagnosis from=20 the first information transferred. For this, two-way communications in = the form=20 of chat is provided to make a precise diagnosis.

Collaboration between doctors at local and = central=20 level

The users in the telemedicine project noted that = their=20 collaboration with professionals changed with the help of telemedicine. = Doctors=20 become more open to advice from their colleagues and specialists. = Doctors came=20 to believe that the process of patient care could be enhanced through=20 telemedicine, and their trust in information technology increased.

Exposure to rural areas

In Nepal, most doctors are reluctant to work in = rural areas=20 owing to professional isolation, lack of facilities to update their = knowledge=20 and lack of continuing education. In medical colleges, as a part of an=20 internship programme, a doctor has to work in rural areas. The = telemedicine=20 process minimized the gap of professional isolation and gave the = opportunity for=20 continuing education in rural areas. This first-hand experience in rural = areas=20 with telemedicine may motivate doctors to work in rural areas when their = medical=20 courses are completed.

Drawbacks

Although telemedicine clearly has a number of = potential=20 benefits, it also has some disadvantages. The main drawbacks are a = potential=20 breakdown in professional relationships and a number of organizational=20 problems.

Breakdown in the relationship between health=20 professionals

Skilled staff at the remote site sometimes perceive = that their=20 autonomy is threatened by the use of telemedicine, or, worse still, = think that=20 they will become no more than technicians, acting solely at the guidance = of the=20 remote specialist.16

Organizational problems

The following organizational problems were = identified in=20 Nepal:

Fear of = the unknown.=20 Nepal remained poorly networked because of inertia, fear and technical=20 inexperience of higher management personnel in government and NGOs.

Lack of = trained=20 manpower. In spite of widespread enthusiasm about IT, there are very few = local=20 facilities for higher-level technical training.

= Possessiveness. In a=20 country with the lowest GNP in the region and having few opportunities, = people,=20 including higher-level management, tend to hoard everything. They do not = hesitate to break contracts, even for minor financial benefits. This = attitude=20 runs counter to networking and information sharing.

Economic evaluation

An analysis was carried out to compare the cost of=20 telemedicine with the cost of traditional methods of providing health = care=20 services (Table=20 17.1). Only variable costs were considered. The cost charged by the = remote=20 site was approximately 50% less than the charge to be paid in city = areas.=20 However, the patient need not bear the cost of transportation and = lodging. The=20 telemedicine service charge would be sufficient to

Table 17.1 Comparison of = variable costs=20 (1 US$ =3D Rs0.65)
Type of service	Charge through traditional method = (Nepalese=20 Rs)	Charge through telemedicine (Nepalese=20 Rs)
Radiology (plain X-ray)	15	15
ECG	400	200
Pathology (cytology)	500	250
Dermatology	200	50
Transportation (nearest city)	200	=97
Lodging	200	=97

cover the fixed costs and to pay the fees of the = expert. Thus,=20 only the cost of the expert=92s Internet connection would have to be = borne by the=20 remote centre. It is too early to calculate all the costs (fixed and = variable)=20 in order to estimate whether tele-medicine could become financially=20 sustainable.

Research findings

We also compared the baseline medical knowledge of = primary=20 care physicians with clinical experts. Here, we also found that there = was no=20 difference in the diagnosis among primary care physicians and expert = doctors.=20 This supports the view that textual information supplemented by images = is=20 sufficient for diagnosis.

The telemedicine system helped primary care physicians = to=20 interact with medical experts. This, in turn, helped to reduce the = professional=20 isolation of health care staff working in rural areas.

At the start of the project, we found technophobia = among health=20 professionals working in rural areas. To reduce this, we provided IT = training=20 courses to all the health professionals working in rural areas. These = training=20 courses helped rural health workers to become familiar with IT. These = health=20 workers also found that IT could enhance their efficiency. The technical = knowledge encouraged staff to use IT in other areas such as hospital = information=20 systems, to improve the efficiency of the hospital and to provide access = to the=20 health literature to update their knowledge.

Future developments

In our research project, we found that there was = potential for=20 telemedicine in Nepal, especially in rural areas, but also in urban = areas. It=20 was also found that textual information with images was sufficient for = diagnosis=20 in many cases. Telemedicine helped medical education, medical care and = collegial=20 support. However, continuation of the work after the project has = finished will=20 depend on how the local health professionals and medical experts support = the=20 services. To support and continue the telemedicine work, there should be = other=20 computerized health services, such as distance education, digital = libraries and=20 computerized hospital information systems. That is, telemedicine cannot = develop=20 in isolation. These types of activities will encourage rural health = workers and=20 medical specialists to continue the telemedicine work. As users become = more=20 comfortable with the technology, they are inclined to experiment with = new=20 applications. These activities help to enhance their efficiency, update = their=20 knowledge and reduce professional isolation.

Low-cost telemedicine based on store-and-forward = systems has=20 also been carried out in other developing countries. For example, the = Swinfen=20 Charitable Trust established a telemedicine link to support the Centre = for the=20 Rehabilitation of the Paralysed (CRP) in Savar, near Dhaka in = Bangladesh, in=20 July 199917 = (see Chapter 19). = Based on the=20 success of the Bangladesh project, the Swinfen Charitable Trust supplied = digital=20 cameras and tripods to more hospitals in other developing countries. = These=20 included the Patan Hospital in Nepal (March 2000), = Gizo=20 Hospital in the Solomon Islands (March 2000), Helena Goldie Hospital in = the=20 Solomon Islands (September 2000) and LAMB Hospital in Bangladesh = (September=20 2000). In South Africa, the technique has been used for referrals from = remote=20 clinics. The US Armed Forces have made use of store-and-forward = telemedicine for=20 telepathology (see Chapter=20 15), and a link has been established between Italian hospitals = worldwide=20 (see Chapter = 16).18=20 Store-and-forward teledermatology has been used in linking remote parts = of=20 Africa to teaching hospitals in the USA and Europe.

Suggestions were invited from the users in Nepal for = improving=20 the telemedicine service. The following were the main suggestions:

Include = separate=20 funding for telemedicine in hospitals with telemedicine units and in = central=20 hospitals providing expert advice.

Improve = the=20 technology for telemedicine from still images to videoconferencing.

Increase = the=20 frequency of consultations and organize videoconferences.

Define a = list of=20 cases for mandatory advice apart from emergency cases.

= Computerize the=20 hospital information systems, which will help to follow up patients = treated=20 earlier.

It is not easy to answer the question whether = telemedicine in=20 a developing country is cost-effective, since this requires evaluation = in a=20 properly controlled, scientific trial. Unless this can be done, the = answer to=20 the question whether telemedicine represents an appropriate use of = resources=20 will remain unknown.19

References

1. United = Nations=20 Development Programme. Nepal Millennium Development Goals (MDG): = Progress=20 Report 2005. Available at:=20 www.undp.org.np/publication/html/mdg2005/mdg2005.php.

2. World = Health=20 Organization. Country Health System Profile: Nepal. Available = at:=20 www.searo.who.int/en/Section313/Section1523_6870.htm.

3. Carnall D. = Medical=20 software=92s free future. BMJ 2000; 321: = 976.

4. American = College of=20 Radiology. ACR Standard for Teleradiology, 1998. Available at:=20 imaging.stryker.com/images/ACR_Standards-Teleradiology.pdf.

5. IrfanView. = Available=20 at: www.irfanview.com.

6. Perednia = DA, Brown=20 NA. Teledermatology: one application of telemedicine. Bull Med Libr=20 Assoc 1995; 83: 42=967.

7. McGee R, = Tangalos=20 EG. Delivery of health care to the undeserved: potential contributions = of=20 telecommunications technology. Mayo Clin Proc 1994;=20 69: 1131=966.

8. Szot A, = Jacobson FL,=20 Munn S et al. Diagnostic accuracy of chest X-rays acquired using a = digital=20 camera for low-cost teleradiology. Int J Med Inform 2004;=20 73: 65=9673.

9. Krupinski = E,=20 Gonzales M, Gonzales C, Weinstein RS. Evaluation of a digital camera for = acquiring radio-graphic images for telemedicine applications. = Telemed J E=20 Health 2000; 6: 297=96302.

10. = Krupinski EA,=20 LeSueur B, Ellsworth L et al. Diagnostic accuracy and image quality = using a=20 digital camera for teledermatology. Telemed J 1999; = 5:=20 257=963.

11. Piccolo = D, Soyer=20 HP, Burgdorf W et al. Concordance between telepathologic diagnosis and=20 conventional histopathologic diagnosis: a multiobserver = store-and-forward study=20 on 20 skin specimens. Arch Dermatol 2002: 138: = 53=968.

12. Lim AC, = Egerton=20 IB, See A, Shumack SP. Accuracy and reliability of store-and-forward=20 teledermatology: preliminary results from the St George Teledermatology = Project.=20 Australas J Dermatol 2001; 42: 247=9651.

13. High WA, = Houston=20 MS, Calobrisi SD et al. Assessment of the accuracy of low-cost = store-and-forward=20 teledermatology consultation. J Am Acad Dermatol 2000;=20 42: 776=9683.

14. Metz CE. = Basic=20 principles of ROC analysis. Semin Nucl Med 1978; = 8:=20 283=9698.

15. Zweig = MH, Campbell=20 G. Receiver-operating characteristic (ROC) plots: a fundamental = evaluation tool=20 in medicine. Clin Chem 1993; 39: 561=9677.

16. Hjelm = NM. Benefits=20 and drawbacks of telemedicine. J Telemed Telecare 2005;=20 11: 60=9670.

17. Vassallo = DJ,=20 Swinfen P, Swinfen R, Wootton R. Experience with a low-cost telemedicine = system=20 in three developing countries. J Telemed Telecare 2001;=20 7(Suppl 1): 56=968.

18. Della = Mea V,=20 Beltrami CA. Telepathology applications of the Internet multimedia = electronic=20 mail. Med Inform (Lond) 1998; 23: = 237=9644.

19. Wootton = R. The=20 possible use of telemedicine in developing countries. J Telemed=20 Telecare 1997; 3: 23=966.

18 Telemedical support for surgeons in=20 Ecuador

Stephen Cone, Edgar J Rodas and Ronald C=20 Merrell

Introduction

A surgery project for the isolated and under-served = in=20 Ecuador, which began more than 25 years ago, has matured into a fixed = element of=20 service delivery. Telemedicine was first applied to support the surgery=20 programme in 1995.1 = Ecuador has=20 characteristics that make it highly suitable for telemedicine.

Ecuador (more properly called the Republic of Ecuador) = has a=20 population of 13 million.2 They = are a=20 mixture of European heritage and indigenous peoples, and occupy three = distinct=20 geographical zones.3 The=20 westernmost zone is the coastal region. The central zone is the = highlands (the=20 Sierra). The easternmost region (the Oriente) marks the beginning of the = Amazonian rainforest.

The majority of the population work in the service = industry,=20 many being employed in eco-tourism.3 = However, the=20 unemployment rate is 10.6%, with poverty affecting 39% of the = population.3 The = gross=20 national product (GNP) for Ecuador is US$4070 per capita.2 The = average=20 per capita expenditure for health care is US$127.2 = Total health=20 care spending for the country is 5.5% of the gross domestic product = (GDP).2

Health concerns in Ecuador

Ecuador has certain medical problems that are common = to much=20 of the rest of the world, some that are common to tropical regions and = some that=20 are common to developing countries. These three categories are important = in=20 considering illness in Ecuador. Like the world in general, Ecuador is = facing=20 changing illness patterns that reflect the emergence of chronic = conditions,=20 rather than the acute, infectious diseases more common in earlier times. = There=20 is also increasing interpersonal violence and trauma (mainly due to = increased=20 motor vehicle activity) and tropical disease. As a developing country, = Ecuador=20 has the common problems of sanitation, nutrition and access to health = care.

Despite these challenges, life expectancy in Ecuador = is similar=20 to that in industrialized countries, with recent data predicting 70 = years for=20 males and 75 years for females.2 = Infant and=20 child mortality are high, at 22 and 25 per 1000 live births, = respectively.2 = Compared with=20 10 years ago, non-communicable diseases have increased in importance (up to 42% of deaths), as have injuries (21% of = deaths), while=20 communicable diseases have declined as a measure of the burden for = mortality=20 (down to 37% of deaths).4

Medical system in Ecuador

Ecuador has developed a health care system based on = a=20 combination of public, private and volunteer support. In 2000, the total = health=20 workforce (physicians, nurses, midwives and dentists) numbered 41 = 000.2 = There were 18=20 000 physicians (or 1.5 per 1000 people).2 = These numbers=20 do not include the traditional tribal healers, once an important part of = the=20 culture of the indigenous peoples. With 39% of the people living in = rural areas,=20 and up to 30% of the population classified as Amerindian,3 the = role of=20 the =91curanderos=92 in health care is still significant.

The more common, Western-style practitioners study in = a=20 traditional style of medical education, modelled on the European system. = The=20 national government supports the education of doctors (six years of = medical=20 school followed by a one-year internship), in return for which the = doctors are=20 expected to provide a year of service, typically in rural/under-served=20 areas.

The national government is also responsible for 41% of = total=20 health spending, of which about 15% is from social security funds, the = rest=20 coming from the Ministerio de Salud Publica (MSP), the public health=20 ministry.2 In = many cases,=20 the patient=92s family is responsible for providing meals, medicines and = some=20 materials during the course of care. Despite the efforts of private = payers, and=20 government support for health care, about 25% of the population do not = have=20 access to health care.2

For people in rural areas and the poorest sections of = urban=20 areas, care may be nonexistent or may come from volunteer providers. = Many=20 providers in the country are philanthropic organizations, such as the = Fundaci=F3n=20 Cinterandes (Cuenca, Ecuador). Many health care workers are volunteers = from the=20 USA and elsewhere. Interplast and Operation Smile are two examples of = plastic=20 surgery missions well established in many developing countries, = including=20 Ecuador.

Intermittent surgical services

Volunteer organizations, such as those mentioned, = provide=20 intermittent surgical services to meet the surgical needs of = under-served=20 populations. This has previously been decried as poor-quality care, = since the=20 surgeon does not follow the care of the patient directly throughout the = process=20 of healing. However, intermittent surgical services are becoming = recognized as=20 part of a comprehensive system of health care delivery.5 With = the use=20 of telemedicine, the distance between patient and surgeon becomes less = of a=20 problem and, with a system of integrated providers (primary care and=20 specialist), the patient need never be without expert opinion.

The original intention of the mobile surgery programme = of the=20 Cinterandes Foundation was to use Ecuadorian and international = volunteers to=20 provide intermittent surgical services to under-served populations. The = system=20 has subsequently expanded to become a more = inclusive,=20 integrated part of a continuum of care.1 = Since 1994,=20 the Cinterandes Foundation has been providing surgical care to remote=20 populations, decreasing the need for patient/family travel (and = travel-related=20 expenses), reducing delays in treatment, and the associated mortality = and=20 morbidity.1

The mobile surgery programme is based on a truck with = an=20 operating room built on it (Figures 18.1 = and 18.2). There = is a small=20 permanent staff, which is supplemented with volunteers and students. = However,=20 even from the beginning, it was apparent that the role of local = providers would=20 be essential. The local primary providers supply initial contact with = the=20 population in need, and act as the continuing contact for follow-up = care. In=20 many ways, the mobile surgery programme operates like the typical = specialist=20 practice, depending on primary care for patient referrals, and then = proceeding=20 through preoperative care, the operation and the immediate postoperative = care.=20 Local surgeons lend support and participate when the mobile programme is = in=20 their community. Thus, the programme is properly integrated into a model = of=20 continuous care.

Prescreening evaluation is extremely important in the = mobile=20 surgery programme. It is during this period that the primary care = providers in=20 the region, working under strict protocols, recruit patients with = surgical=20 problems for further evaluation. Cinterandes personnel then travel to = the area=20 to evaluate the patients, decide which patients are appropriate for the = mobile=20 surgery programme, which of them have priority needs, which patients = have=20 disqualifying comorbidities and which patients need medical treatment = before=20 surgical consideration.1,6=968 This = careful=20 prescreening has

3DImage=20

Figure 18.1 Operating room on the = truck with=20 tents for patient preparation and recovery

3DImage=20

Figure 18.2 Interior view of the = operating=20 room, showing the induction of a patient. Note the laparoscopic = equipment in the=20 background

been important to the success of the programme. = Patients with=20 additional illnesses or infections may be referred to definitive = facilities or=20 may be excluded, to avoid unnecessary complications. Those who are = accepted into=20 the programme must be followed using existing local resources after = surgery.

Prior to the day for surgery, the truck arrives on = location, and=20 parks outside the local health care facility. On the day of surgery, = patients=20 are re-examined in the local facility or in a Cinterandes tent (when = local=20 facilities are lacking).1,7,8 = After surgery,=20 while the patient is recovering from anaesthesia, he or she is = transferred to=20 the recovery area, either in the local facility or in a recovery tent. = During=20 this time, postoperative care is arranged and ambulatory patients are = discharged=20 to home.

Cinterandes personnel provide the initial = postoperative=20 care.1,7,8 = Generally,=20 doctors and students/residents see any patients still in the facility on = the=20 morning of the first postoperative day, returning to base in the = afternoon. For=20 those ambulatory patients sent home on the day of surgery, the = postoperative=20 plan has already been discussed with the patient = and local=20 provider. For those patients spending the night in the facility, = postoperative=20 plans are decided upon and communicated prior to discharge.

Although the initial postoperative evaluation is = performed by=20 the Cinterandes personnel, continuing care requires the support of the = local=20 caregivers. Continued postoperative care generally consists of visits at = one=20 week, one month and six months after surgery =96 or more frequently in = the case of=20 complications or suture removal. While these visits are performed by the = local=20 providers, the Cinterandes personnel remain available for consultation = by=20 telephone, advising about wound care and providing guidance about = transferring=20 patients in need of more advanced care.7

Understandably, this interdependence has made the = interaction=20 with local providers an important part of the success of the = intermittent=20 surgical service in Ecuador. Local providers and patients need the = additional=20 services provided by the intermittent surgical service to avoid costly=20 alternatives or increased morbidity/mortality. The mobile surgery = programme=20 depends on the local providers to find suitable patients, arrange = preoperative=20 evaluations, assist with surgical scheduling and provide postoperative = care to=20 the patients.

In addition, the mobile surgery programme has come to = develop an=20 interaction with local and international medical education. The local = schools in=20 the Cuenca region provide students and residents to help with the = surgery=20 programme, in turn gaining a unique educational experience.1 With = this=20 success, the Cinterandes Foundation has expanded the educational role to = include=20 students from foreign medical schools, who also gain valuable experience = in=20 learning about a new culture and medical system.

Programme activity

The Cinterandes Foundation has been operating the = mobile=20 surgery programme in various areas of Ecuador since 1994.1 In = that time,=20 the programme has visited 15 of the 22 provinces in the country, = performing=20 approximately 40=9650 surgical trips per year, i.e. each location = generally=20 receives more than one visit per year.5 = Thus, the=20 surgical truck is in operation almost every week.

The programme has performed over 4500 operations in = general=20 surgery and specialties such as gynaecological and paediatric = surgery.1,5 Even = with this=20 patient volume in a small, mobile operating room, there has been no = recorded=20 mortality, and only four major complications (bleeding, cardiac arrest,=20 pulmonary embolism and gastrointestinal injury).5 A = complication=20 rate of less than 1% is similar to that of sophisticated US surgical = centres. At=20 this workload, the average cost of an operation performed by the mobile = surgery=20 programme is less than US$100.5 = These costs=20 are met by the programme, so the service is free to patients.

Telemedicine to support surgery

Telemedicine has made a strong contribution to the=20 intermittent surgical service. The first step was to apply digital = records and=20 review the management of the programme. Next, the = primary=20 care, Foundation and international consulting sites were connected by = dial-up=20 Internet connections for email (Figure 18.3). = Then the=20 needs of the programme were assessed. The telemedicine stations were = installed,=20 personnel were trained in their use, and all participants were = encouraged to=20 practice protocols and use the Spanish-language electronic health record = (EHR)=20 before programme implementation. Both store-and-forward and real-time=20 telemedicine were used.

Telemedicine support is, of course, limited by the=20 telecommunications available. The rate that data (bits) can be = transferred=20 between sites is known as bandwidth. Table 18.1 = shows the=20 bandwidths of some of the different means of connectivity. All around = the world,=20 telecommunications continue to improve. However, in remote areas of the=20 developing world, slower-speed connections remain the most robust medium = for=20 telemedicine.

3DImage=20

Figure 18.3 Cinterandes Foundation=20 headquarters in Cuenca, during review of patient postoperative records. = The=20 images shown on the computer screen were collected during the = postoperative care=20 of a patient following a laparoscopic cholecystectomy

Table 18.1 Common = connectivity=20 modalities and associated bandwidths
Modality	Bandwidth
Ordinary telephone network (PSTN)	Up to 56 kbit/s
Integrated services digital network = (ISDN)	64=96128 kbit/s
Digital subscriber line (DSL)	256 kbit/s=962 Mbit/s
Cable modem	512 kbit/s=968 Mbit/s
Ethernet	10 or 100 = Mbit/s

In developing a telemedicine system in such areas, it = is often=20 necessary to use connections of limited bandwidth.6,9 = Satellite=20 transmission could certainly be employed, but the high cost usually = makes this=20 impractical. The ordinary telephone network (PSTN) is available in most = of=20 Ecuador, so that dial-up modems permit connection to an Internet service = provider (ISP).6,8,10 A = technician=20 may operate the equipment for the clinician, while attempting to = familiarize the=20 local providers with the use of such technology.6

The procedure for telemedicine to support mobile = surgery begins=20 with patient registration and the creation of an EHR. The data can be = text,=20 pictures (e.g. JPEG images), video or voice recordings. Registration = includes=20 the medical history and demographics, and can be longitudinal for = primary care=20 management. When surgical consultation is needed, there are, by = protocol, strict=20 criteria for acceptable patient risk for comorbidity and scope of = surgery. The=20 record is forwarded to the Foundation in an email attachment with a = question.=20 Staff at the Foundation assess the problem, recommend further diagnostic = tests=20 if necessary, order preoperative measures and, if appropriate, schedule = the=20 surgical procedure. Videoconferencing between the Foundation and patient = is an=20 option. This has been done using Microsoft NetMeeting. By this screening = mechanism, the requests for surgical care are managed promptly and = efficiently.=20 Prior to telemedicine, large surgery consulting clinics took up enormous = amounts=20 of time, with little patient care offered. After operation, the same EHR = keeps=20 the surgeons apprised of the patient=92s progress and any complications, = for care=20 continuity. This postoperative phase can also use videoconferencing.

The telephone network can also be used during the = operation to=20 allow distant surgeons to advise (telementoring) or to educate (distance = education).10=20 Better-quality video and audio during surgery has been achieved with=20 higher-bandwidth connections, for example using a satellite link from = time to=20 time. While an intraoperative videoconference is certainly improved with = increased bandwidth, the pre- and postoperative visits are also better = with the=20 use of improved video. Low-bandwidth video transmission results in=20 lower-resolution images or slower frame rates, or both, which may be=20 unacceptable.11 = However, in=20 increasing the bandwidth, the biggest problem is the cost. None the = less,=20 clinically acceptable transmission has been consistently achieved at 56 = kbit/s=20 using the ordinary telephone network.6=9610

Videoconference consultations can run as smoothly as = in-person=20 examinations. Telemedicine establishes a sense of continuity in the care = of the=20 patient, and a link between the patient, primary provider and surgeon, = despite=20 the distances and intermittent services. The cost of telemedicine in = Ecuador has=20 been low once computers (US$1500) and digital camera (US$250) have been=20 supplied. Training is provided by volunteers, and the only ongoing cost = is for=20 telecommunication. The cost of a local ISP is quite affordable in = Ecuador.

The cost of telemedicine should be compared with that = of on-site=20 screening and consultation. In general, telemedicine allows time savings = in a=20 three-day surgical mission. For the cost of the ISP, there is a 25% = increase in=20 efficiency. The impact on patient safety is difficult to quantify, but = the=20 rarity of transfers suggests that telemedicine is at least as good as=20 conventional management.

Experience in Ecuador

The role of the primary caregiver in the use of = intermittent=20 surgical care cannot be overemphasized. Likewise, the role of the = primary=20 caregiver in supporting the use of telemedicine should not be = underplayed. The=20 equipment used in primary care centres must be familiar to the = providers, with=20 utility beyond the support of intermittent surgical services. The = equipment=20 should be used daily and computer skills should be encouraged on a = regular=20 basis. This daily practice, along with curiosity and an interest in = providing=20 better care for their patients, prompts primary caregivers to seek = additional=20 skills with computers. Databases can provide a good means of storing = patient=20 data, allowing both archiving and retrieval. Spreadsheets simplify the = process=20 of calculating statistics. The addition of a digital camera to the = equipment=20 available in the clinic allows for digital image documentation of = lesions,=20 radiographs and the general appearance of patients. Digital cameras are = now=20 reasonably easy to use. One primary care doctor in the eastern = rainforest region=20 of Ecuador computerized his entire clinic, networking five computers (Figure 18.4) = in=20 different treatment areas, sharing the same database, and integrating = images=20 from a handheld digital camera, a video camera, a microscope eyepiece = camera and=20 an ultrasound scanner.12 He = has even=20 employed the equipment in remote areas.

3DImage=20

Figure 18.4 Primary care site in = Macas.=20 Computers are connected via a local area network (LAN). The unit shown = is=20 stationed in the clinic=92s laboratory, and can import microscopic = images into the=20 EHR, via an eyepiece camera

Early on, the surgeons in the Cinterandes Foundation = recognized=20 the importance of the role of primary care providers in supporting the = continued=20 intermittent mobile surgery programme. Using existing communications = systems in=20 rural areas of Ecuador, the surgeons have been able to integrate the = primary=20 providers into the prescreening process of surgical care. = Store-and-forward=20 telemedicine, i.e. asynchronous transmission of information, provides = the basis=20 for this support. As in work done in Kenya,9 = primary care=20 providers can send information via email to the surgeons for review = prior to a=20 surgical trip.6=968,10 = With this=20 advance information, surgeons are able to make better decisions about=20 appropriateness for surgery. Equally important, the surgeons may use = this=20 opportunity to address the problems that made the patient inappropriate = for=20 surgery, and may direct further care for the patient. In Ecuador, the = programme=20 has sent students and junior surgeons to the field areas to set up and = perform=20 the remote clinics. Local providers have been enlisted to conduct the=20 prescreening clinics, and have networked with permanent telemedicine = stations in=20 primary care clinics in three areas of Ecuador.7 = These=20 connections employ computers with telephone dial-up modems that deliver, = at=20 best, 26 kbit/s bandwidth. Yet the system has prospered and continues to = function (see Figure=20 18.3). The ISP may not have a fixed Internet Protocol (IP) address = for the=20 subscriber, and this can be very frustrating. Furthermore, the ISP=92s = servers=20 have limited capacity, and there is a consistent decline in quality and=20 reliability during business (high-traffic) hours.

Prescreening of patients only needs store-and-forward=20 telemedicine. However, video interaction by NetMeeting is possible. For = the=20 prescreening work, the videoconferencing may elicit further information = and=20 support informed consent. Low bandwidth may be used intraoperatively, = sometimes=20 with the additional transmission of high-quality still images.13 As = considerable image compression is required at these low bandwidths,=20 higher-bandwidth transmission is certainly easier and faster for = video-intensive=20 applications.11 A=20 hand-carried, portable satellite communications system provides 64 = kbit/s=20 connectivity, while larger models and vehicle-mounted models provide = even=20 greater bandwidths. Using two 64 kbit/s satellite channels in parallel = (i.e. a=20 total of 128 kbit/s), transmission of live surgical images from the = mobile=20 surgery equipment can be performed at 30 frames per second with little = image=20 degradation.14 = Using a=20 computer, rather than a videophone, allows sharing of email messages and = forwarding of still images and other data. A full record of the surgical = procedure is possible with video recording into a computerized database = complete=20 with patient and procedure information.14

Anaesthesia may also make use of telemedicine. In = addition to=20 using store-and-forward technology to share a patient=92s data and = develop an=20 anaesthetic plan, higher bandwidth allows transmission of live = anaesthetic=20 images and data. A single 64 kbit/s satellite connection provides enough = bandwidth to transmit images, including endotracheal intubation via a=20 fibre-optic intubation system, along with physiological data during the = surgical=20 procedure.16

Following surgery, the patient recovers in a familiar = locality=20 with familiar care-givers. It is important in this setting to provide a = means=20 for the concerns of the patient and the health providers to reach the=20 intermittent surgery team. The telemedicine systems in place can provide = support=20 for postoperative care. Wound images and data may = be sent in=20 a store-and-forward manner, unless the surgeon decides that real-time=20 videoconferencing is required. Again, the relationship with the local = providers=20 is important to the success of the intermittent surgical service.

The mobile surgery programme in Ecuador has enjoyed = clinical=20 success. This has been accompanied by great success in maintaining = social=20 support for patients in their communities and solidarity with primary = care=20 providers. Telemedicine has made this programme more efficient, and = therefore=20 available to more patients. The interactions with consultants outside = Ecuador=20 have matured into sound professional friendships.

References

1.=20 The Cinterandes Foundation. Available at: www.cinterandes.org.

2.=20 World Health Organization. Ecuador. Available at:=20 www.who.int/countries/ecu/en.

3.=20 Central Intelligence Agency. The World Factbook: Ecuador. = Available at:=20 www.cia.gov/library/publications/the-world-factbook/geos/ec.html.

4.=20 Pan American Health Organization. Country Health Profile: = Ecuador.=20 Available at: www.paho.org/English/SHA/prflECU.htm.

5.=20 Rodas E, Vicuna A, Merrell RC. Intermittent and mobile surgical = services:=20 logistics and outcomes. World J Surg 2005; 29: = 1335=969.

6.=20 Doarn CR, Fitzgerald S, Rodas E et al. Telemedicine to integrate = intermittent=20 surgical services into primary care. Telemed J E Health 2002;=20 8: 131=967.

7.=20 Mora F, Cone S, Rodas E, Merrell RC. Telemedicine and electronic health=20 information for clinical continuity in a mobile surgery program. = World J=20 Surg 2006; 30: 1128=9634.

8.=20 Rodas E, Mora F, Tamariz F et al. Low-bandwidth telemedicine for pre- = and=20 postoperative evaluation in mobile surgical services. J Telemed=20 Telecare 2005; 11: 191=963.

9.=20 Lee S, Broderick TJ, Haynes J et al. The role of low-bandwidth = telemedicine in=20 surgical prescreening. J Pediatr Surg 2003; = 38:=20 1281=963.

10. Rosser = JC, Bell=20 RL, Harnett B et al. Use of mobile low-bandwith telemedical techniques = for=20 extreme telemedicine applications. J Am Coll Surg 1999;=20 189: 397=96404.

11. = Broderick TJ,=20 Harnett BM, Merriam NR et al. Impact of varying transmission bandwidth = on image=20 quality. Telemed J E Health 2001; 7: = 47=9653.

12. Cone SW, = Hummel R,=20 Leon J, Merrell RC. Implementation and evaluation of a low-cost = telemedicine=20 station in the remote Ecuadorian rainforest. J Telemed Telecare = 2007;=20 13: 31=964.

13. = Broderick TJ,=20 Harnett BM, Doarn CR et al. Real-time Internet connections: implications = for=20 surgical decision making in laparoscopy. Ann Surg 2001;=20 234: 165=9671.

14. Rodas = EB, Latifi=20 R, Cone S et al. Telesurgical presence and consultation for open = surgery.=20 Arch Surg 2002; 137: 1360=963.

15. Cone SW, Leung A, Mora F et al. Multimedia data = capture=20 and management for surgical events: evaluation of a system. Telemed = J E=20 Health 2006; 12: 351=968.

16. Cone SW, = Gehr L,=20 Hummel R, Merrell RC. Remote anesthetic monitoring using satellite=20 telecommunications and the Internet. Anesth Analg 2006;=20 102: 1463=967.

19 A low-cost international e-referral=20 network

Richard Wootton, Pat Swinfen, Roger Swinfen = and Peter=20 Brooks

Introduction

Telemedicine provides the opportunity of delivering = health=20 care at a distance, and reduces the need for a face-to-face interaction. = It is=20 often conducted by videoconferencing, which permits a high-quality = interaction=20 between the parties concerned, but demands relatively expensive = equipment and=20 high bandwidth communications. In the context of developing countries, = there has=20 been little use of videoconferencing, for the obvious reason of cost. = Most of=20 the videoconferencing work that has been conducted has been for the = purposes of=20 education.1=963

Although there has been little use of real-time = telemedicine,=20 much useful clinical work has been performed in developing countries = using=20 store-and-forward techniques, which are less expensive of infrastructure = and=20 easier to organize because the interaction between the parties concerned = is=20 asynchronous. The two main methods of store-and-forward telemedicine are = based=20 on use of web messaging or on email.

Web telemedicine

In web-based telemedicine (for clinical purposes), = the=20 referring doctor connects to the Internet and completes a web-based = proforma=20 that stores the patient details and any associated images on a remote = server.=20 This information is reviewed by a specialist at some later time, and = appropriate=20 diagnostic and management advice is provided. The specialist=92s reply = is stored=20 on the web server, from where the referring doctor can access it. To = ensure=20 patient confidentiality, the information comprising the telemedicine = interaction=20 is normally stored on a secure server and protected by passwords.

The US military had considerable experience with = web-based=20 teledermatology in the late 1990s in Europe.4 They = have also=20 operated a web-based teleconsulting system from the main US Army = hospital in=20 Hawaii that supports referrers in hospitals (mainly military hospitals) = on=20 US-associated Pacific islands.5,6 = Further=20 details are provided in Chapter 15.

Finally, a software package called iPath was developed = for=20 telepathology case conferences, and several tens of thousands of case=20 conferences have now been conducted =96 technically by a number of = different=20 organizations who all use the same software. The use of this software = for=20 general clinical work (i.e. non-pathology) is more recent.7

Email telemedicine

One drawback of web-based telemedicine is that in = developing=20 countries there are still places where Internet connections are = expensive, and=20 therefore web access in particular is restricted. Almost all health care = facilities have, or could have, telephone access to the Internet, so = this=20 represents the lowest-cost communications medium for telemedicine.

In email-based telemedicine, the telephone network is = used to=20 transmit email messages via a dial-up connection to an Internet service = provider=20 (ISP). The referring doctor records the relevant patient information in = the body=20 of the email message, and images of patients, or X-ray films, can be = attached if=20 required. The specialist can reply by email at a convenient time.

Email telemedicine is cheap, but it has some = drawbacks:

On any = significant=20 scale, i.e. with multiple referring doctors and multiple specialists, = managing=20 the traffic is a demanding and labour-intensive task. Messages may then = fail to=20 be replied to.

= Information sent in=20 an ordinary email message is not secure. Although the case details can = be=20 anonymized to protect patient confidentiality, this depends on the = message=20 sender, and is often difficult to enforce in practice.

Because = the=20 referring doctor enters free text, it is much harder to ensure that all = relevant=20 patient history details are collected.

Any system = of=20 communication that employs email will sooner or later be bombarded with = spam or=20 nuisance messages.

Two long-running examples of the use of email for = low-cost=20 telemedicine are the work of the Swinfen Charitable Trust and of = Partners=20 Telemedicine.

Swinfen Charitable Trust

The British military first used email telemedicine=20 successfully in Bosnia.8,9 In = the 1990s,=20 Lieutenant Colonel David Vassallo, together with Surgeon Commander Peter = Buxton=20 and Wing Commander John Kilbey, established a technique in which a = digital=20 camera was used to capture images, which were then downloaded to a = laptop=20 computer. The images were attached to an email message and then sent to = the=20 Royal Hospital Haslar in the UK for evaluation and advice. A commercial = INMARSAT=20 satellite telephone link was employed for communication in the field. = The system=20 proved useful when a Czech Forces Helicopter crashed in Bosnia in = January 1998,=20 severely injuring five crew members.10 = David=20 Vassallo and Peter Buxton generously shared information about the system = with=20 Lord and Lady Swinfen, enabling them to start a pilot project at the = Centre for=20 Rehabilitation of the Paralysed in Bangladesh. This began in 1999 (see=20 below).

Partners Telemedicine

Since 2001, email consultations have been used to = support=20 health workers at a rural clinic in northern Cambodia. The email advice = comes=20 from specialists at a tertiary hospital in Phnom Penh and from the = Massachusetts=20 General Hospital in Boston. In 2003, a second site = at a small=20 hospital in northern Cambodia began referring cases.11 = Further=20 details are provided in Chapter 13.

Start of the network, 1999

The Swinfen Charitable Trust was established in 1998 = to assist=20 poor, sick and disabled people in the developing world. It is an = apolitical,=20 non-religious organization, registered as a charity in the UK. The = Trustees=20 decided to provide medical specialist advice, free of charge, to assist = doctors=20 caring for poor patients, as they were unaware of any such service at = the time.=20 In July 1999, an email telemedicine link was established for a hospital = in=20 Bangladesh, the Centre for the Rehabilitation of the Paralysed (CRP). = The CRP,=20 which is located near Dhaka, is a specialist spinal injury unit that = services a=20 large region of South-East Asia. Email referrals thus concentrated = mainly on=20 orthopaedics and neurology problems.

The email referrals were received by the = administrators of the=20 charity and sent on for reply to members of a small panel of medical = specialists=20 who had kindly offered to provide advice free of charge. This was a = pilot study=20 and, after a year of email referrals, a paper was published = demonstrating that=20 the system worked satisfactorily, and provided patient benefit and = medical=20 education to the referring doctors.12

The CRP has continued to refer cases to the Swinfen = Charitable=20 Trust network. At the time of writing, 182 cases have been referred in = 10 years=20 (Figure = 19.1).

3DImage=20

Figure 19.1 CRP referrals, July = 1999=96June 2008=20 inclusive

Growth of the network, 1999=962004

Although the initial telemedicine link to the CRP = was a pilot=20 study, word of its value quickly spread and, by the end of its first = year of=20 operation, two other telemedicine links had been requested. These were=20 established at hospitals in Kathmandu, Nepal and the Solomon Islands. = From then=20 on, the numbers of links requested and set up grew rapidly.13

Manual management of the messages by the charity (e.g. = forwarding a new referral message to an appropriate specialist, = forwarding the=20 resulting reply to the referrer and dealing with any subsequent = dialogue) was=20 satisfactory for a single hospital, but rapidly became unmanageable as = the=20 number of hospitals and the email workload increased. It was also = difficult to=20 extract statistics about the operation of the network, since plain email = provides a poor archive, because it is =91unthreaded=92. An automatic = email=20 message-handling system was therefore developed by the Centre for Online = Health=20 at the University of Queensland.14 = This came=20 into operation in 2002, and solved several of the problems associated = with=20 manual message management.

From July 1999 to March 2003, the network grew to 17 = hospitals.=20 As well as more referring hospitals, more volunteer specialists were=20 recruited.13 = Many were=20 from the UK and Australia. The Swinfen Charitable Trust continues to be = indebted=20 to the consultant specialists and others who contribute voluntarily to = the=20 operation of the network.

Iraq and the Middle East

The Iraq war began in March 2003 with the invasion = of Iraq by=20 a multinational coalition of troops from the USA and the UK, supported = by=20 smaller contingents from Australia, Poland and other nations. In 2004, = the=20 administrators of the Swinfen Charitable Trust visited Basra as part of = a=20 British medical mission. During that visit, contact was made with = doctors from=20 several Iraqi hospitals, who subsequently joined the email referral = network (Figure 19.2). = This led=20 to a jump in the number of cases referred from Iraq in particular, and = from=20 other parts of the Middle East generally (Table = 19.1).

A review conducted in 2007 showed that there was = evidence of=20 improved management of cases as a result of email telemedicine.15 = The review=20 also showed that the case mix from countries of the Middle East was = different=20 from that from the rest of the world (although, technically, the = difference was=20 not significant at p < 0.05). There was more obstetrics and=20 gynaecology, and less medicine and radiology (Table 19.2). = Despite=20 the majority of Middle Eastern cases being referred from Iraq, = relatively few=20 were the direct result of conflict, and there were fewer trauma and = fracture=20 cases than from the rest of the world. There were also comparatively = fewer=20 referrals in infectious and tropical diseases. The relative absence of = trauma=20 cases can perhaps be explained by well-developed local expertise in = trauma care.=20 This local expertise was honed during the Iraq conflict, during the = eight years=20 of the Iraq=96Iran war and during the internal troubles of the Saddam = Hussein=20 regime.

Table 19.1 Origin and numbers = of cases=20 referred from July 2002 to June 2008
Middle East		Rest of World
Afghanistan	85	Antarctica	2
Iraq	311	Bangladesh	254
Kuwait	1	Bolivia	15
Pakistan	28	Cambodia	16
Uzbekistan	31	China	2
		East Timor	27
		Ethiopia	28
		Gambia	2
		Guinea	12
		Laos	2
		Lithuania	1
		Madagascar	1
		Malawi	9
		Mozambique	7
		Nepal	272
		Papua New Guinea	59
		Russia	1
		Sierra Leone	2
		Solomon Islands	93
		Sri Lanka	23
		St Helena (UK)	24
		Sudan	28
		Tibet	10
		Tristan da Cunha (UK)	34
		Uganda	20
		Yemen	2
		Zambia	15
Total	456	Total	961

The U21 consortium

The Universitas 21 (U21) is an international = grouping of 21=20 leading research-intensive universities in 13 countries from around the = world.=20 The purpose of the consortium is to facilitate collaboration between the = member=20 universities and to create opportunities for them on a scale that none = of them=20 could achieve by operating independently or through traditional = bilateral=20 alliances. The U21 consortium has a strong health sciences group, led by = the=20 deans of medicine, nursing, dentistry and rehabilitation sciences of the = various=20 member universities.

3DImage=20

Figure 19.2 First-referral dates for = Iraqi=20 hospitals (n =3D 49)

Table 19.2 Types of queries = for the=20 cases referred from July 2002 to June 2008
	Middle East		Rest of world
	n	%	n	%
Allied health	2	0.2	12	0.9
Anaesthetics	19	2	3	0.2
Emergency medicine	5	0.6	4	0.3
General practice	1	0.1	0	0.0
Internal medicine	227	27	456	33
Mental health	5	0.6	10	0.7
Nurse	4	0.5	11	0.8
Obstetrics and gynaecology	159	19	66	5
Other	19	2	23	2
Paediatrics	168	20	260	19
Pathology	23	3	36	3
Radiology	15	2	94	7
Surgery	203	24	392	29
Total	850	100	1367	100

At the suggestion of the health sciences group, a = Memorandum of=20 Understanding was signed between the U21 consortium and the Swinfen = Charitable=20 Trust in 2006. The main objective of the Memorandum was to advance the = aims of=20 the Swinfen Charitable Trust by drawing on U21 resources, such as = consultants,=20 medical students, nursing/allied health students and other support.

The first pilot project involved U21 universities = providing=20 support to an under-served health facility in a developing country.16 = The initial=20 aim was to assist local doctors via information and communications = technology =96=20 telemedicine =96 and to involve U21 medical students on elective = placements. As=20 well as establishing low-cost telemedicine networks in developing = countries, a=20 long-term aim was to gather data about their effectiveness.

The project began in mid-2005. In the first two years, = a total=20 of eight medical students from four U21 universities spent their = electives at=20 hospitals in Pakistan, Papua New Guinea and Sri Lanka. Most electives = lasted=20 about four weeks. Most of the students were in their final year.

A total of 49 cases were referred either directly by = the=20 students or indirectly by the medical staff with whom they worked (i.e. = after=20 the students had left).17 = The students=20 were responsible for a total of 49 e-referrals, which resulted in 67 = queries in=20 a wide range of specialties. The median response time was 20 hours=20 (interquartile range 5=9685). Follow-up data were obtained in 14 of the = 30 cases=20 from one hospital (47%). The major categories of the 67 queries were = internal=20 medicine, paediatrics and surgery, and in very similar proportions to = the 785=20 queries managed by the Swinfen Charitable Trust over the same = period.

Before the project began, some initial concerns were = expressed=20 by certain consortium members about possible medicolegal risks, and = whether=20 students would feel superfluous in a local health care environment. = Happily,=20 none of these matters turned out to be real problems. Indeed, the = students=20 reported that the U21 project gave a purpose to their placement. One = student=20 expressed it as follows: =91often students don=92t always have a = =93role=94 other than=20 to sometimes feel as though you are hanging around as the silent = observer. This=20 way you could feel as though you were contributing.=92 17

The presence of a medical student facilitated = e-referrals by=20 relieving the pressure on the local doctor to undertake the necessary = clerical=20 and technical work. The students reported a rewarding elective = experience, which=20 appears to have the potential to increase the ease with which heavily = burdened=20 medical staff in developing countries can make use of e-referrals.

The future

Over the first 10 years of its operation, the Trust = has=20 established telemedicine links for 135 hospitals/clinics in 34 countries = and=20 dealt with over 1700 referrals (Figure 19.3). = How do we=20 rate the success of this international e-referral network after 10 years = of=20 operation? There are many indicators that could be employed to measure = success=20 in telemedicine.18 = These=20 include longevity and clinical outcomes.

If longevity is the criterion, then the Swinfen = Charitable Trust=20 is doing pretty well

3DImage=20

Figure 19.3 Swinfen Charitable Trust = Network=20 (July 2008)

for a telehealth operation, many of which =96 as has = been=20 observed elsewhere =96 blossom on a wave of initial enthusiasm and then = wither=20 when the seed funding runs out. However, if clinical outcome is the = criterion,=20 then the operation represents a failure at present, because there are no = formal=20 follow-up data. This is due to the fact that the majority of patients, = once=20 treated, return home, and do not come back to the hospital for follow-up = appointments. This occurs because of travel distance, time and cost, = including=20 loss of income. However, one of the aims of the U21 involvement is to = obtain=20 follow-up information, and the medical students in Papua New Guinea have = begun=20 providing it (and it is showing useful outcomes).17

It is also worth pointing out that the Swinfen = Charitable Trust=20 must be providing a clinically useful service to the referrer doctors, = or they=20 would not continue to use it. This was confirmed in a survey of = referrers=20 conducted in 2004.19

Ultimately, sustainability probably depends on scaling = up the=20 size of the present operation, which in turn requires the real costs to = be met,=20 i.e. when operating on a large scale, depending only on volunteers would = be=20 difficult. This would mean paying for the medical time involved in = answering the=20 referrals, for example, which in turn would require an income stream. = Charities=20 may have difficulty in operating in this environment, i.e. where there = are=20 pressures to increase in size to make things financially sustainable, = with=20 simultaneous counter-pressures to reduce in size because things depend = on=20 volunteers.

The work of the Swinfen Charitable Trust (and others)=20 demonstrates that low-cost telemedicine in the developing world is = feasible,=20 clinically useful, scalable and apparently sustainable. However, = telemedicine is=20 not yet being used on a significant scale. What = then is the=20 right strategy? The sensible approach appears to be to build = intra-country=20 telemedicine networks as soon as practicable. That is, we need = telemedicine=20 networks that rely largely on within-country resources. Such = telemedicine=20 networks might need to begin with support from outside the country, but = they=20 should become independent of outside resources as quickly as = possible.20

References

1.=20 Geissbuhler A, Bagayoko CO, Ly O. The RAFT network: 5 years of distance=20 continuing medical education and tele-consultations over the Internet in = French-speaking Africa. Int J Med Inform 2007; = 76:=20 351=966.

2.=20 Vincent DS, Berg BW, Hudson DA, Chitpatima ST. International medical = education=20 between Hawaii and Thailand over Internet2. J Telemed Telecare = 2003;=20 9(Suppl 2): 71=962.

3.=20 Ozuah PO, Reznik M. The role of telemedicine in the care of children in=20 under-served communities. J Telemed Telecare 2004;=20 10(Suppl 1): 78=9680.

4.=20 Pak HS, Welch M, Poropatich R. Web-based teledermatology consult system: = preliminary results from the first 100 cases. Stud Health Technol=20 Inform 1999; 64: 179=9684.

5.=20 Callahan CW, Malone F, Estroff D, Person DA. Effectiveness of an = Internet-based=20 store-and-forward telemedicine system for pediatric subspecialty = consultation.=20 Arch Pediatr Adolesc Med 2005; 159: = 389=9693.

6.=20 Person DA. Pacific Island Health Care Project: early experiences with a=20 Web-based consultation and referral network. Pac Health Dialog = 2000;=20 7: 29=9635.

7.=20 Brauchli K, Oberli H, Hurwitz N et al. Diagnostic telepathology: = long-term=20 experience of a single institution. Virchows Arch 2004;=20 444: 403=969.

8.=20 Vassallo DJ, Buxton PJ, Kilbey JH, Trasler M. The first telemedicine = link for=20 the British Forces. J R Army Med Corps 1998; = 144:=20 125=9630.

9.=20 Vassallo DJ, Buxton PJ, Kilbey JH. Telemedicine made easy =96 the = British way.=20 Mil Med 1998; 163: iii.

10. Vassallo = DJ, Klezl=20 Z, Sargeant ID, Cyprich J, Fousek J. British=96Czech co-operation in a = mass=20 casualty incident, Sipovo. From aeromedical evacuation from Bosnia to = discharge=20 from Central Military Hospital, Prague. J R Army Med Corps = 1999;=20 145: 7=9612.

11. = Heinzelmann PJ,=20 Jacques G, Kvedar JC. Telemedicine by email in remote Cambodia. J = Telemed=20 Tele-care 2005; 11(Suppl 2): 44=967.

12. Vassallo = DJ, Hoque=20 F, Roberts MF et al. An evaluation of the first year=92s experience with = a=20 low-cost tele-medicine link in Bangladesh. J Telemed Telecare = 2001;=20 7: 125=9638.

13. Wootton = R,=20 Youngberry K, Swinfen R, Swinfen P. Referral patterns in a global=20 store-and-forward tele-medicine system. J Telemed Telecare = 2005;=20 11(Suppl 2): 100=963.

14. Wootton = R. Design=20 and implementation of an automatic message-routing system for low-cost=20 telemedicine. J Telemed Telecare 2003; 9(Suppl = 1):=20 44=967.

15. = Patterson V,=20 Swinfen P, Swinfen R et al. Supporting hospital doctors in the Middle = East by=20 email telemedicine: something the industrialized world can do to help. = J Med=20 Internet Res 2007; 9: e30.

16. Wootton = R,=20 Jebamani LS, Dow SA. E-health and the Universitas 21 organization: 2.=20 Telemedicine and underserved populations. J Telemed Telecare = 2005;=20 11: 221=964.

17. Wootton = R, Swinfen=20 PA, Swinfen R et al. Medical students represent a valuable resource in=20 facilitating telehealth for the underserved. J Telemed Telecare = 2007;=20 13(Suppl 3): 92=967.

18. Wootton = R, Hebert=20 MA. What constitutes success in telehealth? J Telemed Telecare = 2001;=20 7(Suppl 2): 3=967.

19. Wootton = R,=20 Youngberry K, Swinfen P, Swinfen R. Prospective case review of a global = e-health=20 system for doctors in developing countries. J Telemed Telecare = 2004;=20 10(Suppl 1): 94=966.

20. Wootton = R.=20 Telemedicine support for the developing world. J Telemed = Telecare 2008;=20 14: 109=9614.

20 Telemedicine in China: Opportunities and=20 challenges

Jie Chen and Zhiyuan Xia

Introduction

China is a large country, with a huge population and = poor=20 telecommunications infrastructure (although communications are being = improved=20 rapidly). The level of social and economic development differs greatly = between=20 the coastal areas of the country and the rural areas in the west. Health = resources are relatively well developed and easily available in the = coastal=20 areas, while there are shortages of medical care and drugs in the poor = and rural=20 areas. Patients in rural areas often experience difficulties in = accessing=20 medical care. If they travel long distances to access higher-quality = medical=20 care, they incur a heavy financial burden.

Telemedicine past and present in = China

In industrialized countries, the concept of using=20 communications technology to distribute medical expertise is not = particularly=20 new. However, the development of tele-health is relatively new in China. = The=20 earliest telehealth activities began in the late 1980s. An emergency=20 consultation in 1986 that was provided for a ship=92s crew via = radiotelegrams is=20 recognized as the earliest telehealth activity in China. In 1988, the = General=20 Army Hospital in Beijing carried out a neurosurgery case discussion with = a=20 German hospital. Shanghai Medical University developed one of the = earliest=20 tele-medicine systems in China. In September 1994, they succeeded in = performing=20 a tele-consultation between the Huashan hospital and staff at the = Shanghai=20 Jiaotong University.1

The first generation of telemedicine systems in China = was based=20 on videoconferencing via the telephone network (PSTN). In 1995, with the = support=20 of the Shanghai Education and Research Network, Shanghai Medical = University=20 launched a pilot tele-medicine project and established a telemedicine=20 centre.2 At = about that=20 time, people began to employ the Internet to search for medical help. = One of two=20 well-known cases occurred in March 1995: a girl named Yang Xiaoxia in = Shandong=20 Province had an unidentified disease and asked for help through the = Internet.=20 The disease was finally diagnosed as a phagocytic bacterial infection in = her=20 muscles. The other case was in the same year. A = student named=20 Zhuling at Beijing University was sick for unknown reasons. After = searching for=20 help via the Internet, more than 1000 reply emails helped her to prove = that she=20 had heavy-metal poisoning.1

At this stage, a few health-related institutions began = to=20 develop experimental tele-health systems. The authorities noticed this = trend,=20 and began to support these tele-health activities.

In 1997, the telemedicine system of Shanghai Medical = University=20 obtained the re cognition of the country leaders at the national IT = exhibition.=20 This boosted interest in telehealth. Various organizations and = institutions=20 began their telehealth programmes. The late 1990s was a period of rapid = progress=20 for telehealth in China. The Jin-Wei (Golden Health) Telemedicine = Network began=20 operation in July 1997, and many national-level hospitals in Beijing and = Shanghai were included in this network. The network provided remote = consultation=20 and remote education services for hospitals in 21 provinces, including = Yunnan,=20 Sichuan, Tibet and Xinjiang, via satellite communication. In the same = year, the=20 International Medical Network Committee of the China Medical Foundation=20 established their telemedicine network. Following these two large = telemedicine=20 programmes, many others emerged. The Shuang-wei (Satellite Health = Education=20 Network of the Ministry of Health) network was sponsored by the Ministry = of=20 Health, and the MediChina BYL telemedicine network was sponsored by the = Shanghai=20 municipal government. There were also many telehealth programmes = initiated in=20 other areas, including Guangdong, Sichuan, Fujian and Yunnan = provinces.3 When = telehealth activities began to grow in China in the late 1990s, the = national=20 health authority recognized the importance of supervising them, and the = Ministry=20 of Health established a set of rules for telehealth in 1999.4

The rapid development of telecommunications = infrastructure in=20 the late 1990s helped to make telehealth a routine activity in China. = The=20 ordinary telephone network, the ISDN network, satellite communications = and the=20 Internet were all employed for telehealth purposes. Many different=20 organizations, including the government, medical universities, hospitals = and=20 even some private companies, built telehealth networks and made = telehealth a=20 routine application. Generally, they provided remote consultations and = remote=20 education services for users of their networks.

Telehealth programmes in China

Since 1997, many different telehealth programmes = have been=20 conducted in China. These programmes have been sponsored by different = entities,=20 have employed different telecommunication means and have operated at = different=20 scales. Some programmes have built large telehealth networks and = connected many=20 different health organizations.

One of the most well-known telehealth programmes was = the Jin-Wei=20 Telemedicine Network (the Golden Health Medical Network). This network = was=20 established with the support of the Ministry of Health. The network = operation=20 centre was located in Beijing and was a satellite network covering the = whole=20 country. Many national-level and lower-level hospitals from more than 20 = provinces were included in this network. The = satellite=20 communication allowed an 8 Mbit/s upload speed and 2 Mbit/s download. = Between=20 1997 and 2003, the Jin-Wei Telemedicine Network provided remote = consultation=20 services for more than 1000 patients, and provided remote education = services for=20 more than 50 000 doctors and nurses. The Jin-Wei organization also = developed a=20 website to provide health-related information services for users. = However, the=20 high cost of satellite devices and communications prevented many = low-level=20 hospitals from connecting to this network. Subsequently, the Jin-Wei = network=20 began to employ ISDN as a second telecommunication method to cover more=20 hospitals.3,5

The CMF (China Medical Foundation) Telemedicine = Network was also=20 a large-scale telemedicine programme. It was supported by a = non-profit-making=20 organization, the International Medical Network Association. It began in = 1997.=20 From the start, several different methods of telecommunication were = employed.=20 First, telephone lines were used to establish a network covering basic = level=20 hospitals, then ISDN and the Internet were used to connect higher-level=20 hospitals, and eventually satellite communication was used to connect=20 national-level hospitals. The aim of the CMF Telemedicine Network was = different=20 from that of the Jin-Wei network, in that it mainly provided telehealth = services=20 for basic-level hospitals. It used telephone line communication and = desktop=20 videoconferencing.3,5

The aim of the Shuang-wei (Satellite Health Education = Network of=20 the Ministry of Health) network was to provide remote medical education = services=20 for doctors and nurses all over the country. It was supported by the = Ministry of=20 Health and began routine operation in 2001. Satellite and optical fibre = were=20 employed as the major telecommunication means. The network supported = different=20 kinds of remote education, such as live broadcasting, video on demand, = the=20 interchange of online education materials, and point-to-point or = multipoint=20 videoconferencing.3,6

The BYL Telemedicine Network was a branch of the China = Social=20 Development Network. It was supported by the Shanghai municipal = government and=20 connected Shanghai and western areas of China. Various telecommunication = media,=20 including satellite, fibre-optic cables, the Internet and telephone = lines, were=20 employed in this network. Specialists in Shanghai provided an image = consultation=20 service for patients in other areas. When Shanghai provided telehealth = services=20 for western areas via this network, they also provided business = information=20 services.3

A Chinese Traditional Medicine Telemedicine Network = was=20 established by the Chinese Academy of Traditional Chinese Medicine in = 1997. It=20 employed ISDN for telecommunication to provide a traditional Chinese = medicine=20 consultation service for international and domestic patients.3

Several other telehealth programmes were set up in = China in the=20 late 1990s. These included the Sino-Japanese Telemedicine Collaboration = for=20 high-resolution medical image consultation, the Sino-Russian Satellite=20 Telemedicine Collaboration, and the telemedicine programmes of the Sun = Yet San=20 University, the Shanghai Second Medical University and the Western China = Medical=20 University. The Shuang-wei and BYL networks are still in operation. The=20 programmes had different purposes, employed different technologies and=20 telecommunication media, and were supported by different = organizations.3 = Since 2003,=20 some provinces have established their own regional telemedicine = networks: the=20 Fujian Province Telemedicine Network was set up in = late 2003=20 and the Gansu Province Telemedicine Network in late 2007. All these = regional=20 telemedicine networks are supported by local government and are still in = operation.

Telehealth programme of Shanghai Medical=20 University

Shanghai Medical University (SMU) provided medical = services,=20 teaching and research, and had about 5000 students. It had an excellent=20 technical reputation in China. Many departments in SMU-affiliated = hospitals were=20 well equipped, and some departments were ranked the best in the country. = In=20 2000, SMU was merged with Fudan University to set up a new Fudan = University.

SMU was a pioneer of telehealth in China. In 1994, it = began a=20 telehealth pilot project. It developed the first general telehealth = system in=20 China, which was based on low-bandwidth videoconferencing over the = telephone=20 network. Through this system, a surgeon in Huashan Hospital (an = affiliated=20 hospital of SMU) succeeded in providing a remote consultation service = for a=20 patient in Shanghai Jiaotong University. In 1995, with the support of = the=20 Shanghai Education and Research Network, SMU launched a pilot telehealth = programme and established a telemedicine centre. It began to develop = telehealth=20 systems conforming to international standards. In 1996, SMU began = cooperation=20 with the telecommunications authority in Shanghai. Various = telecommunication=20 companies began to establish different telecommunication connections for = the=20 telemedicine centre.2,7

In 1997, SMU established a telehealth network based on = the=20 telemedicine centre. The telehealth service providers were 7 affiliated=20 hospitals of SMU, and the telehealth service users were more than 20 = hospitals=20 from remote and rural areas. The task of the telehealth centre was to = act as the=20 administrative and telecommunication centre. All the service providers = were=20 connected to the telemedicine centre by optical fibre. The service users = were=20 connected by the ordinary telephone network, the ISDN network or = satellite,=20 according to cost. The network connected hospitals from 21 provinces, = including=20 Xinjiang, Tibet, Yunnan, Sichuan, Heilongjiang, Jiangsu and Zhejiang. In = the=20 telemedicine centre, there were nurses for remote consultation = administration=20 and technical staff for support. Each hospital of the service providers = and=20 service users had its own operation staff. Figure 20.1 = illustrates=20 the structure of the network.8

The SMU Telemedicine Centre developed many = administrative rules=20 for remote consultation in China. Only professors or associate = professors were=20 eligible to provide telehealth services. The operation staff had to have = completed special training in the network. When the service users = requested a=20 remote consultation, they had to submit full information about the = patients.=20 Because most of the hospitals in the network from remote and rural areas = lacked=20 digital devices, they often needed to digitize images using a digital = scanner.=20 The Telemedicine Centre provided a set of operational guidelines for the = service=20 users after their research in this field. The Telemedicine Centre also = designed=20 a procedure for remote consultation administration. In 1999, it = developed a=20 web-based remote consultation administration database. By using = this

3DImage=20

Figure 20.1 The structure of the SMU = Telehealth Network

database, the service users could apply for remote = medical=20 consultation services via the network, and the Telemedicine Centre could = despatch remote consultation requests to the appropriate service = providers.=20 Also, the consultation providers in Shanghai could schedule the remote=20 consultations via the network. As a multimedia database, it could accept = data in=20 the form of images, video and audio information relating to the remote = cases=20 that needed consultation.8

In 1996, the SMU Telehealth Network began to = experiment in=20 distance medical education. It provided distance education services for = the=20 doctors and nurses in the hospital on Chongming Island. Subsequently, = the SMU=20 Telemedicine Centre developed a remote education system. This comprised = two=20 parts. One was a videoconference system, by which teachers and students = could=20 have real-time discussions. The other part was a media system, which = could be=20 used for media broadcasting, video on demand, recording and editing. By = using=20 this system, teachers could finish their own tasks via the Internet.

The SMU Telehealth Network (now part of Fudan = University) is=20 still in operation. It has provided remote consultation services for = more than=20 2000 patients in remote and rural hospitals. These patients have been = from=20 various specialties, including cardiology, oncology, surgery, neurology = and=20 paediatrics. In their remote consultations, the specialists only provide = a=20 second opinion or suggestion for the doctors in the user hospitals, = because of=20 the absence of legislation that would permit them to make a diagnosis. = The=20 network has also provided more than 1000 hours of distance medical = education for=20 the Dali Medical College in Yunnan province and other hospitals in the=20 network.

After they began providing telehealth services for = remote and=20 rural users, the specialists received much feedback about the services. = A letter=20 from the hospital of Xindu, Sichuan province = described how=20 patients benefited from telehealth. For example, one patient with colon = cancer=20 made a full recovery after the operation, following the advice provided = in the=20 teleconsultation. She was the oldest patient to have recovered following = such an=20 operation at that hospital. Another patient with colon cancer recovered = fully=20 without requiring chemotherapy following the advice provided in the=20 tele-consultation. One patient with heart disease avoided an operation = to=20 implant a pacemaker.

Video and audio quality varies, depending upon how the = rural=20 sites are connected with the telemedicine centre. The best quality is = achieved=20 with a digital connection (DDN), followed by ISDN and satellite; = unsurprisingly,=20 the quality is quite low via an ordinary telephone line. In China, when=20 providing a telehealth service via telephone line, it can be expected to = be=20 interrupted every 5=9610 minutes because of connection problems. The = quality of=20 the consultation service is therefore poor, and remote education cannot = easily=20 be delivered via telephone line.

The costs of the different communication methods also = differ=20 greatly. Satellite communication is the most expensive, followed by DDN = and=20 ISDN. Telephone line and Internet communication are the cheapest.

Satellite communication is not suitable for a remote=20 consultation service, because of the time delay. However, it is suitable = for a=20 unidirectional broadcast service, such as that required for remote=20 education.

When considering all the factors relating to the = quality of the=20 system, cost and breakdown rate of the service, it appears that ISDN=20 communication is the most appropriate means of communication for = telehealth=20 services in China at present. Internet communication can be used in=20 non-real-time applications, for example to access databases and to apply = for=20 remote consultations. Because the bandwidth of Internet communication = has been=20 much improved, it can also be used for videoconferencing and remote = education,=20 for example video on demand and broadcasting for distance education. = Thus,=20 Internet communication has great potential as a communications method = for=20 telehealth in China.

Opportunities for telehealth in = China

China has the largest population in the world: at = the end of=20 2005, it was 1.3 billion. Health expenditure in China is rising: in = 2004, it was=20 75.9 billion RMB, and accounted for 5.6% of the gross domestic product. = In 2004,=20 the per capita expenditure in urban areas was about 4.2 times that in = rural=20 areas.9

The health sector in China faces two opposing demands: = first, it=20 must provide expanded and equitable access to high-quality health care = services;=20 second, it must reduce, or at least control, the rising costs of health = care.=20 Telehealth offers the promise of giving people equal access to = high-quality=20 medical care at affordable cost.

As in most other countries, the highest concentration = of medical=20 resources (personnel, information and facilities) in China is in the = major=20 cities, so telehealth could be a useful mechanism to balance the = differences in=20 the level of access to medical resources.

Information technology in China has grown very rapidly = in the=20 last few years. There has been rapid expansion of the telecommunication = market=20 and very fast diffusion of the Internet. By December 2007, there were = 210=20 million Internet users in China.10 = Health IT is=20 also developing very rapidly in China: many hospitals have developed a = hospital=20 information system, and now health information-sharing networks are = developing=20 in many cities. This will facilitate the development of telehealth in = China.

The large population and relatively insufficient = health=20 resources have produced demands for China to develop telehealth, and the = rapid=20 development of IT has provided the opportunities to do so. In 2003, = China=20 formulated its national strategy in e-health. The plan outlined the = strategy and=20 activities for China to develop e-health in 2003=962010. The plan = described the=20 background information, the principles, the goals and the main tasks for = China=20 to develop e-health.11 = Telehealth=20 development is part of this plan.

Challenges for telehealth in China

Although there are undoubted opportunities, = telehealth also=20 faces many challenges in China.12 = Despite the=20 successes of early telehealth systems in China, not many of them were=20 self-sustaining, and few are still in operation today. A number of=20 implementation barriers remain to be overcome. These include the = following.

A lack of understanding of telehealth by=20 society

Often, telehealth is perceived by health authorities = as a low=20 spending priority. Because telehealth is not clearly defined, there are=20 different definitions of telehealth, which makes it difficult for = patients to=20 understand its potential. Telehealth might adversely affect the = relationship=20 between health professionals and patients compared with normal = face-to-face=20 consultations. The reasons include physical and mental factors,=20 depersonalization, different process of consultation, reduced confidence = of=20 patients and health professionals, different knowledge and skills = required of=20 health professionals, and ergonomic issues. There are also various = factors that=20 prevent health professionals from accepting telehealth, including too = much=20 change, lack of a user-friendly interface, failure to collect the most = important=20 information, inadequate training of physicians to use the system, and = lack of=20 control by the organization over physician practices. Factors such as = doubt=20 about the quality of the telehealth and conflicts between the telehealth = procedure and traditional clinical schedules will prevent patients and = health=20 professionals from accepting the new system.

Incomplete telehealth organizational = structure and lack=20 of human resources

In many health institutes that conduct telehealth = programmes,=20 there are no special telehealth departments or staff. Lack of = organizational and=20 personnel resources is a major constraint on telehealth = development.

Lack of standards

In China, the telehealth systems and services are = developing=20 very rapidly, but the standardization of telehealth lags behind. = Standardization=20 of telehealth system components and services is an important element for = integration of heterogeneous systems. There are no standards for = telehealth in=20 China, and this has restricted developments. For example, in the rural=20 hospitals, there is no digital X-ray equipment, so, when they need to = transmit=20 X-ray images to specialists in the cities, the X-ray films are often = digitized=20 using a scanner. In practice, poor-quality images result, which would be = much=20 improved if there were standards to control the digitization = process.

Absence of legislation and=20 regulation

Lack of legislation and regulation is also a major = barrier to=20 telehealth development and deployment. There are some national = regulations for=20 telehealth, such as regulations governing remote consultation = administration.=20 But the work on regulation lags far behind the development of = telehealth. There=20 are also some legislative barriers. There is no related law focusing on=20 telemedicine, electronic signatures and patient privacy protection. = There are=20 problems with medical malpractice liability, because of legal = uncertainties.

High cost and insufficiency of funds for = telehealth=20 development

Telehealth depends on new technologies. The devices = are often=20 relatively expensive. Also, telecommunication costs can be high. = However, funds=20 for telehealth are insufficient, because the benefits of telehealth are = mainly=20 realized by the patients. Thus, investors do not have a great interest = in this=20 field. Another problem is that hospitals in remote and rural areas have = a higher=20 demand for access to telehealth services, but also have smaller = budgets.

Unbalanced development in different areas in=20 China

Because of unbalanced development, many hospitals in = remote=20 and rural areas cannot apply telehealth, owing to limitations of = equipment,=20 human resources and telecommunications.

Lack of reimbursement for telehealth=20 services

In China, health insurance does not cover = expenditure on=20 telehealth services. Thus, patients need to pay for telecommunications = and=20 specialists=92 fees themselves. This represents a major economic burden = for=20 patients.

Lack of evaluation of telehealth=20 programmes

Policy makers lack evidence from evaluation research = to help=20 them to decide how to support the development of telehealth.

Policy recommendations

China can learn from experiences in industrialized=20 countries.12 = This=20 suggests that, for the development of telehealth in China, it is = necessary to do=20 the following:

= Strengthen=20 the leadership of government in telehealth development. The = government=20 should establish a special organization to lead telehealth development = and=20 promote a government focus on telehealth.

= Strengthen=20 the supervision of telehealth development. In China, many = different=20 organizations are involved in telehealth activities. Many of these = organizations=20 are not health related. It is important to strengthen the supervision of = telehealth and prevent unqualified organizations from taking part in=20 telehealth.

= Promote the=20 development of telehealth standards. Health authorities should = promote=20 the development of telehealth standards with users, researchers, = technical and=20 scientific bodies, and industry. Establishing national standards and = adopting=20 international standards will be important tasks for China.

= Develop a=20 legal and regulatory infrastructure that will facilitate = telehealth.=20 Legislation related to telemedicine, electronic signatures and patient = health=20 information protection should be constituted.

= Increase the=20 investment in telehealth. The government should strengthen its=20 financial support for telehealth development. Also, other sources must = be=20 attracted to invest in telehealth. In China, there is a high demand for=20 telehealth services, especially for remote medical education services. = Many=20 early distance medical education programmes are still in operation = today.

= Train health=20 professionals and technical staff in telehealth. Training will = help=20 health professionals to understand telehealth, and will also promote the = efficiency of telehealth systems.

= Promote=20 international collaboration, sharing and learning experiences from=20 industrialized countries. This will help China to develop = telehealth.=20 Telehealth is relatively new to China. It can overcome geographical = barriers and=20 make high-quality services available without regard to location. This = can help=20 to reduce the unbalanced distribution of health resources. Because=20 telecommunications are developing rapidly in China, there are many = opportunities=20 to develop telehealth. There are also many challenges for telehealth to=20 overcome. If the importance of telehealth for China is widely = recognized, it=20 will have a better future in China.

Telehealth is relatively new to China. It can = overcome=20 geographical barriers and make high-quality services available without = regard to=20 location. This can help to reduce the unbalanced distribution of health=20 resources. Because telecommunications are developing rapidly in China, = there are=20 many opportunities to develop telehealth. There are also many challenges = for=20 telehealth to overcome. If the importance of telehealth for China is = widely=20 recognized, it will have a better future in China.

References

1.=20 Zhu SJ, Cai JH, Yang QS. The establishment and development of = telemedicine.=20 Hosp Adm J Chin PLA. 1998; 5: 277=9698.

2.=20 Zhao JA, Xu YX, Chen J. The implementation of telemedicine network = group.=20 Chin Hosp Manage 1998; 18: 27=968.

3.=20 Fu Z, Lian P. Telemedicine. Beijing: People=92s Military = Medical Press,=20 2005.

4.=20 Ministry of Health, People=92s Republic of China. [Rules for the = Development=20 of Telemedicine]. Available at: www.moh.gov.cn.

5.=20 Li BZ. The progress and prospect of Jinwei program. Chin Hosp = Manage=20 1998; 18: 41=963.

6.=20 Ministry of Health, People=92s Republic of China. [Satellite Health = Education=20 Network of Ministry of Health. Shuang-wei Network]. Available at:=20 www.sww.com.cn.

7.=20 Xu YX, Mo MQ, Zhao JA. New Progress on the Internet and Using It in=20 Medicine. Shanghai: Fudan University Press, 2001.

8.=20 Xia ZY. The administration of telemedicine. Medl Inf 2005;=20 18: 907=969.

9.=20 Ministry of Health, People=92s Republic of China. [Official website]. = Available=20 at: www.moh.gov.cn.

10. China = Internet=20 Network Information Center. Statistical Survey Report on the = Internet=20 Development in China. January 2008. Available at:=20 www.cnnic.org.cn/uploadfiles/pdf/2008/2/29/104126.pdf.

11. China = Centre for=20 Information Industry Development. [e-Health Development Plan for = China in=20 2003=962010]. Available at:=20 industry.ccidnet.com/art/793/20051024/356253_1.html.

12. Xia ZY. = Challenges=20 faced for telemedicine development in China and corresponding = recommendations.=20 Med Inf 2005; 18: 206=969.

21 Telemedicine in South Africa

Maurice Mars

Introduction

South Africa is similar to most other sub-Saharan = African=20 countries in facing a substantial burden of disease with limited human = and=20 financial resources. South Africa is a relatively large country of over = one=20 million square kilometres, with a total population of 45 million. Its = people are=20 almost equally divided between rural (46%) and urban areas. With a gross = domestic product of US$200 billion, South Africa has one of the largest=20 economies in Africa and accounts for about a quarter of the entire gross = domestic product of the continent. Despite this, it has an official = unemployment=20 rate of 26% and an unofficial unemployment rate of 41%. About 50% of its = people=20 live below the poverty datum.

Burden of disease

The burden of disease in South Africa is great. = Until=20 recently, it had more HIV-positive people than any other nation. HIV = prevalence=20 in adults aged 15 years or older is 17% and the incidence of = tuberculosis is=20 1.3%.1 Data = from 2000=20 show HIV/AIDS as the greatest cause of death (30%), with cardiovascular = disease=20 (17%), intentional and unintentional injuries (12%), non-HIV-related = infectious=20 and parasitic disease (10%), and malignant neoplasms (8%) as the next = major=20 causes.2

Health provision

Public health services and budgets are devolved from = the=20 national Department of Health (DOH) to provincial Departments of Health, = with=20 some primary health care services being provided by municipalities. The = annual=20 health care expenditure by the government is US$158 per capita.1 There = is a=20 major inequality in health care funding, with private expenditure per = person=20 about six times higher than public sector expenditure per person.3 By = African=20 standards, South Africa is relatively well supplied with doctors, with = 77=20 doctors per 100 000 people,1 but = again the=20 distribution of doctors is skewed, with the provincial hospital sector = being=20 served by 24 doctors per 100 000 people and 10 specialists per 100 000 = people.=20 On average, 34% of the medical posts in the public health sector are=20 vacant.3

Telecommunications

Africa did not benefit from the substantial = telecommunication=20 infrastructure roll-out and deregulation that occurred during the dot.com boom. As = in most=20 African countries, telecommunication in South Africa is still tightly = regulated,=20 with the government following a policy of =91managed liberalization=92. = There has=20 until very recently been a telecommunication monopoly. A licence for a = second=20 service provider has now been awarded, but services have yet to = commence. The=20 government has 37% and 30% shareholdings in these two service providers, = respectively.4 = International=20 bandwidth is provided by undersea cable (SAT 3) and satellite. Although = plans=20 for an additional undersea cable running up the east coast of Africa = (EASSY) are=20 well developed, the project appears to be stalled at present. Satellite = services=20 are licensed to one company, which is totally owned by the Department of = Communications.

Internet access charges in South Africa are relatively = high when=20 compared with those in industrialized countries, with 20 hours of = Internet=20 access costing US$33 per month, compared with US$15 per month for the = USA.=20 Similarly, ISDN costs are high, with a 30-minute ISDN link to the USA = (at 128=20 kbit/s) costing US$15.80.5 ISDN = and ADSL=20 access is available in most cities and towns. Wireless coverage is = limited by=20 legislation, but it is hoped that Wimax will be made available by = several large=20 municipalities. In an attempt to provide low-cost bandwidth facilities, = the=20 government has established a state-owned company, but it has yet to = trade.4

Mobile phone coverage is good and uptake is high. 3G = and HSDP=20 services are available in most cities, and GSM coverage is estimated at = 93%.=20 Data for the year 2004 indicate that 36% of South Africans have mobile = phone=20 access. Local figures suggest that access to a mobile phone may be as = high as=20 75%.4

Lack of bandwidth, especially in rural areas, is a = major problem=20 facing telemedicine delivery in South Africa. All provincial hospitals = are=20 linked to the government network (Govnet). Access to computers with = Internet=20 access for doctors and nurses is limited in many rural hospitals and = clinics,=20 with doctors having to send store-and-forward cases from home using = local=20 Internet service providers. In KwaZulu-Natal, most hospitals have access = to a=20 total bandwidth of 128 kbit/s, which must be shared across all sectors = of the=20 hospital. Migrating videoconferencing from ISDN to IP is not feasible as = yet,=20 because of the limited bandwidth. ISDN access is not always easy to = obtain, and=20 delays of up to a year for installation are not uncommon. Likewise, = support from=20 the telecommunication company is poor, and the time from registering an = ISDN=20 line problem to a repair visit can be several months. ADSL, while = available in=20 most cities and larger towns, is dependent on the state of the local = telephone=20 exchanges. A survey conducted in 2006 showed that fewer than half of the = hospitals in KwaZulu-Natal could be provided with ADSL if requested.

Telemedicine governance

In 1995, the new government formed the National = Health=20 Information Systems Committee of South Africa, tasked with designing a=20 comprehensive national health information system = for South=20 Africa. Under the auspices of this Committee, a National Telemedicine = Task Team=20 was formed in 1998, to implement a national telemedicine strategy for = South=20 Africa. Four technical teams were established to work on telemedicine = protocols,=20 network infrastructure, legal licensure and ethical issues, and = teleeducation.=20 These teams were active until 2001, by which time Phase One of the = national=20 telemedicine strategy had been implemented. While the national DOH has a = Telemedicine Director, management and implementation of telemedicine = services=20 was devolved to provincial level during the Phase One project. In order = to=20 coordinate this at a provincial level, the Health Act of 2004 requires = Members=20 of the Executive Council at provincial level to form a committee that = will =91=85=20 establish, maintain, facilitate and implement health information in the=20 province=92. The provinces have taken different approaches to = telemedicine. In=20 most provinces, telemedicine is seen as part of the duties of the = provincial=20 representatives attending the National Health Information Systems = Committee, who=20 may or may not be interested in telemedicine. As a result, telemedicine = activity=20 has been limited or non-existent in some provinces. Other provinces have = appointed specific telemedicine committees, some of which have been = extended to=20 include academic input from the medical schools. Only a few provinces = actually=20 provide a budget and posts for telemedicine, but this is slowly = changing.

The national telemedicine strategy planned for three = phases of=20 development of tele-medicine. Only Phase One was implemented and, after=20 evaluation, it was decided not to continue with the project. However, = after=20 several years of relative inactivity, there has been renewed interest in = telemedicine. The national DOH is developing a new strategic plan for = 2008=962013.=20 The Presidential National Commission on Information Society and = Development is=20 working on an e-health White Paper, the Departments of Communications = and Trade=20 and Industry have included e-health in their most recent strategic = plans, and=20 the Meraka Institute of the Council for Scientific and Industrial = Research=20 (CSIR) is developing an e-health strategic plan.

The Medical Research Council (MRC) of South Africa has = a=20 Telemedicine Lead Programme tasked with evaluating existing and planned=20 telemedicine systems, coordinating national telemedicine activities and=20 establishing tele-education for health care professionals. The eight = medical=20 schools in the country have been slow to participate in telemedicine. = The=20 University of KwaZulu-Natal is the only medical school with an academic=20 department of Telehealth, and the Walter Sisulu University has a = Telemedicine=20 Unit.

Telemedicine background

Telemedicine in South Africa began in the early = 1990s, with:=20 radiologists linking CT scanners in Provincial Hospitals in = KwaZulu-Natal to the=20 Academic Radiology Department;6 = neurosurgeons=20 in the province providing a teleradiology-assisted service;7 rural = doctors=20 using email-based store-and-forward telemedicine for dermatology, = orthopaedics=20 and radiology; and ophthalmologists linking with Moorfields Hospital in=20 London.8 At = the Walter=20 Sisulu University Medical School, store-and-forward telepathology = services have=20 been used since 1995, with links to the Armed Forces=20 Institute of Pathology in Washington and various pathology departments = in=20 Europe.9

Phase One of the National Telemedicine Strategic Plan = was=20 implemented between March 1999 and September 2000, establishing 28 = telemedicine=20 sites in six of the nine provinces. Telemedicine services offered = included=20 store-and-forward teleradiology using scanned X-ray films, = tele-ultrasonography=20 (both real-time and store-and-forward), store-and-forward telepathology = and=20 tele-ophthalmology. Of these projects, only the teleradiology service = linking=20 three rural hospitals with the Pretoria Academic Hospital could really = be deemed=20 a success. In the first 9 months of the Pretoria service, 264 = radiographic=20 studies (10% of all the studies performed) were sent for specialist = radiologist=20 reporting.10 = Over the=20 years, this developed into a useful CT scan radiology service with the=20 neurosurgical department, but the service ended when the department = moved into a=20 new building with no ISDN line access. Tele-ultrasonography, trialled in = the=20 Northern Province and KwaZulu-Natal, was used occasionally and then = stopped, and=20 the tele-ophthalmology project in KwaZulu-Natal was beset with software = problems=20 and never started.

This lack of success meant that the second and third = phases of=20 the project, to expand telemedicine capabilities to 71 and then to 200 = sites,=20 was not undertaken. The second phase was then changed to an educational = project=20 linking the eight medical schools, with the expectation that they would = initiate=20 shared tele-education projects throughout the country. Although the = medical=20 schools were supplied with videoconference units, this project lacked = the=20 support of the deans of the medical schools, and never started.

Many lessons were learned in this process, and were = similar to=20 those experienced by others. These can be summarized as follows:11

Failure to = fully=20 appreciate the need for a well-structured change management plan

Lack of=20 participatory buy-in from doctors at the sending and receiving sites

Inadequate = training=20 and support

Failure of = provincial Departments of Health to take ownership and commit human and=20 financial resources to the devolved project.

At the same time as the telemedicine project was = being rolled=20 out, the Nkosi Albert Luthuli Central Hospital was built and = commissioned in=20 Durban, KwaZulu-Natal in 2002. It is a paperless hospital, and has = exposed its=20 staff to aspects of telemedicine through the use of radiology and = pathology=20 PACS.

Telemedicine projects

With the relative inactivity of most of the = provincial=20 Departments of Health, telemedicine activity was taken up by other = agencies and=20 academia. The South African Defence Force together with the MRC = developed a=20 mobile laboratory with satellite communication and telemedicine = capability.12 = However, no=20 information has been published about its subsequent deployment. The MRC=20 developed a test bed in Mpumalanga Province, linking two clinics and a = hospital=20 to the Pretoria Academic Hospital by videoconference. Limited=20 data are available on its use: in 2002, 78 videoconference sessions took = place =96=20 68 teleconsultations and 10 tele-education sessions. This has been = extended to a=20 wireless network, and a teleradiology project is planned.

In collaboration with the University of Stellenbosch, = the MRC=20 has developed a =91home-grown=92 primary health care workstation for use = in primary=20 health care facilities run by nurses and part-time doctors and dentists. = It has=20 been trialled intermittently over the past two years at the Grabouw = Community=20 Health Centre, with an ISDN-based link to the Tygerberg Academic = Hospital. The=20 unit has been designed to be used by health professionals who have = limited or no=20 previous computing experience. Features include:13

removal of = the need=20 to interact with the operating system

a = simplified=20 alphanumeric input device

integrated = and=20 intelligent video control

a document = interface=20 that is familiar to the local users

seamless = integration=20 of peripheral devices

a back-up = power=20 source

use of = open-source,=20 loyalty-free software.

The experience has revealed some of the common = challenges=20 associated with starting telemedicine services in environments where = there is a=20 shortage of staff at both the sending and receiving sites:

Adequate = buy-in has=20 to be obtained from users.

The = service must be=20 integrated into the normal workflow of the hospital.

Incentives = should be=20 offered for already overworked staff to use telemedicine, which is seen = as an=20 additional and time-consuming burden.

There = should be a=20 local telemedicine champion to drive the changes.

The unit has been used predominantly for = teledermatology and=20 paediatric consultations.

Various other enthusiast-driven telemedicine projects = have=20 commenced. At the Walter Sisulu Medical School in the Eastern Cape = Province, the=20 telepathology services that started in the 1990s have migrated to the = iPath=20 platform, with an iPath server located in Umtata. In the first 4 years, = 36=20 pathology cases were referred for international opinion.9 This = service=20 was then expanded to include a teledermatology project, with a general=20 practitioner in a small town in a rural area sending 110 cases in 6 = years.14 An = innovative=20 wireless solution, developed by the CSIR, was piloted in a rural Eastern = Cape=20 clinic staffed by a nursing sister. The region does not have telephone = coverage,=20 and images are sent via a webcam, with a simultaneous voice link, to a = doctor in=20 another town.15 The = activity=20 in the Eastern Cape has resulted in the formation of an active = telemedicine=20 committee within their DOH. They have set up an education centre with = Internet=20 and videoconference facilities in East London, and they are embarking on = a=20 large-scale project linking 23 sites, focusing on teleradiology, = teledermatology=20 and tele-spirometry. The project is not yet fully functional, and has = yet to be=20 evaluated.

A different approach has been taken in KwaZulu-Natal. = In 2002,=20 the University of KwaZulu-Natal established an = academic=20 department of telehealth, with a mandate to assist the provincial DOH in = developing telemedicine, conduct research in telehealth, and develop = academic=20 programmes in telemedicine and medical informatics. In addition to the=20 long-standing teleradiology and teleneurosurgery services in the = province, a=20 store-and-forward tele-ophthalmology service has been running between a=20 peripheral hospital and the academic ophthalmology department for = several years.=20 When last audited, this service had referred 282 cases in 18 months and = had=20 saved 82% of the patients an unnecessary transfer to the academic unit, = 118 km=20 away. Despite efforts, it has not yet been possible to replicate this = service in=20 any of the other 64 provincial hospitals. A real-time teledermatology = service=20 has been running between one hospital and the medical school for several = years.=20 At audit in 2006, 132 patients had been seen over 27 months, with 80% = being=20 saved a transfer. This service has been replicated in two other = hospitals, and=20 further sites are planned. Store-and-forward teledermatology services = have been=20 running in parallel, with cases sent from 23 hospitals.

Fledgling synchronous services have commenced in = paediatric=20 surgery, plastic surgery and psychiatry. Store-and-forward burn = management and=20 diabetic retinopathy screening programmes have also started. Through = various=20 externally funded initiatives, there are now 35 hospitals in = KwaZulu-Natal with=20 videoconference facilities, not all of which are currently active. The=20 provincial DOH, while being supportive of these initiatives, has not = taken=20 ownership of telemedicine. As a result, it has only provided limited = technical=20 support, and has not yet provided a specific telemedicine budget. This = has=20 recently changed with the provision of posts for telemedicine, the = development=20 of a strategic plan and a budget for telemedicine, and the formation of = a joint=20 DOH and university Telemedicine Steering Committee for the province.

The national Department of Science and Technology has = funded a=20 consortium of the MRC, the Meraka Institute of the CSIR and the = University of=20 KwaZulu-Natal in a major three-year project in KwaZulu-Natal. The = project will=20 investigate various bandwidth solutions in rural areas, aiming to = achieve a=20 minimum of 512 kbit/s. It will also compare the locally produced primary = health=20 care workstation with a Chinese tele-medicine workstation that has been = acquired=20 through a bilateral government agreement, and will conduct research into = the=20 development of appropriate administrative and financial models for the = use of=20 telemedicine in the South African public health care sector. Other aims = are to=20 investigate cultural and ethical matters relating to the use of = telemedicine in=20 rural communities, to conduct telemedicine training, to develop a = telemedicine=20 hub site and establish a virtual hospital to support the hospitals in = the=20 province, and to develop capacity in telemedicine through masters and = PhD=20 programmes. It is hoped that this project will result in a sustainable = model for=20 telemedicine in South Africa.

The Free State, Northern Cape and North West Province = were the=20 other three provinces that received telemedicine infrastructure in Phase = One of=20 the national telemedicine project. Their services in teleradiology and=20 tele-ultrasonography have stopped. The Free State is actively = investigating the=20 establishment of telemedicine in the province, and has been considering = a=20 web-based PACS system for province-wide teleradiology.

The three provinces that were not part of Phase One = were=20 Gauteng, the Western Cape and Limpopo. In Limpopo, a telemedicine = steering=20 committee was established in June 2006. Videoconferencing was set up = between=20 four hospitals. With the assistance of the MRC and the University of=20 KwaZulu-Natal, an ambitious telemedicine and tele-education programme = began in=20 the third quarter of 2007. The project includes dermatology, emergency = medicine,=20 psychiatry, dentistry, ENT, orthopaedics and surgery.

In Gauteng, work is under way to develop teleradiology = in the=20 provincial hospitals. In the Western Cape, an email-based = store-and-forward=20 telemedicine project has been running for several years between three = district=20 hospitals and the Tygerberg Children=92s Hospital.16 A = pilot=20 store-and-forward teledermatology project has been started by the MRC = and the=20 University of Cape Town, with nursing sisters at four rural sites = sending images=20 and case histories back to a dermatologist in Cape Town.17

Telemedicine in the private health sector has not been = well=20 documented. One large hospital group and some large radiology practices = use=20 teleradiology and commercial PACS to transport and store X-ray images = and=20 reports, and pathology practices are following suit. There are several = informal=20 reports of images being captured during arthroscopic and endoscopic = surgery and=20 being sent by email for another opinion. There is at least one = ophthalmologist=20 who is sending photographs of retinal images to a colleague for second=20 opinion.

At present, there are no telepsychiatry services in = South=20 Africa, but two services and a psychiatry tele-education programme are = planned.=20 With recent changes to the Mental Health Act and the requirement to = treat=20 psychiatric patients at district and regional hospital level for at = least 72=20 hours, telepsychiatry may prove to be a major growth area. While=20 videoconferenced patient follow-up is relatively common in the = industrialized=20 world, it is not yet being used in South Africa. This may be because of = the=20 shortage of doctors and the lack of telemedicine site coordinators.

Some novel applications have been developed in South = Africa.=20 Cell-Life is a mobile phone and Internet method of monitoring HIV = patient=20 adherence to antiretroviral medication.18 = SIMpill is a=20 device that utilizes mobile phone technology and SMS text messages to = monitor=20 patients=92 medication compliance. When a patient opens the pill bottle = to take=20 their medication, an SMS text message is sent to a central server. If = the=20 patient fails to open the pill bottle within a defined time, the server = sends an=20 SMS message to the patient=92s mobile phone and, if there is repeated=20 non-compliance, to the patient=92s physician.19

Tele-education

Staffing of rural hospitals has been a long-term = problem in=20 South Africa. The Government has had to employ doctors from other = countries in=20 order to maintain services in some rural areas. In 2004, there were 240 = Cuban=20 doctors working in South Africa. A recent press release reported that = 1000=20 doctors are to be recruited from Tunisia, Cuba, Iran and elsewhere to = work in=20 rural areas. Studies of the factors that influence local doctors=92 = decisions to=20 work in rural hospitals have identified salaries and professional isolation as key issues. The government has improved = salaries=20 through the provision of a scarce skills allowance. Tele-education and=20 telemedicine have been cited as ways of overcoming professional = isolation, and=20 the National Telemedicine Strategy included tele-education as an = important=20 component of the strategic plan. The attempt to get the eight medical = schools to=20 jointly develop a national teaching programme was not successful, and = individual=20 medical schools have undertaken tele-education.

In 2001, as part of an e-health learning initiative, = the Free=20 State Department of Health set up an interactive satellite broadcast = system, and=20 now offers health care training at 40 venues. Their last evaluation = included=20 over 2200 users. After the cessation of Phase One telemedicine services = in=20 KwaZulu-Natal, the local university approached the provincial DOH, in = 2001, and=20 was given approval to use the videoconferencing infrastructure for = postgraduate=20 medical education. Equipment has been upgraded, and postgraduate = teaching=20 sessions are multicast from the Nelson R Mandela School of Medicine to = four=20 other academic sites. In 2006, 765 hours of tuition in 17 academic = programmes=20 were shared by videoconferencing. A total of over 72 000 person-hours of = tuition=20 were offered in 2006, with approximately 40% of participants situated at = rural=20 hospitals. The medical school also shares its teaching sessions with = other=20 provinces, including the Walter Sisulu Medical School and the East = London=20 Medical Complex in the Eastern Cape, and the Polokwane Hospital in = Limpopo.=20 International teaching has taken place in collaboration with several = countries=20 in North Africa, Europe and North America.

The Walter Sisulu University has begun postgraduate = teaching by=20 videoconferencing, and the Universities of Stellenbosch and Pretoria = have=20 offered postgraduate courses by satellite TV. The University of the=20 Witwatersrand has been funded to start a videoconferenced academic = programme in=20 public health. The College of Radiology of South Africa, aware of the = extreme=20 shortage of radiologists in the academic sector, funded a pilot project = to share=20 postgraduate teaching sessions between all eight medical schools by=20 videoconference. The first four sessions have been completed, and are = being=20 evaluated before a decision is made to continue the project.

Mindset Health is a partnership between the Mindset = Network, the=20 national DOH and Sentech (the Government-owned satellite information and = communication technology service provider), which aims to deliver = large-scale=20 health education and health promotion. This is achieved through the = development=20 of digital health education material delivered by video, by multimedia = computer=20 lessons and print, and by daily satellite broadcast to 200 hospitals in = South=20 Africa, with on-demand satellite datacasts for health care staff. The TV = receivers for the satellite broadcasts are usually placed in the = outpatient=20 departments of rural hospitals. The initial focus has been on = tuberculosis and=20 HIV/AIDS.20

Telemedicine training

Since the Phase One project, there has been very = little formal=20 telemedicine training for health care workers. In Mpumalanga, several = members of=20 staff were sent to China to be trained on a Chinese telemedicine unit in = expectation of its deployment. In the Eastern Cape, a telemedicine = training=20 workshop was arranged under the auspices of the Regional Impact of = Information=20 Society Technologies in Africa project. Training has also=20 been provided by the MRC, the Walter Sisulu University and the = University of=20 KwaZulu-Natal to specific individuals participating in projects.

At postgraduate level, the principles and potential of = telemedicine and medical informatics are included in several Masters in = Public=20 Health programmes. Formal training in telemedicine is offered at the = University=20 of KwaZulu-Natal, where students can take a Masters in Public Health = degree with=20 specialization in telemedicine or a Master of Medical Science in=20 telemedicine.

Legislation and guidelines

The DOH is drafting a Telemedicine Act that will = address=20 matters such as licensure, consent, data security and patients=92 = rights. With the=20 shortage of doctors in South Africa, there is a need for a pragmatic = approach to=20 the issue of licensure, so that the country can take advantage of = international=20 telemedicine services. It is hoped that the Act will be enabling and not = restrictive. At the same time, the Health Professionals=92 Council of = South Africa=20 is drafting ethical guidelines for telemedicine. While these initiatives = are=20 well intentioned, they may be premature, as there is as yet an = insufficient base=20 of physicians and nurses with practical experience in telemedicine in = South=20 Africa to fully appreciate and debate the implications of some the = proposals in=20 the Act. Legislation that may be appropriate for an industrialized = country may=20 not be appropriate in a developing country with a shortage of doctors = and=20 nurses, and may indeed obstruct the use of telemedicine.

Conclusions

Telemedicine in South Africa appears to be at a = crossroads.=20 While its potential is apparent, it is not yet clear whether the = potential can=20 be realized in an environment in which there are human resource = constraints at=20 both the sending and receiving sites. Despite several years of activity, = the=20 volume of telemedicine use is still very low, and most services must be=20 considered as being still in the pilot phase. Efforts to date have been = hampered=20 by several common factors. These include lack of buy-in from provincial=20 governments, lack of support from health professionals, lack of = technical=20 support, insufficient training, failure to provide site coordinators, = lack of=20 administrative and financial models for the public sector, and failure = to=20 understand the complexity of change management.

Videoconferenced tele-education for health = professionals has=20 been successful, and demand is growing. Tele-education may prove to be = the=20 catalyst for rural practitioners to become involved in telemedicine = activity.=20 There is renewed interest in telemedicine in South Africa, and this = needs to be=20 well managed and coordinated for telemedicine to succeed. To do so = probably=20 requires the formation of a national telemedicine association, bringing = together=20 the government and the provincial DOHs, universities, nongovernmental=20 organizations, the private health sector and industry. The aim would be = to=20 ensure that mistakes are not repeated, that pilot projects are scaled up = through=20 cooperation and that local best practice is shared for the common good. = If South=20 Africa cannot make telemedicine work, then other = poorly=20 resourced African countries are unlikely to succeed.

References

1.=20 World Health Organization. World Health Statistics 2007. = Available at:=20 www.who.int/whosis/whostat2007/en/index.html.

2.=20 Bradshaw D, Groenewald P, Laubscher R et al. Initial burden of disease = estimates=20 for South Africa. S Afr Med J 2003; 93: = 682=968.

3.=20 Health Systems Trust. Health Statistics. Available at:=20 www.hst.org.za/healthstats/index.php?indtype_id=3D004002.

4.=20 Esselaar S, Gilwald A, Stork C. South African Telecommunications = Sector=20 Performance Review 2006. Available at:=20 link.wits.ac.za/papers/SPR-SA.pdf.

5.=20 World Bank. ICT at a Glance Tables. Available at:=20 web.worldbank.org/WBSITE/EXTERNAL/DATASTATISTICS/0,,contentMDK:20459133~m= enuPK:1192714~pagePK:64133150~piPK:64133175~the
SitePK:239419,00.html.=

6.=20 Corr P. Teleradiology in KwaZulu-Natal. A pilot project. S Afr Med = J=20 1998; 88: 48=969.

7.=20 Jithoo R, Govender PV, Corr P, Nathoo N. Telemedicine and neurosurgery:=20 experience of a regional unit based in South Africa. J Telemed = Telecare=20 2003; 9: 63=966.

8.=20 Kennedy C, Kirwan J, Cook C et al. Telemedicine techniques can be used = to=20 facilitate the conduct of multicentre trials. J Telemed = Telecare 2000;=20 6: 343=967.

9.=20 Brauchli K, Oberli H, Hurwitz N et al. Diagnostic telepathology: = long-term=20 experience of a single institution. Virchows Arch 2004;=20 444: 403=969.

10. Gulube = SM,=20 Wynchank S. Telemedicine in South Africa: success or failure? J = Telemed=20 Telecare 2001; 7(Suppl 2): 47=969.

11. Gulube = SM.=20 Evaluation Report of the First Phase of the SA National Telemedicine = System=20 (NTS). Available at: www.kznhealth.gov.za/telemedreport.pdf.

12. Science = in Africa.=20 Telemedicine Gets Mobile. Available at:=20 www.scienceinafrica.co.za/2004/september/telemedicine.htm.

13. Abrahams = JF,=20 Molefi M. Implementing telemedicine in South Africa =91A South = African=20 Experience=92. Available at: = www.hrhresourcecenter.org/node/1265

14. Brauchli = K,=20 O=92Mahony D, Banach L, Oberholzer M. iPath =96 a telemedicine platform = to support=20 health providers in low resource settings. Stud Health Technol = Inform=20 2005; 114: 11=9617.

15. Chetty = M, Tucker=20 W, Blake E. Telemedicine in the Eastern Cape Using VOIP Combined = with a=20 Store and Forward Approach. Available at:=20 pubs.cs.uct.ac.za/archive/00000202/01/Chetty.pdf.

16. = Bridges.org.=20 The Tygerberg Children=92s Hospital and Rotary Telemedicine = Project.=20 Available at: www.bridges.org/case_studies/353.

17. Colven = R, Todd G,=20 Wynchank S et al. A Teledermatology Network for Underserved Areas of = South=20 Africa. Available at:=20 www.medetel.lu/download/2005/parallel_sessions/presentation/0407/A_Telede= rmatology_network.pdf.

18. = Cell-Life.=20 Cell-Life. Available at: www.cell-life.org.

19. SIMpill. = Simpill. Available at: www.simpill.com.

20. = International=20 Marketing Council of South Africa. Beaming Education to the = Nation.=20 Available at:=20 www.southafrica.info/ess_info/sa_glance/education/mindsetedu.htm.

22 Telemedicine in sub-Saharan = Africa

Maurice Mars

Introduction

What is the state of telemedicine in sub-Saharan = Africa? There=20 is no single repository of information on telemedicine in Africa, so it = is=20 difficult to provide current and accurate information on every country. = However,=20 it is apparent that many telemedicine projects in Africa are launched = with a=20 fanfare of press releases, but there is little or no information about = their=20 subsequent progress.

Demographics

Africa has a land mass of 30 million square = kilometres, with=20 a total population of approximately 965 million people, who constitute = 14% of=20 the world=92s population.1 = Health=20 provision in Africa is poor. The difference between Africa and the=20 industrialized world was highlighted in the WHO World Health Report of=20 2006:2

The WHO Region of the Americas with 10% of the = global=20 burden of disease, has 37% of the world=92s health workers spending more = than 50%=20 of the world=92s health financing, whereas the African Region has 24% of = the=20 burden but only 3% of health workers commanding less than 1% of world = health=20 expenditure. The exodus of skilled professionals in the midst of so much = unmet=20 health need places Africa at the epicentre of the global health = workforce=20 crisis.

Sub-Saharan Africa can be defined as that part of = Africa=20 lying to the south of the Sahara Desert. This includes five countries = whose=20 political boundaries are traversed by the geographical boundary. It is = made up=20 of 42 countries and 6 island nations, extending as far east as Mauritius = in the=20 Indian Ocean.

Burden of disease and population=20 predictions

The burden of disease is great. Africa has most of = the=20 HIV-positive people in the world =96 approximately 24 million. A million = people=20 die annually of malaria, and Africa accounts for over 90% of the half = billion=20 new cases of malaria each year. There is a high prevalence of = tuberculosis, and=20 poliomyelitis has re-emerged.3 The = leading=20 causes of death in the WHO African Region in 2002, in order, were = HIV/AIDS,=20 malaria, lower respiratory tract infections, diarrhoeal diseases, = perinatal=20 conditions, cerebrovascular vascular disease, tuberculosis, ischaemic = heart=20 disease and measles.4 While = the focus=20 of the industrialized world is on the ageing population and how to keep people out of hospital, average life expectancy = is still=20 falling in many African countries. Life expectancy is less than 45 years = in 7=20 countries.3 For = the=20 foreseeable future, there will be a large number of people dying in = Africa and a=20 substantial birth rate, both of which place heavy demands on health care = providers.

Provision of doctors

The WHO recommends that at least 20 doctors per 100 = 000=20 population are required to provide minimum basic health care services.=20 Thirty-eight sub-Saharan African countries fail to meet this standard, = 31=20 countries have fewer than 10 doctors per 100 000 population and 13 = countries=20 have fewer than 5 doctors per 100 000. It has been estimated that Africa = would=20 require an additional one million doctors to meet this minimum = requirement. The=20 shortage of health professionals in Africa is a result of = underproduction, loss=20 through migration and, surprisingly, in some countries, unemployment. = There are=20 121 medical schools in Africa, with a ratio of 1 per 7.6 million people, = compared with the industrialized world=92s norm of 1 per 2 million = people.5 The = medical=20 schools are not equally distributed, with 87 medical schools in 47 = sub-Saharan=20 African countries and 34 schools in 6 Mediterranean-rim countries. Four=20 sub-Saharan countries do not have a medical school. The brain drain of = health=20 professionals from the developing world is the focus of the WHO World = Health=20 Report 2006, with rates of migration of health workers from African = countries=20 ranging from 8% to 60%.4

Health care funding

There is extreme poverty, with 41% of people in = sub-Saharan=20 Africa living on less than US$1 per day.6 = Funding of=20 health care remains difficult. A realistic estimate of the cost of = providing=20 basic health care to people in Africa is about US$34 per person per = annum. Based=20 on 2004 data, the governments of 34 sub-Saharan African countries = allocate less=20 than US$34 per capita per annum to health; 23 countries spend less than = US$10=20 per capita. The average per capita expenditure on health in sub-Saharan = Africa=20 is US$22.

In 2001, Member Heads of States of the Organisation of = African=20 Unity signed the Abuja Declaration on HIV/AIDS, Tuberculosis and Other = Related=20 Infectious Diseases, in which they pledged to set a target of allocating = at=20 least 15% of their annual budgets to the improvement of the health = sector. This=20 was re-affirmed by the Ministers of Health in the Gaborone Declaration = of 2005.=20 Only two countries have achieved this. By 2004, the average general = government=20 expenditure on health was 8.8% in the WHO African Region3 and, = by 2005, a=20 third of the countries had reached 10%. There was also a commitment by = developed=20 countries to give 0.7% of their annual income in aid. By 2006, only = Denmark,=20 Luxembourg, the Netherlands, Norway and Sweden had honoured this = pledge.

Telemedicine as a solution?

Telemedicine has great potential to solve problems = such as=20 the shortage of health-workers and the provision of care to underserved = rural=20 populations (Box=20 22.1).7 = The

Box 22.1 The plight of many rural = patients in=20 Africaa

Patients are referred to the Black Lion = Teaching Hospital=20 in Addis Ababa from all over Ethiopia. If they do not die on the = way to=20 Addis Ababa, they often face long waiting times once they get = there.=20 Under-investment in rural health care facilities, a shortage of = doctors=20 and the lack of incentives to retain medical staff in rural areas = all=20 serve to increase the problem.

Demissie Sahle is a 68-year-old farmer who = lives in=20 Amhara, about 200 km north of Addis Ababa. He was ill for six = months, and=20 tried to obtain treatment at the nearest health post, but without = success.=20 Together with his son Laike, he raised nearly 4000 birr (US$500) = to travel=20 to the capital: =91whatever we could sell, we have sold to get = here and to=20 pay for treatment, including our only oxen=92, said Laike. Father = and son=20 embarked on the journey, leaving their families and their land = behind,=20 unsure whether anyone would look after them.

Telemedicine, if it were to be rolled out to = rural areas,=20 could make Demisse Sahle=92s journey a thing of the past. This = case=20 exemplifies the plight of many rural patients in Africa and = highlights the=20 potential for telemedicine in Africa.

aAdapted=20 from Abebe S. Ethiopia: Digital Doctors. London: = Panos.7

World Health Assembly Resolution on e-health = (WHA58.28) of=20 2005 called on member nations to develop long term e-health strategic = plans,=20 provide the telecommunications infrastructure necessary for e-health and = establish national centres of excellence. Several African countries have = started=20 to develop strategies.

It is disheartening to note that neither the WHO = African=20 Regional Health Report of 2006 nor the 2007 WHO publication, African = Health=20 Monitor, which was devoted to the crises in Human Resources For = Health in=20 Africa, mentions telemedicine as a possible solution to the shortage of = health=20 workers or the training of health workers in Africa. The World Health = Report=20 2006 mentions telemedicine/telehealth/e-health once: =91Greater access = to=20 education at lower cost can be achieved by regional pooling of resources = and=20 expanding the use of information technologies such as telemedicine and = distance=20 education.=922 = Similarly, the=20 Africa Health Strategy: 2007=962015, developed by the African Union = Ministers of=20 Health in April of 2007, makes no mention of telemedicine, telehealth or = e-health.8 The = use of=20 information communication technology (ICT) is mentioned twice, in the = context of=20 its lack of use to provide evidence to guide action within a health = system, and=20 as an =91ingredient=92 that makes up a functional health system. = Africa=92s commitment=20 to the use of telemedicine is not clear.

The UN Millennium Development Goals (MDGs) include = four relating=20 to health: access to clean drinking water, reduced child mortality under = the age=20 of 5 years (currently 16.6%), improved maternal health, and combating = HIV/AIDS,=20 malaria and other diseases. It is unlikely that any African country will = achieve=20 these goals. In 2007, the UN Secretary General found it necessary to = form a=20 Millennium Development Goals Africa Steering Group to help African = countries=20 improve their performance in meeting the goals.9 = Forty-one=20 countries have begun developing their national strategies in line with = the MDGs,=20 and several have included telemedicine in their plans.

Obstacles to telemedicine

There are many obstacles to the implementation of = telemedicine=20 in Africa.

Telecommunication costs

Many barriers to the introduction of telemedicine in = Africa=20 centre on telecommunications legislation, infrastructure and costs.=20 Telecommunications are not fully deregulated in Africa, and = liberalization of=20 policies is required. In 2003, there were monopolies for local, = long-distance=20 and international call services in over 60% of the countries, with 10% = of the=20 countries allowing monopolies for mobile and very small-aperture = terminal (VSAT)=20 services and Internet service providers (ISPs). This, and the fact that = about=20 70% of Africa=92s continental Internet traffic passes out of Africa, = pushes up=20 Internet cost.10 In = the USA,=20 the average cost for 20 hours of Internet access (10 hours peak and 10 = hours=20 off-peak usage), based on the cheapest available tariff and including = telephone=20 usage charges, is US$15.11 The = average=20 monthly cost for sub-Saharan African countries is US$55. Twenty hours of = Internet access a month, for a year, exceeds the annual gross national = income=20 (GNI) per capita, in 26 countries. To put these costs into perspective, = the=20 annual GNI per capita is US$41 400 in the USA and the percentage of GNI = for 20=20 hours of Internet access is 0.4%. It is not surprising that fewer than = 4% of=20 Africans have Internet access and that broadband access is below = 1%.10

Because of the cost of Internet access, even simple=20 store-and-forward telemedicine is not always an affordable option in = Africa.=20 Videoconferencing via ISDN is also expensive. The average cost of a = 30-minute=20 videoconference at 128 kbit/s, from Africa to the USA, is US$48.30.11 = Satellite=20 connectivity is also expensive. While VSAT access is available to all = African=20 countries, its use in telemedicine has been impeded by legislative = problems,=20 which have tended to restrict private enterprise and have resulted in = high=20 costs. The average annual VSAT licence fee in 83 African universities is = US$13=20 553, compared with US$426 for European Union universities.12 = VSAT=20 communication has been widely used in pilot projects, but the associated = high=20 costs are a factor in the lack of sustainability of some projects.

There has been rapid growth in the use of mobile = phones in=20 Africa. Mobile penetration has risen from 3% in 2003 to 21% in 2007, and = is=20 forecast to reach 30=9635% by 2011. Costs are also relatively high, = averaging 27%=20 of GNI per capita per annum, compared with 0.3% in the USA.

Other obstacles

Other obstacles to the introduction of telemedicine = include:

a lack of=20 telemedicine policies at national and regional levels and, as a result, = a lack=20 of budgets

poor = connectivity to=20 the rural areas that are most in need of support

the = shortage of=20 doctors and nurses in almost all countries

low levels = of=20 computer literacy among health professionals

lack of = training in=20 telemedicine

poor = technology=20 support

continuing = regional=20 conflicts in Africa

the = absence of=20 administrative and financial models for telemedicine in the African=20 setting.

The shortage of doctors is a particular problem. = Telemedicine=20 requires additional effort and, while its potential benefits are = acknowledged by=20 most doctors, many will not participate in telemedicine because of the = extra=20 work involved and/or the disruption to their work routine.

International telemedicine services may be a method of = addressing the shortage of doctors in Africa. However, in the absence of = adequate funding, service providers outside Africa are unlikely to be=20 remunerated at the rates to which they are accustomed, if at all. Also,=20 diagnostic and treatment algorithms used in the industrialized world may = not be=20 appropriate in Africa, and pharmacopoeias are likely to differ from = country to=20 country. The question of liability is yet to be formally resolved.

What has proved to be effective in South Africa is=20 videoconferenced education, and there is a growing demand from African = medical=20 schools to participate in shared education. The provision of education = may prove=20 to be the catalyst for developing tele-medicine services.

Telemedicine initiatives in sub-Saharan=20 Africa

Telemedicine in Africa is not new. In 1984, doctors = in London=20 made a diagnosis of Crouzon=92s syndrome in a patient in Swaziland, = using=20 satellite communication.13 In = 1987,=20 there was clinical case-conferencing between Canada, Kenya and Uganda. = This=20 consisted of twice-weekly satellite audio-conferences, with EEGs = transmitted=20 from Mulago in Kampala to the Health Science Centre at St John=92s in = Canada.14=20 Satellite-based store-and-forward telemedicine was used by the US Army = in=20 Ethiopia in 1993.15

Pan-African telemedicine = initiatives

The African Union is an international organization = of 53=20 member states. The New Partnership for Africa=92s Development (NEPAD) is = a special=20 programme of the African Union. NEPAD has developed a health strategy = for the=20 African Union, which does not refer to telemedicine or e-health but does = refer=20 to =91the appropriate use of technology=92.16 The = NEPAD=20 e-school project makes provision for the incorporation of an =91e-health = point=92.=20 The first NEPAD e-school was launched in mid-2005 at the Bugulumbya = Secondary=20 School in Busobya Village in Uganda, and a consortium of private = companies has=20 agreed to sponsor the demonstration project of 6 schools in each of the = 16=20 participating countries.

The former President of India announced the launch of = the Pan=20 African Network, which aims to connect 53 African countries by satellite = and=20 fibre-optic links, to provide tele-education, telemedicine, Internet = access,=20 videoconferencing and voice-over-Internet protocol (VOIP) services. For=20 telemedicine, one remote hospital in each country will have access to 10 = specialist hospitals (7 in Africa and 3 in India). The remote hospitals = will be=20 provided with email and videoconferencing facilities, and facilities for = transmission of ultrasound scans, echocardiographs and ECGs. The project = has=20 financial backing for five years, and will be coordinated by the African = Union. While this will not provide a solution to = Africa=92s=20 medical problems, it might serve as a starting point for further = development and=20 cooperation.

A workshop sponsored by the European Commission and = the European=20 Space Agency was held in Brussels in 2006. It established a Telemedicine = Task=20 Team, which has subsequently reviewed telemedicine opportunities in = Africa. It=20 will make recommendations for future telemedicine actions in Africa and = in=20 particular sub-Saharan Africa, with an emphasis on the use of satellite=20 communications.17

International telemedicine=20 initiatives

Some international store-and-forward projects, in = which=20 African doctors have participated, have been in operation for several = years.=20 However, use of these services in Africa has been limited. Why is this? = The=20 obvious reasons include the lack of infrastructure, the shortage of = health=20 professionals and the cost of bandwidth. What is often overlooked is the = lack of=20 training of African health professionals in simple store-and-forward=20 telemedicine. The assumption is made that everyone knows how to take a=20 photograph and send an email message. Many of the obstacles listed = previously=20 are relevant.

The Moorfields Eye Hospital ophthalmology projects = have linked=20 three regional hospitals in South Africa to England for second opinion = services=20 by videoconference and email,18 and = their=20 web-based second-opinion service is used by doctors in South Africa, = Gambia,=20 Tanzania and Ghana. The Orbis Cybersight programme also offers = store-and-forward=20 services to ophthalmologists in Ethiopia and Tanzania. The Swinfen = Charitable=20 Trust=92s store-and-forward telemedicine service has been used by = doctors in=20 Sierra Leone, Ethiopia, Malawi, Uganda and Zambia,19 as = has iPath,=20 which commenced as a telepathology service and evolved into dermatology = and=20 radiology services. Private and multinational companies have also set up = telemedicine services, both for their employees and for private patients = who are=20 able to afford international service.

In the Francophone African countries, the RAFT = (R=E9sau en Afrique=20 Francophone pour la T=E9l=E9m=E9dicine) project, based at the H=F4pitaux = Universitaires=20 de Gen=E8ve, has been running at eight sites in Mali since 2001, with = additional=20 sites in Mauritania, Morocco, Burkina-Faso, Senegal, Tunisia, Cameroon, = C=F4te=20 d=92Ivoire, Madagascar, Djibouti and Niger coming on line in 2005. Over = the first=20 5 years, this project ran 98 webcast teaching sessions (50 from Geneva = and 48=20 from Bamako in Mali). The infrastructure was also used for = teleconsultations=20 using the web-based iPath platform and IP-based videoconferencing for = remote=20 consultations. Only 14 international teleconsultations, for = neurosurgery,=20 radiology and dermatology, were reported by 2005. This project has noted = that=20 the =91high expectations of satellite technology are still unmet, as the = cost of=20 connectivity remains unaffordable for rural communities=92.20

The African Medical and Research Foundation (AMREF), = based in=20 East Africa, was founded in 1957, and has a long history as a flying = doctor and=20 radio doctor service. It is currently involved in developing four=20 store-and-forward telemedicine sites in Kenya and Tanzania.

Projects within countries

As well as the international store-and-forward = services, there=20 are several examples of telemedicine projects in sub-Saharan Africa. As = stated=20 previously, this summary of activity in sub-Saharan African countries is = likely=20 to be incomplete, and may refer to some projects that are no longer = active, as=20 failure is not often reported.

In Angola and the Democratic Republic of the Congo, a=20 non-governmental organization (NGO) called Promoting Social Development = in=20 Africa ran a trial store-and-forward project in collaboration with = Partners=20 Telemedicine. The project was not sustainable, and ended in 2005. = Botswana has=20 identified the need to set up telemedicine services, and the = Botswana=96Baylor=20 Children=92s Clinical Centre of Excellence has established the first = telemedicine=20 site in the country. Benin has a histopathology store-and-forward = service with=20 Paris, for the management of Buruli ulcers. Burkina-Faso is part of a=20 tele-epidemiology network with France, and also participates in the RAFT = project. Burundi participates in the iPath programme. Chad participates = in the=20 RAFT programme.

Anesthesia Overseas is assisting in training nurse = anaesthetists=20 in Eritrea, and is setting up a telemedicine distance education resource = centre=20 in one of the hospitals. Ethiopia is relatively active, although the = country=92s=20 five-year health sector development plan does not include the use of = digital=20 technology to improve rural health. In 2006, an ICT for Health workshop = attended=20 by 300 people agreed to set up a working group to formulate an e-health = strategy=20 for Ethiopia. Telemedicine activity has been supported by a recent grant = of US$2=20 million from India to fund a telemedicine project between Ethiopia and = India for=20 3 years. There is also a report of 10 local hospitals being linked for=20 telemedicine. Doctors have participated in both the Swinfen and iPath = programmes=20 and Johns Hopkins runs biweekly HIV clinical case presentations at the = distance=20 learning centre in Addis Ababa.

Gabon has participated in iPath. The Gambia has used = the Swinfen=20 Charitable Trust service and has participated in the Moorfields project. = Ghana=20 too has participated in the Moorfields and iPath programmes, and = Satellife has=20 been very active in the evaluation of personal digital assistants (PDAs) = for=20 clinical data capture. Ghana is in the process of expanding its = fibre-optic=20 connections throughout the country, which will improve its capacity to = offer=20 real-time telemedicine. At the same time, two projects are being piloted = in a=20 collaborative programme between the University of California at Berkeley = and=20 Intel Research. These are the REACH (Remote Asynchronous Communication = for=20 Healthcare) and TIER (Technology and Infrastructure for Emerging = Regions)=20 projects. In the latter, 5 WiFi networks covering distances of up to 58 = km have=20 been installed in Ghana, for use in education.

Guinea, which had early support from the International = Telecommunication Union for telemedicine development, does not appear to = have=20 made further advances. Guinea-Bissau is participating in the Spacedream = project=20 funded by the European Space Agency, which is investigating how Earth=20 observation, navigation and telecommunication systems can be used to = improve=20 access to antiretroviral therapy and health care. Telecommunications = will be=20 used to connect health workers in rural areas with a central = hospital.

Kenya is working on an e-health initiative. The AMREF = group has=20 set up telemedicine pilot projects, and the Agah Khan Hospital group has = telemedicine links with North America. They are also investigating the = use of=20 videoconferenced education between their centres. The Regenstrief = Institute at=20 the University of Indiana has a long association with Moi University in = Eldoret=20 and helped to found the Open MRS project, which is developing a = framework for=20 electronic patient records in resource-poor areas.

The Malawi Polytechnic is developing a wireless = network to be=20 used for telemedicine, and the Baobab Health Partnership has developed a = touch-screen clinical workstation in open source software, which = captures data=20 in real time at the point of patient contact. The patient management = system=20 allows poorly qualified health care workers to provide high-quality HIV=20 treatment.

Mali was an early partner in the RAFT programme and, = with the=20 ongoing assistance of the H=F4pitaux Universitaires de Gen=E8ve, has = implemented the=20 e-well project, which supplies stable power supplies and Internet = connections to=20 six sites to enable telemedicine, primary school education, adult = literacy and=20 the development of small business enterprises. In 2005, a = store-and-forward=20 teleradiology service was established between four hospitals using open = source=20 software via switched telephone links. After a slow start due to = technical=20 problems, 338 cases were sent in the first 4 months, a case load of=20 approximately 30 X-rays per hospital per month, or about 1 case per day = per=20 hospital.

Mauritania has participated in the Raft and iPath = programmes,=20 and a strategy for community access to ICT has been proposed. In 1997, = Mauritius=20 =96 which is classified as part of sub-Saharan Africa =96 launched its = first=20 telemedicine project. The project failed, and a new store-and-forward = service=20 for radiology and ECGs between a private hospital and a hospital in = India was=20 set up in 2005, with a supplementary videoconference link.

Mozambique had a teleradiology service operating in = 1998 between=20 two hospitals, but this project was not sustainable. Namibia is a large = country=20 with a small population and no medical school. A nuclear medicine = telemedicine=20 link between Namibia, South Africa and the UK was established in 2003. = Niger is=20 part of a tele-epidemiology network with France, which monitors = infectious=20 disease. Doctors in the country have also made use of the RAFT and iPath = programmes. Nigeria has Africa=92s first and only national telemedicine=20 association. In 2006, the first telemedicine centre was launched with a=20 videoconference-based service between a private hospital and a hospital = in=20 India.

Rwanda formally launched its national telemedicine = programme in=20 2007. Videoconference links have been established between three = hospitals. An=20 active distance education programme in public health has been running = between=20 the National School of Public Health and Tulane University. Sao Tome has = sent=20 cases to iPath. Sites in Senegal have participated in the RAFT = programme, with=20 reports of videoconferenced consultations with Toulouse and three = hospitals with=20 store-and-forward facilities for teleradiology and teledermatology. = Sierra Leone=20 and Sudan have sent cases to the Swinfen Charitable Trust.

South Africa has several new and established = projects and=20 services, which are described in Chapter 21. = Tanzania has a=20 store-and-forward project with the Rikshopitalet in Oslo and the Aga = Khan Board=20 of Volunteers in North America. AMREF has linked two sites in Tanzania = as part=20 of its four-site pilot project. Healthspan International, an NGO, has = been=20 active in setting up telemedicine projects using telephone lines, video = cameras=20 and television monitors for both store-and-forward and real-time=20 telemedicine.

Uganda has connected three hospitals, and has been = very active=20 in a PDA project to gather health data, using Healthnet and Satellife. = Through=20 the International Telecommunication Union, there are several projects = providing=20 ICT access to rural communities. Cases have been sent to the Swinfen = Charitable=20 Trust service from Uganda and Zambia. In Zambia, two hospitals were = recently=20 linked to the University Teaching Hospital through a Swedish = International=20 Development agency grant.

Conclusion

While there is an upsurge in telemedicine activity = in=20 sub-Saharan Africa, it remains to be seen whether sustainable programmes = will=20 emerge. There is a need for telemedicine training throughout Africa, as, = without=20 it, telemedicine practice will remain the domain of a few enlightened=20 enthusiasts. The use of international projects such as the Swinfen = Charitable=20 Trust, iPath, RAFT and the new Pan African Telemedicine Project will = assist the=20 introduction of telemedicine, but, unless substantial use is made of = these=20 services, they will not make a major contribution to improved health = care in=20 Africa. Problems such as international cross-border practice of = telemedicine=20 have not yet been adequately addressed, nor have questions of = international and=20 ethical standards for the practice of telemedicine. Africa needs to = solve these=20 problems so that they do not impede further progress.

For telemedicine to be of assistance in Africa, there = needs to=20 be greater government will to embrace telemedicine, changes in = telecommunication=20 policies, provision of affordable bandwidth, and the development of = sustainable=20 and affordable rural tele-medicine solutions. This will require = substantial=20 external assistance, goodwill and perseverance.

References

1.=20 United Nations. World Population Prospects: The 2006 Revision = Population=20 Database. Available at: esa.un.org/unpp.

2.=20 2 World Health Organization. The World Health Report 2006 =96 = Working Together=20 for Health. Available at: www.who.int/whr/2006/en/index.html.

3.=20 World Health Organization. World Health Statistics 2007. = Available at:=20 www.who.int/whosis/whostat2007/en/index.html.

4.=20 World Health Organization. The African Regional Health Report.=20 Available at:=20 www.afro.who.int/regional-director/african_regional_health_report2006.pdf= .

5.=20 Institute for International Medical Education. Database of Medical=20 Schools. Available at: www.iime.org/database/index.htm.

6.=20 United Nations. Assessing Progress in Africa towards the Millennium=20 Development Goals Report 2008. Available at:=20 www.uneca.org/cfm/2008/docs/AssessingProgressinAfricaMDGs.pdf.

7.=20 Abebe S. Ethiopia: Digital Doctors. London: Panos. Available = at:=20 www.igloo.org/libraryservices/download-nocache/Library/external/gvsubmis/= 922007to/ethiopia.

8.=20 African Union Conference of Ministers of Health. Africa Health = Strategy:=20 2007=962015. Available at:=20 www.africa-union.org/root/UA/Conferences/2007/avril/SA/9-13%20avr/doc/en/= SA/AFRICA_HEALTH_STRATEGY_FINAL.doc.

9.=20 United Nations. Ban Ki-moon launches =91unprecedented=92 group to boost = Africa=92s=20 development. United Nations News Centre. Available at:=20 www.un.org/apps/news/story.asp?NewsID=3D23809&Cr=3Dmillennium&Cr1= =3Ddevelopment#.

10. United = Nations.=20 Better IT connectivity can unleash Africa=92s economic potential, UN = officials=20 say. United Nations News Centre. Available at:=20 www.un.org/apps/news/story.asp?NewsID=3D23870&Cr=3Dinformation&=20 Cr1=3Dtechnology&Kw1=3Dafrica&Kw2=3Dconnectivity&Kw3=3Deconom= ic+potential.

11. World = Bank.=20 ICT at a Glance Tables. Available at:=20 web.worldbank.org/WBSITE/EXTERNAL/DATASTATISTICS/0,,contentMDK:20459133~m= enuPK:1192714~pagePK:64133150~piPK:64133175~the
SitePK:239419,00.html.=

12. Hawkins = R.=20 Enhancing Research and Education Connectivity in Africa. = Available at:=20 www.aau.org/tunis/presentation/Panel1/NREN%20ATICS%20WSIS%20Nov%202005.pd= f.

13. Ojo T.=20 Communication networking: ICTs and health information in Africa. Inf = Dev 2006; 22: 94=96101.

14. House M, = Keough E,=20 Hillman D et al. Into Africa: the telemedicine links between Canada, = Kenya and=20 Uganda. CMAJ 1987; 136: 398=96400.

15. Crowther = JB,=20 Poropatich R. Telemedicine in the U.S. Army: case reports from Somalia = and=20 Croatia. Telemed J 1995; 1: 73=9680.

16. NEPAD. = The New=20 Partnership For Africa=92s Development (NEPAD) Health Strategy. = Available at:=20 www.nepad.org/2005/files/documents/129.pdf.

17. = Asamoah-Odei E, de=20 Backer H, Dologuele N et al. eHealth for Africa. Opportunities for = enhancing the=20 contribution of ICT to improve health services. Eur J Med Res = 2007;=20 12(Suppl 1): 1=9638.

18. Kennedy = C, Kirwan=20 J, Cook C et al. Telemedicine techniques can be used to facilitate the = conduct=20 of multicentre trials. J Telemed Telecare 2000; = 6:=20 343=967.

19. Swinfen = Charitable=20 Trust. Available at: www.swinfencharitabletrust.org.

20. = Geissbuhler A,=20 Bagayoko CO, Ly O. The RAFT network: 5 years of distance continuing = medical=20 education and tele-consultations over the Internet in French-speaking = Africa.=20 Int J Med Inform 2007; 76: 351=966.

23 Telehealth for mountainous and remote areas of = northern=20 Pakistan

Hameed A Khan and Irfan = Hayee

Introduction

Pakistan is ranked 124 out of 191 countries in terms = of health=20 care.1 About = a third=20 of the population lives below the poverty line, with unhygienic living=20 conditions, poor health, and food and water insecurity. As a = consequence, there=20 is a high burden of infectious and chronic diseases among people in = Pakistan,=20 especially women and children. Poor nutrition and repeated infections = have=20 aggravated the situation. According to a health assessment conducted by = the Aga=20 Khan University, Pakistan ranks 157th in the world in terms of infant = mortality,=20 and 39th in child mortality.2 = Moreover, with=20 agriculture being the main occupation in the country, the majority of = the=20 population still live in rural and remote areas that are underprivileged = in=20 terms of access to basic health care services.

The northern area of Pakistan, comprising five = districts=20 (Gilgit, Skardu, Diamer, Ghizer and Ghanche), is one of the most remote = and=20 disadvantaged regions of Pakistan. The area has a population of around = one=20 million people, who live in more than 600 villages scattered over 72 000 = km2 of = rugged=20 terrain. Lack of communications is a major problem.

People in the northern area of Pakistan have long been = poorly=20 served in terms of access to health and education services. The area is = known=20 for its difficult terrain, extreme climate and geographical remoteness = from=20 large cities (Figure=20 23.1). Baltistan and Hunza, particularly, being remote and = underdeveloped=20 mountainous regions, do not have access to high-quality health care = services.=20 The health facilities do not have specialists, particularly for = women=92s health=20 care. Major hospital and health facilities are a long way away. For = instance,=20 Gilgit is about 800 km away from a tertiary health care facility. Owing = to the=20 lack of satisfactory health services, people suffer as a result of late=20 diagnosis and treatment. Furthermore, the rural health centres (most of = which do=20 not have doctors) are not linked to the hospitals in the main urban = centres,=20 resulting in avoidable mortality and morbidity, especially among women, = children=20 and the elderly. Lack of information and communication facilities and = the=20 absence of development networking compound the problems.

The Commission on Science and Technology for = Sustainable=20 Development in the South (COMSATS) was established in 1994 to promote = science=20 and technology in all spheres of life. It has 21 developing countries as = its=20 members and there are 16 centres

3DImage=20

Figure 23.1 Northern area of = Pakistan

of excellence. In view of conditions in the northern = parts of=20 Pakistan, COMSATS launched a project on telehealth, which went into = service in=20 2005. Its objective was to facilitate access to specialized health = services and=20 education, and thereby contribute towards raising the standard of living = in the=20 area. The Baltistan Health and Education Foundation, which was working = to=20 improve health care services for women in the remote and backward = regions of=20 Baltistan, collaborated with COMSATS on the project. The International=20 Development Research Centre (IDRC), a Canadian government development=20 organization, was the principal funding organization (see Chapter 7).

Telemedicine in northern Pakistan

Establishing a telehealth service in the mountainous = and=20 remote areas of northern Pakistan required not only having reliable = technology=20 but also matching the services to the socioeconomic and cultural = environment of=20 the area. This required cultural change, although, after three years, = the=20 telehealth service is now well established and accepted by the local=20 communities.

In the rural areas of Pakistan, the lives of people = are strongly=20 governed by cultural and traditional norms, which makes introducing = change=20 difficult. Women are particularly marked by certain limitations as far = as their=20 mobility and interaction with the outside world are concerned. In such a = situation, building a rapport with the local people, convincing them to = adopt=20 telehealth and interact with people who did not belong to their = community, as=20 well as disclosing personal information, especially in the case of = women, was a=20 formidable task. However, the COMSATS team was successful in bringing = about=20 change in the attitudes of the local people. This meant involving = members of the=20 local community in delivering the services, so that patients coming in = for=20 consultation did not feel alienated.

The lack of telecommunication infrastructure in the = region was a=20 major problem. The government had installed landlines (digital telephone = exchanges) to some villages, but these were of poor quality and also = expensive=20 for the users. On an experimental basis, the government introduced = wireless=20 local loop (WLL) in some villages, but this was not very successful. The = only=20 Internet service provider (ISP) in Gilgit was established by = COMSATS.

The technology required for the project was installed = by=20 COMSATS Internet Services (CIS), the executive agency of COMSATS. The = tasks=20 included:

= establishing an ISP=20 at Skardu

capacity = building at=20 the Gilgit node

training = the project=20 staff

operating = the ISP at=20 Skardu

assisting = with=20 procurement of equipment

= documenting the=20 technical aspects of the project.

The equipment for the project is listed in Table 23.1. A = major=20 task was obtaining a licence to operate an ISP in Hunza.

Very-small-aperture terminal (VSAT) links between = Skardu and=20 Islamabad and between Hunza and Islamabad were established at an initial = bandwidth of 128 kbit/s. Internet bandwidth was provided from Islamabad = at=20 subsidized rates. Once an ISP had been established at Skardu, surplus = money=20 being generated could be invested in the telehealth services.

Project experience

Medical services

During the first phase of the project, a needs = assessment was=20 carried out at Skardu. This showed the need for teleconsultations in = five=20 medical fields. In order to develop standard operating procedures and to = synchronize the efforts of the Telehealth Centre (Skardu) and the = Resource=20 Centre (Islamabad), a study was made of various aspects:

level and = type of=20 medical services

= availability of=20 medical specialists

scheduling = of=20 services

medical = equipment=20 required

clinical=20 requirements of the telehealth service.

The three major areas of focus were:

(1) designing and establishing a telehealth = centre

(2) identifying a suitable team of medical = specialists

(3) selecting and procuring appropriate medical = equipment.

Teleconsultancy services were required in five = specialties:=20 general medicine, cardiology, gastroenterology, dermatology and = nephrology.=20 After three years of operation, services are now being provided in all = fields=20 except nephrology. Services in

Table 23.1 Project = equipment
	Quantity
Equipment for the resource centre at=20 Islamabad
Ethernet switch	1
Videoconference equipment	1
Computer (P -IV, 850+)	1
Printer (HP Laser Jet)	1
Scanner	1
Uninterruptible power supply (3 kViA)	2
Webcam =96 high-resolution	1
Air conditioners	1
Dish/VSAT equipment	1
Satellite receiver	1
Equipment for telehealth at=20 Skardu
Videoconference equipment	1
Computers	2
Laser printers	2
Scanner	1
Multimedia projector	1
Generator (25 kViA)	1
Uninterruptible power supply (3 kViA)	1
Interfaces for X-ray and ultrasound	1
Camcorder	1
ECG machine	1
Treadmill stress testing machine	3
X-ray board	1
Ultrasound machine	1
Equipment for the ISP at=20 Skardu
Generator (25 kViA)	1
Uninterruptible power supply (3 kViA)	3
Server (for authentication, proxy and = billing)	3
Networking (e.g. cables and connector)	16
Switch (24 ports)	1
Satellite receiver/modem	1
Dish/VSAT	1
Router	1
HDSL modems	2
Access server	1
Computers	14

psychiatry are being considered. It was initially = expected=20 that asynchronous (store-and-forward) telehealth would be used most = frequently,=20 but later on, as telehealth came into routine use, the synchronous = (real-time)=20 method became common.

Medical equipment

After careful examination it was felt necessary to = have=20 similar videoconferencing equipment at both the Telehealth Centre = (Skardu) and=20 the Resource Centre (Islamabad). The equipment chosen (VSX 7000, = Polycom)=20 transmitted video calls over an IP connection. The Telehealth Centre was = established in the premises of the Abdullah Hospital in Skardu and = operated by=20 the collaborating institution, the Baltistan Health and Education = Foundation.=20 The hospital is a secondary-level health care unit. The Telehealth = Centre is=20 located close to the ultrasound room, reception and the conference room, = which=20 makes patient care efficient and reduces teleconsultation times.

To reimburse medical specialists for teleconsultation, = it was=20 decided to pay them for each visit to the Resource Centre, and not on = the basis=20 of the number of patients seen. Reimbursement for delivering seminars = was=20 handled separately. To coordinate a team of medical specialists, it was=20 necessary to have a coordinator between the specialists and the people = at the=20 Resource Centre and the Telehealth Centre.

Telehealth Centre at = Skardu

Five medical specialists and a telehealth consultant = were=20 employed at Islamabad. Teleconsultancy services were operated for a test = period,=20 and then later run operationally for patients in Skardu. Training and=20 orientation of staff at the Abdullah Hospital were carried out. = Development of a=20 patient information system and linkages with experts and donor and = medical=20 organizations were also made.

A total of 361 patients received specialist = consultations in the=20 first 4 months of operation. Dermatology was the most common specialty. = Women=20 benefited greatly from the service, and showed confidence and = satisfaction. In=20 one period, 101 female patients received a specialist consultation, in=20 comparison with 51 male patients. Feedback received from the specialist = doctors=20 at Islamabad, as well as project staff at Skardu, called for increased = bandwidth=20 to improve the quality of the service.

Experience with the = service

The level of trust and confidence of the community = grew=20 steadily, as indicated by the steady number of follow-up cases, which = ranged=20 between 15% and 20% of the patients each month. A substantial proportion = of=20 females benefitted from the service (58% overall).

Despite some problems due to connectivity, infrequent=20 availability of a general practitioner at Skardu and difficulties in = data=20 transfer, the telehealth service continued smoothly with minor glitches, = and the=20 level of satisfaction of patients and doctors remained satisfactory (on = the=20 basis of initial and post-project interviews).

The 1000th consultation was conducted during May 2006. = More=20 importantly, women and children (between the ages of a few months and 13 = years)=20 were the main beneficiaries of telehealth services. = Women=20 account for 61% and children 21% of those receiving specialist = consultations=20 from doctors in Islamabad. It was observed that women and children are = the ones=20 who suffer the most in the absence of specialized medical services. = First, they=20 find it difficult to travel on their own to tertiary care centres in = remote=20 areas. Second, it costs them more to travel, since they are dependent on = male=20 family members to accompany them because of societal and cultural = norms.

Another important fact that indicated the acceptance = of the=20 service was that people from rural areas came pouring in to receive = specialist=20 consultation. No promotional campaign was run to inform people from = outlying=20 areas, and word of mouth seemed to be enough. The consultation data show = that in=20 the first few months more consultancies were provided for people from = urban=20 areas, while in the later months more consultancies were provided for = people=20 from rural areas (Figure=20 23.2).

Teleconsultations continued as scheduled after the = launch of the=20 service in April 2005, i.e. one session a week for dermatology, = cardiology,=20 gastroenterology and general medicine. However, the services were = disrupted for=20 some time in the wake of the earthquake of October 2005, which caused = havoc in=20 the northern parts of Pakistan and killed some 80 000 people.

Although the earthquake did not affect the Baltistan = region=20 directly, it made the specialists at the Resource Centre (Islamabad) = unavailable=20 for telehealth for most of the consultations in the following month and = a half.=20 Most of the medical specialists were engaged in serving a large influx = of=20 patients from the earthquake-hit areas at their principal medical = facilities,=20 and therefore routine consultations had to be reduced or postponed owing = to the=20 emergency situation.

3DImage=20

Figure 23.2 Number of = teleconsultations during=20 the first 14 months of the project

Problems and corrective measures

Connectivity

Low bandwidth and poor connectivity were the major = impediments=20 to telehealth services. Although the telehealth clinic was connected to = the ISP=20 through an HDSL modem, the increased client=E8le of the ISP at Skardu = affected the=20 bandwidth available for data transfer and videoconferencing. Weather = conditions=20 and physical damage to copper wires also caused problems.

Various measures were taken to overcome these = difficulties. The=20 videoconferencing system was adjusted to make the calls at 128 kbit/s so = that=20 packet loss could be minimized. This greatly improved the audio quality = during=20 consultations. Separate downlink services were arranged from another = service at=20 the ISP in Skardu to make VSAT link bandwidth available for the = telehealth=20 project (Figure=20 23.3). An average of only 32 kbit/s was then used by the COMSATS = Internet=20 service from the total 128 kbit/s VSAT link. Fine tuning was done at the = ISP to=20 decrease the choking and packet loss.

The graphs of bandwidth usage obtained from the ISP = identified=20 the time when the Internet usage was least, and the timings for = teleconsultation=20 were adjusted to take advantage of this. The connection between the = Telehealth=20 Centre and the ISP was lost twice owing to physical damage to the copper = wires=20 between the two sites, which subsequently halted the telehealth service = for two=20 or three days each time. Therefore, a second cable link was made = available so=20 that it could be used as an alternative connection in case of similar = problems=20 in the future.

3DImage=20

Figure 23.3 Telecommunications

Unavailability of human = resources

Infrequent availability of general physicians or = well-trained=20 paramedical staff has been one of the major problems in providing the = telehealth=20 service at Skardu. Most doctors in Pakistan prefer to work in large = cities=20 (either to gain experience or to earn more), and only those who are = visiting=20 their families, or female doctors whose spouses are stationed in army = units, are=20 available in rural areas. Often, these doctors are available only for a = limited=20 period of time, and many leave within a few months. There are few = paramedics in=20 the northern parts of Pakistan, and not many are sufficiently trained to = provide=20 telehealth services. In view of these problems, the following steps were = taken.

A doctor dedicated to the telehealth service at the = Abdullah=20 Hospital in Skardu was employed for telehealth. The doctor=92s role was = to present=20 accurate and detailed information about the patients (e.g. the history = and basic=20 physical examination results) to the specialist doctors. Having detailed = medical=20 data is important for successful tele-consultation. In view of the large = number=20 of female patients seen by telemedicine, a female doctor was hired.

All the specialists opined that the quality of = consultation was=20 satisfactory when there was a supporting doctor (general physician) = present at=20 the remote site to provide the basic data. In the absence of a general=20 physician, it was observed that the consultations were manageable, but = did not=20 meet the satisfaction of the specialists.

The computer operator, who was responsible for running = the=20 remote Telehealth Centre, gained a lot of experience through hands-on = training.=20 He was formally supervised by the doctors at the Telehealth Centre and = the=20 Resource Centre, which helped him to gain expertise in delivering = services.=20 After training, the computer operator could take a good patient history = and=20 perform a general physical examination, e.g. checking blood pressure, = pulse and=20 temperature. This was useful if the general physician at the remote = centre was=20 not available. Given suitable training, a paramedic or non-medical = person can be=20 a useful substitute when a doctor is not available for conducting=20 telemedicine.

Patient information = software

The patient information software proved to be of = great help in=20 maintaining the medical records of visitors and patients. Initially, the = patient=20 information system was developed as a client=96server application. The = information=20 was thereafter transmitted using file transfer protocol (FTP) servers at = both=20 ends. In addition, FTP servers were placed at the ISP to increase the = rate of=20 transfer of files, as well as to avoid undue delays in the transfer = during power=20 failure or problems in the computers. This option improved the situation = to some=20 extent, leaving only the problem that complete data on a patient could = not be=20 accessed from one program, making it rather time-consuming. In the light = of=20 experience, it was realized that a web-based solution would be a better = way in=20 the future of providing similar services from different sites.

It was also realized that there is a need to provide = the patient=20 data to the specialists at their workplace and at their homes, so that = they can=20 conduct telemedicine without coming to the Resource Centre. Visits of = the=20 medical consultants to the Resource Centre could be reduced by using a = web=20 portal.

Service methodology

Although the consultations in this project were = mainly based=20 on real-time videoconferencing, in a few instances where live = consultation was=20 not possible (for technical reasons), the diagnosis and expert opinion = were=20 based on store-and-forward information. About 10% of all consultations = were=20 performed in this way. It turned out that patient management decisions = were=20 easily made in dermatology, while, in the single instance of a = cardiology case,=20 it was most difficult. The reason may be that the images in dermatology = cases=20 are self-explanatory and require little elaboration, whereas in = cardiology there=20 are often many unanswered questions. However, the store-and-forward = technique=20 was more time-consuming than live interaction, for both the physician = and the=20 patient.

In discussion with the specialists, it appeared that = both=20 patients and doctors felt that store-and-forward consultations were = inferior to=20 real-time consultations, except in dermatology. In dermatology, a = detailed=20 history of the patient along with high-resolution pictures could be sent = easily,=20 thus facilitating the correct diagnosis.

Recommendations

Based on our experience, we recommend that careful = attention=20 be paid to the design and implementation of telehealth services in=20 underdeveloped areas. It is feasible to utilize relatively inexpensive = and=20 robust equipment that is easy to operate and repair. Activities must be = chosen=20 that result in benefits for as many people as possible, while the = technology=20 chosen should be compatible with immediate health care needs.

As well as support from the government, it is = important to=20 persuade private sector and local organizations to participate in = planning and=20 implementing telehealth services. The participation of local = organizations will=20 not only assist in developing health care services attuned to the local=20 settings, but also facilitate the acceptance of these services in the = area. The=20 collaboration between COMSATS and the Baltistan Health and Education = Foundation=20 has been a success. It demonstrates how local organizations can catalyze = the=20 implementation of telehealth and bring ownership to the community.

Appropriate guidelines need to be developed for = establishing=20 high-quality and consistent standards for teleconsultations. Formulating = a=20 tele-education strategy and conducting a resource inventory may be = helpful in=20 this regard.

An important factor in a successful telehealth service = is the=20 information management system. This should be devised in conjunction = with the=20 specialists and other doctors who are involved in delivering the = telehealth=20 services.

Conclusions

Despite the difficulties, telehealth can be a = practical method=20 of providing specialist consultations and supporting other health care = services=20 for people in developing countries, particularly = those in=20 remote regions. Telehealth can also be used to improve access to the = health care=20 providers of these regions and reduce their isolation.

Establishing a telehealth service in Skardu was a = difficult=20 task. However, with an enthusiastic team, the project was successful, = and it is=20 clear that many patients, especially women and children, have benefited = from the=20 service. Those who are unable to travel to cities to obtain specialist = advice=20 now have easy access to specialist health care.

Economies may be possible in future by using digital = cameras or=20 newer versions of webcams, instead of specialized videoconferencing = equipment.=20 In future, the resource centre might be established at a hospital to = save time=20 for both the doctor and the patient. While promoting telehealth to = doctors, it=20 is important to emphasize that existing health care delivery methods = will not be=20 replaced =96 rather, telehealth will supplement them.

Finally, the general public, patients and health = professionals=20 should be informed as much as possible about telemedicine, so that they = feel=20 comfortable with the concept. This will mean that future generations = will feel=20 at ease in using telehealth to improve traditional methods of health = care=20 delivery.

References

1.=20 World Health Organization. The World Health Report 2000 =96 Health = Systems:=20 Improving Performance. Available at:=20 www.who.int/whr/2000/en/whr00_en.pdf.

2.=20 Aga Khan University. Assessment of Health Status and Trends in=20 Pakistan. Available at:=20 aku.edu/CHS/pdf/HealthSituationandTrend-Pakistan,2001.pdf.

24 Teleneurology: Past, present and = future

Usha K Misra and Jayantee = Kalita

Introduction

Telemedicine has been used in many areas of health = care. A=20 Medline search for telemedicine papers found 911 articles concerning its = use in=20 radiology, 931 in surgery and 735 in pathology (Figure 24.1). = There=20 were 69 articles concerning telemedicine in neurology and 19 concerning=20 epilepsy.

The term =91imaging=92 was found in 710 articles, = =91video=92 in 969 and=20 =91electrocardiography=92 in 250. =91Electroencephalography=92, the = typical=20 investigation of epilepsy, was found in 27 articles only. The most = commonly=20 mentioned aim of telemedicine was consultation (3022), followed by = diagnosis=20 (3654) and education (1718). Other

3DImage=20

Figure 24.1 The number of = telemedicine articles=20 published in different specialities (PubMed search, April 2008)

indications were instrumentation (1729), treatment = (2984),=20 cost (2015) and payment (45).

Clinical telemedicine applications can be considered = on two=20 axes: a vertical axis representing the level of maturity and a = horizontal axis=20 representing the extent of the application. The maturity is based on = several=20 factors, including quantity and quality of research pertaining to the=20 application, the degree to which the application has been accepted by = the=20 profession, and the development of standards or protocols for its use. = The=20 evidence of the application refers to attributes such as technical = feasibility,=20 diagnostic accuracy, sensitivity, specificity, clinical outcome and=20 cost-effectiveness. Tele-radiology, telesurgery and telepathology rank = high on=20 the maturity scale. Psychiatry, dermatology and ophthalmology are = regarded as=20 maturing areas of telemedicine, whereas paediatrics and emergency = medicine, for=20 example, are emerging specialties with respect to the use of = telemedicine (Figure = 24.2).1

In neurology, real-time telemedicine has the greatest = potential=20 in the management of neurological emergencies such as status = epilepticus, stroke=20 and movement disorders and in neurophysiology. Status epilepticus and = stroke=20 require urgent treatment within the window period for better outcome.=20 Transporting these patients to a specialist centre might take several = hours,=20 resulting in high mortality and morbidity. Live demonstration or video=20 recordings of patients with movement disorders and neuro-physiological = tracings=20 (electroencephalography, nerve conduction studies and evoked potentials) = can be=20 transmitted to a specialist centre for expert opinion without physical = referral=20 of the patient.

3DImage=20

Figure 24.2 Categorization of = medical=20 specialties according to their maturity in telemedicine

Epilepsy

Epileptic seizures can be infrequent and difficult = to=20 diagnose. The best method of diagnosis is by observation of the seizure = episode,=20 and in its absence one has to rely on the description of a bystander. = The data=20 concerning seizures are so important that full information should be = made=20 available to the physician so as to make or revise the diagnosis. = Patients with=20 epilepsy often have travel limitations placed on them, which may cause=20 difficulties with the different centres involved in treatment of = multiple=20 handicap. Communication between different hospitals and physicians in=20 difficult-to-diagnose epilepsies can be greatly helped by=20 telecommunication.2 This = can not=20 only avoid frequent and sometimes arduous visits to experts in different = hospitals and repeated investigations, but also allow the simultaneous = opinion=20 of different physicians to be obtained.

Status epilepticus is an emergency in which seizures = recur=20 without the patient regaining consciousness between two discrete = seizures, or=20 individual seizures continue for at least 30 minutes. Often, a patient = is=20 admitted to a primary centre and is referred to another more specialized = centre=20 when the seizure is not controlled. Finally, when the patient reaches an = advanced specialized centre, he or she may be have been undergoing = status=20 epilepticus for several hours or even longer. This is likely to result = in=20 various complications and a poor prognosis. Early diagnosis and prompt = treatment=20 would assist with controlling the attack and improving the prognosis. = According=20 to a recent study, a telemedicine-based epilepsy service was as safe and = effective as conventional face-to-face consultation.3 In = this study,=20 a neurologist was based at a centre and managed epilepsy patients at a = rural=20 hospital by video link. Patients were usually accompanied by a family = member and=20 always by a trained nurse, who acted as care manager, coordinated = medication and=20 ensured compliance, and was able to reinforce what the neurologist said. = A=20 comparison was made of patients managed by this method and those managed = by a=20 conventional urban clinic. Seizure frequency, emergency room visits and = hospital=20 admissions were used as measures of efficacy and safety. No difference = was found=20 in these outcome measures between telemedicine and conventionally = treated=20 patients.3

Acute stroke

Recombinant tissue-type plasminogen activator (rtPA) = represents a major breakthrough in the treatment of ischaemic stroke. If = it is=20 administered within 3 hours of onset of stroke, it results in improved = survival=20 and outcome.4 Many=20 institutions lack the specialized personnel and resources necessary to = provide=20 the response for acute stroke patients. These institutions depend on the = rapid=20 transfer of patients to regional stroke centres for therapy. In = practice, the=20 main reason for patients not receiving this therapy is their late = arrival after=20 the critical time window of 3 hours. Telemedicine is emerging as an = efficient=20 means of making early decisions about therapy.

At the medical centre of the University of Maryland, = the=20 tele-stroke service uses videoconferencing and CT image transfer. = Between 1999=20 and 2001, 50 stroke consultations were reviewed. Of these, 23 were = managed by=20 telemedicine and 27 by traditional telephone = conversation=20 followed by transfer. Two of the 23 telemedicine consultations were = aborted=20 because of technical difficulties. Of the patients evaluated by the = traditional=20 method, 1 (4%) received rtPA, whereas 5 patients from the telemedicine = group=20 (24%) received rtPA and there were no complications due to this therapy. = Telemedicine provided a treatment option that was not previously = available at=20 the remote hospital. For administration of rtPA, telemedicine was safe, = feasible=20 and well received.5,6

Assessing the stroke patients and their CT scan by = using=20 videoconferencing offers an opportunity to improve stroke care in remote = and=20 rural areas. In a study from Swabia, seven rural hospitals were = connected to the=20 stroke unit via videoconferencing. One hundred and fifty-three patients = were=20 examined by teleconsultation, and a relevant contribution could be made = in more=20 than 75% of cases regarding diagnostic work-up, CT assessment and = therapeutic=20 recommendations.7

Although the number of emergencies is increasing, = there is=20 growing anxiety about medical errors and an increasing number of medical = negligence cases. Pre-hospital use of telemedicine for stroke is already = being=20 piloted, linking patients in an ambulance to the emergency = department.6

Movement disorders

Telemedicine has been found to be useful for = diagnosis,=20 treatment and follow-up of patients with various movement disorders. = Live video=20 or prerecorded video clips can be used for these purposes. In a recent = study,=20 video clips of normal and abnormal gait disorders were used by a = geriatrician=20 for diagnosis and were compared with the diagnosis of the treating = clinicians,=20 i.e. the latter was considered the gold standard. The agreement of the = video=20 clip examination with the gold standard in identifying abnormal gait = ranged from=20 substantial to excellent among assessors, although there was only a low=20 agreement with the gold standard in the detection of specific gait = diagnosis.=20 This technique appears to be a valid screening procedure for detecting = gait=20 abnormalities, with a sensitivity of 100% and a specificity of 70%.8

Telemedicine has also been used to follow up patients = with=20 Parkinson=92s disease in remote areas. Over a 3-year period, 100 = teleconsultations=20 were carried out on 34 patients with Parkinson=92s disease. Each = teleconsultation=20 lasted for 30=9660 minutes. Patients and providers were satisfied with = the=20 consultations, and they reduced the time and cost of travelling.9

Neurophysiology

Digital technology for clinical neurophysiology = allows=20 teleneurophysiology to be developed. Such a service may improve patient = care in=20 remote areas, since the clinician can obtain a second opinion from other = centres. The process may even help in education and the creation of a = national=20 data bank. A telemedicine facility of this kind has been established in=20 Scandinavian countries.10

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Neurological outpatients

In remote areas where neurologists are not = available,=20 telemedicine has been used for providing outpatient consultations to=20 neurological patients. In a randomized controlled trial, the efficacy of = telemedicine consultation was compared with face-to-face consultation, = the=20 groups comprising 82 and 86 patients, respectively.11 The = diagnostic categories were similar in the two groups. The patients in = the=20 telemedicine group had more investigations, but there was no difference = in the=20 number of drugs prescribed. The patients were generally satisfied with = both=20 processes, although they were concerned about confidentiality and = embarrassment=20 in the telemedicine consultation.

Teleneurology, although feasible in the outpatient = setting, is=20 less well accepted than face-to-face consultation, and can lead to=20 over-investigation.11 = However, in a=20 remote area where there are too few neurologists, telemedicine may = become a=20 viable option, especially in developing countries.

Mobile phones

The telephone has always been used for consultation = between=20 doctors, especially for fixing appointments, calling for home visits or=20 obtaining immediate advice. Following the mobile phone revolution, most = urban=20 and even rural people have access to a telephone. This has opened up=20 opportunities for using mobile phones for health care delivery. In = developing=20 countries, the doctor:patient ratio is far too low. Specialized and even = primary=20 hospitals are overcrowded. The use of a mobile phone can help in = obtaining=20 appointments and monitoring therapy, especially in chronic disorders = such as=20 epilepsy, migraine, headaches and stroke. Such patients often have to = travel=20 long distances, and it may take several hours or even days to obtain a=20 consultation. In such a situation, adjusting the dose of drugs, checking = compliance, monitoring side effects and defining the patients who need = an early=20 appointment may be done by telephone or mobile phone. The difference = between a=20 mobile phone and the ordinary telephone service is not only the = former=92s=20 mobility, but also that mobile phones have additional capabilities, = including=20 text messaging, video and Internet facilities.

There is a paucity of randomized controlled trials = evaluating=20 the efficacy and satisfaction level of mobile phone consultations in = comparison=20 with conventional face-to-face consultations. Psychotherapy delivered by = telephone revealed a significant improvement in depression. In=20 telephone-administered cognitive=96behavioural therapy, there was an = improvement=20 compared with usual care.12 = Patients can=20 often capture an event such as a seizure or movement disorder and = present it to=20 a physician for evaluation during consultation.

Medical education

Telemedicine has great potential to transform = medical=20 education at undergraduate, postgraduate and professional levels. The = educator=20 has to select the appropriate context, content and = delivery=20 method to suit the needs of the largest number of the learners. In = medicine,=20 education has to continue throughout the professional=92s career. = Learning is=20 greatest when adults act as self-directed, motivated learners, perusing = the=20 topics of their interest in the appropriate context, i.e. interactive, = practical=20 and self-paced.13 = These=20 principles can be incorporated into a distance education programme.14 = Online=20 continuing medical education (CME) and web-based CME have also provided = CME=20 credits for the practising physician. The Internet also has the ability = to=20 support the presentation of complex multimedia presentations to augment=20 learning. The Internet has created learning communities.

A survey was conducted regarding the motivation and = choice of=20 topics for a journal club and the websites accessed in two institutions. = The=20 institutions were the Sanjay Gandhi Post Graduate Institute of Medical = Sciences=20 in Lucknow and the King George Medical University in Lucknow. The views = of=20 specialty (n =3D 58) and subspecialty (n =3D 97) = residents were=20 compared.15 = Most of the=20 residents used Medline and PubMed for choosing their journal club = topics. The=20 choice of Google, the Oxford database, Science Direct and the Cochrane = Review=20 did not differ between the residents of the two institutions. At the = Post=20 Graduate Institute, the choice of articles was based on the availability = of good=20 articles, whereas in the Medical College, it was faculty driven. The = choice of=20 articles related to patient management and examination were not = different=20 between the two institutions. Female residents more frequently selected = articles=20 related to patient management or examination, although the difference = was not=20 significant.

Internet use by residents and faculty members of the = Medical=20 College and the Post Graduate Institute was surveyed by us, and we found = that=20 89% of individuals performed a computer literature search at least once = a month.=20 The reason for a computer-based literature search was for presentation = in 90% of=20 cases, research in 65% and patient care in 60%. The benefit of = literature=20 searching was acknowledged in learning and teaching by 80% of = respondents, in=20 research by 65% and in patient care by 54%. Formal training in = computer-based=20 literature searching was received by 41%, of whom 80% were residents. Of = the=20 participants in this survey, 64% had a home Internet connection and the=20 remainder used the Internet at their workplace or at a cyber caf=E9, = suggesting=20 widespread use of computers and the Internet by medical personnel.16

We have used videoconferencing for neurology teaching = in India.=20 We have conducted a neurology educational conference between the Post = Graduate=20 Institute and the Medical College. These locations are 1500 km apart. = Faculty=20 members and residents of the two departments participated. Desktop=20 videoconferencing systems were connected by an ISDN line at 128 kbit/s. = During=20 2001=962004, there were 30 sessions, 22 of which were successful and 8 = partly=20 successful (owing to power and communication failure). In each session, = two to=20 four cases were discussed, with clinical pictures, neurophysiological = and=20 radiological data as illustrations. Discussions provided inputs for both = learning and patient management (Figure = 24.3).17

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3DImage=20

Figure 24.3 A videoconferencing = session between=20 the Sanjay Gandhi Post Graduate Medical Institute and a remote centre in = India

Telemedicine in India

There are few reports in the literature of the = successful use=20 of telemedicine in India. Mahakumbh Mela is a religious congregation = that occurs=20 every six years and in which millions of Hindus gather for religious = ceremonies=20 and discussions. Such a large gathering of people is associated with = inherent=20 health problems, such as infections and accidents, so that health care = for the=20 attendees is a major public health problem. The Post Graduate Institute = used=20 telehealth to avoid an outbreak of cholera at the Mahakumbh Mela in = Allahabad,=20 Uttar Pradesh.18=20 Ganapathy19 = took the=20 initiative of providing consultations to distant areas in India in = Aragonda and=20 Sriharikota. Desai et al20 = used=20 teleconsultation between a tertiary cancer centre and a rural cancer = hospital.=20 Ninety-three cases were analyzed in which static pathology and = telepathology=20 were used to obtain a consultation between the Tata Memorial Hospital, = Mumbai=20 and the Nargis Dutt Memorial Cancer Hospital at Barshi. A diagnosis was = offered=20 in 92 (98%) cases.

Resource availability

In developing countries, an increasing population = and a very=20 low doctor:patient ratio represent a difficult challenge for health = care. A=20 total of some 800 neurologists in a country such as India with a = population of=20 1.3 billion is inadequate. It will take more than = 20 years to=20 achieve a ratio of one neurologist for 50 000 population at the rate of = 50=20 neurologists being produced per year. However, it is not only the = numbers that=20 are important. Increasing specialization has reduced the number of = physicians=20 who are good at managing emergencies. Although the number of emergencies = is=20 increasing, there is growing anxiety about medical errors and increasing = number=20 of medical negligence cases.

There is no single solution for upgrading the = emergency=20 services, but a favoured model has been a large central hospital with = associated=20 local hospitals to which patients are discharged. Unfortunately, this = may make=20 the services worse rather than better. Medical emergencies usually occur = in a=20 patient=92s home, and are followed by a journey to the hospital, = assessment,=20 admission, treatment and then discharge. A large central hospital means = a long=20 journey, which may delay treatment and influence outcome, as in status=20 epilepticus and stroke. In developing countries, roads and = transportation are=20 far from satisfactory. Increased distance also causes problems for = visiting=20 families, and weakens the link with primary care, which is crucial when=20 discharging patients from hospital. Large numbers of patients in = emergency=20 departments lead to long waiting periods. The local hospitals do not = share care=20 or staff with large hospitals, and have poor nursing and medical = infrastructure.=20 They are uncomfortable about managing seriously ill patients, and thus = assume=20 the role of nursing homes, rather than hospitals.

Black et al21 = have proposed=20 a reverse model in which patients are admitted to a local hospital, = which acts=20 as the catchment area of a big hospital. The medical and nursing staff = would be=20 part of the team working in the central hospital, and would rotate = between the=20 hospitals. The local unit would have imaging (CT scanning) and = laboratory=20 support (EEG, ECG and biochemistry), as well as high-quality electronic = links=20 with the central hospital that would allow the specialists to know = almost as=20 much about the patients as if they were examining them directly. Such a = system=20 would result in avoiding delay in treatment. Patients who did not need = admission=20 could be quickly discharged, perhaps within a single day, and some = patients=20 would never need to go to the central hospital at all. Those who went to = the=20 central hospital would not need to be assessed again, so that the = transfer and=20 admission would be faster.21

The cost-effectiveness of telemedicine has been a = concern=20 because, in a study of teleneurology from the UK, a comparison of 65 = patients in=20 a conventional group and 76 in a teleconsultation group revealed that = the=20 telemedicine group needed more investigations and reviews than the = conventional=20 group. The average cost of conventional consultation was =A349, compared = with =A372=20 for the telemedicine group.22

Legal questions

The use of telemedicine has raised several legal = questions.=20 These include licensing, reimbursement and liability. The question of = data=20 security is also a concern in telemedicine. Thus, accidental loss and = data=20 corruption must be prevented by providing effective data control = management and=20 artefact recognition algorithms. As personal data is involved, the = possibility=20 of loss or criminal access must be considered and prevented.=20 Special encryption mechanisms to secure data against unauthorized access = or=20 modification are therefore necessary.12 = Patients=92=20 right to confidentiality is paramount.

Unless otherwise agreed by both sides, the liability = in=20 telemedicine is normally considered to rest with the consulting rather = than the=20 advising physician. Procedures for reimbursement of logistical costs in=20 telemedicine need to be developed.

Conclusion

There are concerns that physicians in future may = become=20 =91telecarers=92, at least for part of their working time. A telecarer = is a health=20 professional who delivers responsive, high-quality information services, = and=20 supports remote patients or clients by using the most appropriate = communication=20 technology, such as the telephone, email or instant messaging. The = advantages of=20 telecare are the possibility of working from home and better continuity = of=20 patient care. However, there are concerns about over-investigation, = clinical=20 mistakes and confidentiality. There are also worries about commercial=20 pressures.

A wider market for health service information and = products=20 should be welcome. However, the danger of commercial suppliers or=20 cyber-physicians undercutting primary health care services is a = possibility,=20 although it may ultimately result in healthy competition. The digital = divide in=20 society may also be a concern. People with low education and old age may = be=20 excluded from telemedicine, and society must ensure that this does not = occur.=20 Telemedicine is a powerful tool, but should be used judiciously and in = the=20 interests of society at large.

References

1.=20 Krupinski E, Nypaver M, Poropatich R et al. Telemedicine/telehealth: an=20 international perspective. Clinical applications in = telemedicine/telehealth.=20 Telemed J E Health 2002; 8: 13=9634.

2.=20 Elger CE, Burr W. Advances in telecommunications concerning epilepsy.=20 Epilepsia 2000; 41(Suppl 5): 9=9612.

3.=20 Rasmusson KA, Hartshorn JC. A comparison of epilepsy patients in a = traditional=20 ambulatory clinic and telemedicine clinic. Epilepsia 2005;=20 46:767=9670.

4.=20 National Institute of Neurological Disorders and Stroke rt-PA Stroke = Study=20 Group. Tissue plasminogen activator for acute ischemic stroke. N = Engl J=20 Med 1995: 333: 1581=967.

5.=20 LaMonte MP, Bahouth MN, Hu P et al. Telemedicine for acute stroke: = triumphs and=20 pitfalls. Stroke 2003; 34: 725=968.

6.=20 LaMonte MP, Xiao Y, Hu PF et al. Shortening time to stroke treatment = using=20 ambulance telemedicine: TeleBAT. J Stroke Cerebrovasc Dis 2004; = 13: 148=9654.

7.=20 Wiborg A, Widder B. Teleneurology to improve stroke care in rural areas: = the=20 Telemedicine in Stroke in Swabia (TESS) Project. Stroke 2003;=20 34: 2951=966.

8.=20 Salih SA, Wootton R, Beller E, Gray L. The validity of video clips in = the=20 diagnosis of gait disorder. J Telemed Telecare 2007;=20 13: 333=966.

9.=20 Samii A, Ryan-Dykes P, Tsukuda RA et al. Telemedicine for delivery of = health=20 care in Parkinson=92s disease. J Telemed Telecare 2006;=20 12: 16=9618.

10. = St=E5lberg S. Small=20 bits to big bites. Muscle Nerve 2002; 11 = (Suppl):=20 S119=9627.

11. Chua R, = Craig J,=20 Wootton R, Patterson V. Randomised controlled trial of telemedicine for = new=20 neurological outpatient referrals. J Neurol Neurosurg = Psychiatry 2001;=20 71: 63=966.

12. Ludman = EJ, Simon=20 GE, Tutty S, Von Korff M. A randomized trial of telephone psychotherapy = and=20 pharmacotherapy for depression: continuation and durability of effects. = J=20 Consult Clin Psychol 2007 75: 257=9666.

13. Knowles = MS.=20 Andragogy in Action: Applying Modern Principles of Adult = Learning. San=20 Francisco: Jossey-Bass, 1984.

14. Ward JP, = Gordon J,=20 Field MJ, Lehmann HP. Communication and information technology in = medical=20 education. Lancet 2001; 357: 792=966.

15. Misra = UK, Kalita=20 J, Nair PP. Traditional journal club: a continuing problem. J Assoc=20 Physicians India 2007; 55: 343=966.

16. Kalita = J, Misra=20 UK, G Kumar. Computer based literature search in medical institutions in = India.=20 Ann Indian Acad Neurol 2007; 10: 44=968.

17. Misra = UK, Kalita=20 J, Mishra SK, Yadav RK. Telemedicine for distance education in = neurology:=20 preliminary experience in India. J Telemed Telecare 2004;=20 10: 363=965.

18. Ayyagari = A,=20 Bhargava A, Agarwal R et al. Use of telemedicine in evading cholera = outbreak in=20 Mahakumbh Mela, Prayag, UP, India: an encouraging experience. = Telemed J E=20 Health 2003; 9: 89=9694.

19. = Ganapathy K.=20 Telemedicine and neurosciences in developing countries. Surg = Neurol=20 2002; 58: 388=9694.

20. Desai S, = Patil R,=20 Chinoy R et al. Experience with telepathology at a tertiary cancer = centre and a=20 rural cancer hospital. Natl Med J India 2004; = 17:=20 17=969.

21. Black S, = Andersen=20 K, Loane MA, Wootton R. The potential of telemedicine for home nursing = in=20 Queensland. J Telemed Telecare 2001; 7: = 199=96205.

22. Chua R, = Craig J,=20 Wootton R, Patterson V. Cost implications of outpatient teleneurology. = J=20 Telemed Telecare 2001; 7(Suppl 1): 62=964.

25 Telepaediatric support for a field hospital in = Chechnya

Boris A Kobrinskiy and Vladimir I=20 Petlakh

Introduction

Emergency situations involving multiple victims = require=20 efficient decisions about medical care. The use of modern = telecommunications=20 allows improved support for disaster medicine. This includes monitoring = of the=20 medical situation, communications about patient transportation problems, = and=20 consultative support for the medical stuff working in the disaster area. = Teleconsulting may be useful in disaster medicine in a number of = ways:

efficient = transfer=20 of information about the nature of the emergency, which is needed to = plan the=20 order and scale of evacuation measures

= consultations with=20 medical specialists to support the physicians on site

= optimization of the=20 choice of specialized hospitals for further treatment of the = victims.

Modern telecommunications were used for the first = time in=20 disaster medicine by the US National Aeronautics and Space = Administration (NASA)=20 in 1985 after the earthquake in Mexico City. This allowed better = estimation of=20 the medical consequences of the earthquake and facilitated proper rescue = measures.1

In the former Soviet Union, the first use of = teleconsultations=20 in an emergency situation was after the Armenian earthquake of 1988. = Telemedical=20 =91space bridges=92 (i.e. video connections) were established by NASA = between=20 Russian and American specialists. This was the first experience of = international=20 telemedical collaboration in an emergency situation.2 The = project=20 included audio=96video and fax communication between the disaster area = in Armenia,=20 clinics in Moscow and four medical centres in the USA.

In 1999, after a train crash in Bashkiria, = teleconsultations=20 took place between a hospital in Ufa (Bashkiria), a surgical clinic in = Moscow=20 and the Yerevan Diagnostic Centre in Armenia. Dedicated telephone lines = were=20 used to provide audio communication and slow-scan black-and-white video = images.=20 When connected to the =91space bridge=92, the system enabled = consultations about=20 patients in Ufa with conditions such as burns and psychological trauma,=20 involving specialists at medical centres in Moscow and the USA.

In 1993, the US Department of Defense started using = telemedicine=20 to support a peacekeeping force (IFOR) undertaking humanitarian missions = in a=20 number of countries. The telemedicine system was called PrimeTime. = Physicians at=20 field hospitals in Macedonia, Croatia and Bosnia were connected to = hospital=20 specialists in Germany, Hungary and the USA.3,4

The most recent use of telemedicine in an emergency = situation in=20 Russia was to support the Children=92s Field Hospital of the All-Russia = Centre of=20 Disaster Medicine in the Chechen Republic in 2001. The doctors of the = field=20 hospital had to provide care for patients with various conditions = resulting from=20 explosion trauma and from fire-arms, as well as providing diagnosis and=20 treatment for children with a wide range of pathologies, including acute = and=20 chronic diseases (e.g. congenital, malignant, neurological and = cardiovascular).=20 This situation required distant medical support, which was realized by=20 installing a telemedicine unit at the field hospital.

Remote decision support for the Children=92s = Field=20 Hospital

By 2001, medical services in Chechnya had been = almost=20 completely destroyed owing to long-term military conflict. Paediatric = care was=20 almost unavailable. The Children=92s Field Hospital in the Gudermes = district of=20 the Chechen Republic included an admission and consultation department, = a=20 surgery department, a department of internal medicine and an intensive = therapy=20 unit, as well as laboratory and radiology services (Figure 25.1). = The=20 hospital was equipped for X-ray imaging, ultrasound scanning and basic=20 laboratory investigations.

The field hospital was admitting not only wounded = children, but=20 also children with various diseases from a number of districts of the = Chechen=20 Republic. This created serious problems for the relatively small medical = staff=20 of the hospital. It was not realistic to refer all the complicated cases = to=20 clinics in Moscow or to other Russian cities.

3DImage=20

Figure 25.1 Structure of the field=20 hospital

Besides, in a number of cases, urgent consultations = with=20 specialists were required, including multispecialist consultations. = Therefore,=20 even from the start of the hospital=92s work, there was a need for = support from=20 specialist institutions. Telephone consultations were impractical in = Chechnya in=20 2001, owing to the very poor quality of telephone connections, and their = complete absence in a number of areas. An efficient means of = communication was=20 required to support the physicians working in emergency situations, = including=20 urgent support from specialists. The consultations had to be provided = both in=20 store-and-forward mode and in real-time, using videoconferencing.

The implementation of this telemedical support =96 the = first=20 Russian system for disaster telemedicine =96 was performed by = specialists of the=20 Moscow Research Institute for Paediatrics and Children=92s Surgery, the = All-Russia=20 Centre of Disaster Medicine, the Dorodnicyn Computing Centre of the = Russian=20 Academy of Sciences, the State Central Air-Carried Rescue Team and a = company=20 called Web Media Service.5

It was decided that the Medical Centre for New = Information=20 Technologies of the Moscow Research Institute for Paediatrics and = Childen=92s=20 Surgery would act as the head telemedicine centre of the system. The=20 telemedicine centre was equipped with a videoconferencing system and = modern=20 telecommunication equipment, including fibre-optic cables enabling ISDN=20 connection at 2.048 Mbit/s and IP connection at 1.024 Mbit/s.

Emergency and scheduled teleconsultations were = provided by the=20 telemedicine centre, as well as multispecialty videoconference=20 consultations.6 The = Medical=20 Centre for New Information Technologies provided technical support for = the field=20 hospital, initially acting as the sole consulting centre. Later on, = regular=20 working contacts were established between the field hospital and the = Scientific=20 Institute of Medical and Biological Problems in Northern Ossetia, the = Fund for=20 Development and Dissemination of New Medical Technologies in Stavropol, = the=20 Stavropol Area Hospital and the Republican Children=92s Hospital in=20 Vladikavkaz.

System architecture

It was clear from the beginning that only satellite=20 communication would be appropriate for telemedicine (Figure 25.2). = One=20 satellite channel was used to provide the connection between the = consultants in=20 the telemedicine centre and the physicians in the field hospital, and a = second=20 channel was used to send requests to the telemedicine centre. Both=20 store-and-forward and real-time traffic were sent by satellite.

Originally, the equipment at the telemedicine unit = in the=20 field hospital included:

a VSAT = terminal,=20 including a computer for information transfer at a bandwidth of 1.0 = Mbit/s=20 through the satellite system HeliosNet

a = satellite phone=20 system (GlobalStar) to transfer the date to the telemedicine centre at a = bandwidth of 9.6 kbit/s

a = videoconference=20 system

a = workstation for=20 the preparation of medical documents (in digital form)

3DImage=20

Figure 25.2 Comunication = architecture for=20 disaster telemedicine

peripheral = devices,=20 including a digital camera, digital videocamera and flatbed scanner.

The telemedicine unit was set up in one of the = tents of the=20 field hospital. The telemedicine unit included work places for = videoconferencing=20 and for data preparation (e.g. review of case material and digitizing of = documents). A satellite dish was installed near the telemedicine unit = tent.

Because of technical limitations on videoconferencing = with the=20 GlobalStar communication system, other solutions were sought. A duplex = satellite=20 terminal (AT&T) was installed at the field hospital. It provided a = bandwidth=20 of 12=9616 kbit/s for data transfer. It was also less expensive to use = than=20 GlobalTel or INMARSAT.

The satellite link enabled real-time consulting using = an=20 asymmetrical IP connection between the field hospital and the = telemedicine=20 centre. The experience demonstrated that any reliable communication = channel with=20 a transfer rate of 9.6 kbit/s for audio and 56 kbit/s for video could be = used as=20 a request channel (provided that no fast movements needed to be = demonstrated to=20 the remote party). For the response channel, from the telemedicine = centre to the=20 field hospital, a high-rate satellite channel was used.

Experimental use of the telemedicine system began in = August=20 2001. By the beginning of September 2001, operational usage had begun. = Between=20 October 2001 and July 2002, the telemedicine system was operational 24 = hours a=20 day.

Telemedicine in the field hospital

Teleconsultations were based on asymmetrical = access, with a=20 high-speed channel from the telemedicine centre to the field hospital = and a=20 low-speed channel in the other direction. The process included:

(1) preparation of the patient=92s data

(2) digitizing any graphical material

(3) forming the request

(4) transfer of the request and digitized medical=20 documents

(5) real-time consultation.

Receipt of the request and the documents was done = by a=20 coordinator at the telemedicine centre, who checked the quality of the = received=20 data, referred the documents to a consultant, made journal records about = the=20 nature of the consultation and recorded the subsequent consultant=92s=20 recommendation. The scheme included two main phases: a preliminary phase = and the=20 consultation itself.

During the preliminary phase at the field hospital, = the patient=20 documentation was assembled and then sent to the telemedicine centre = with the=20 consultation request using the low-bandwidth communications channel. The = documentation included textual materials and graphical data (e.g. X-ray = and=20 ultrasound images and photographs). The total file size was on average = about 3=965=20 Mbyte per patient.

The second phase was information exchange between the=20 telemedicine unit of the field hospital and the telemedicine centre in = Moscow=20 using an asymmetrical duplex IP connection. The high-speed channel was = used for=20 transfer of large volumes of information, including multimedia data, = from the=20 Moscow centre to the hospital, while the low-speed channel was used to = transfer=20 relatively limited volumes of information (text, sound, graphical data = and,=20 rarely, video data) from the hospital to the telemedicine centre.

On establishing the connection, the participants = decided which=20 case to start with. The consultant then opened the relevant document on = the=20 screen of a PC in Moscow. Within 5=9615 seconds, the same document = automatically=20 opened on the screen of the computer in the field hospital. The hospital = physician could ask questions orally; if needed, the physician could use = a White=20 Board option to show the consultant some part of an opened document (or = image).=20 All the consultant=92s comments (audio, text and graphics) were = presented at the=20 field hospital, being transferred via the satellite channel. All the=20 consultations were recorded, which allowed them to be reviewed = afterwards, if=20 required.

The subsequent course of a consultation was defined = by the=20 situation. Four main variants were possible:

1. A physician could ask another question on the = case or=20 document being discussed.

2. The parties could begin the discussion of a new = case.

3. The parties could move to a decision about = organizational=20 matters.

4. The discussion could be stopped.

Clinical aspects of telemedicine = support

During a 14-month period ending in 2002, the = Children=92s Field=20 Hospital delivered care for over 30 000 patients from 17 districts of = Chechnya.=20 A total of 2700 inpatients were treated. Telemedicine provided valuable=20 long-term support for the physicians of the field hospital. A total of = 179=20 consultations were conducted (including those in the trial period). The = main=20 result was that over 40% of patients were able to continue their = treatment in=20 the field hospital after the consultation, instead of being transported = to other=20 medical centres. The severity of the conditions of the consulted = patients can be=20 seen from the two lethal outcomes in children for whom urgent = consultations were=20 requested.

During the period of maximum activity (April=96June = 2002), there=20 were 64 teleconsultations. The most common consultations (23%) were for = children=20 with trauma and orthopaedic problems. Other groups had multiple birth = defects=20 (six cases) or congenital hip dislocation (three cases). Trauma = consultations=20 were required in six cases: three with complicated ankle fractures, two = with leg=20 wounds due to mine explosions and one with hip pseudoarthrosis.=20 Teleconsultations in plastic surgery were required for ten patients: = three with=20 cleft palate, three with nerve and tendon trauma, three with burn scar=20 contracture, and one with post-traumatic alopecia. Neurosurgeons = conducted=20 consultations for two cases of spinal cord hernia, two of cranial hernia = and one=20 of severe cranial trauma. Burn surgeons were consulted about three = patients with=20 severe burns. There were teleconsultations in medical genetics: two = cases of=20 acrocephalosyndactylia, one of Noonan=92s syndrome and one of distal = acromelia.=20 Cardiologists were consulted about three patients: two with myocarditis = and one=20 with rheumatoid arthritis. Two consultations were conducted for children = with=20 Hodgkin=92s lymphoma. Lung diseases were found in two patients: = bilateral=20 pneumonia complicated by pyopneumothorax and a severe case of bronchial = asthma.=20 Children with portal hypertension and haemocolitis were consulted by a=20 hepatologist and a gastroenterologist.

A number of medical institutions participated in the=20 teleconsultations, including six medical research institutes and five = large=20 hospitals. Most of the consultations were conducted by surgical (32) or=20 paediatric (11) departments of the Moscow Research Institute for = Paediatrics and=20 Children=92s Surgery. Ten consultations involved other medical centres = of Moscow,=20 while 11 consultations were conducted in the hospitals of the northern = Caucasus.=20 The results of teleconsultations during the last three months of the = hospital=92s=20 work are shown in Table=20 25.1.

The ages and numbers of patients were as follows:

under 1 = year: 11=20 patients

1=963 = years: 8=20 patients

4=967 = years: 9=20 patients

8=9611 = years: 10=20 patients

12=9615 = years: 9=20 patients

over 15 = years: 8=20 patients.

Table 25.1 Teleconsultations = at the=20 Children=92s Field Hospital
	Number of = consultations
Recommendations about treatment at the field=20 hospital	16
Decision for emergency evacuation	8
Decision for elective transfer outside the = Chechen=20 Republic	37
Not completed	3
Total	64a
a Ten=20 patients had more than one = consultation.

During the first months of operation of the = telemedicine=20 system, the age distribution of the patients remained similar.

Of the 54 patients who received teleconsultations, 8 = were=20 transported to other clinics for further treatment: to Moscow (4), = Makhachkala=20 (2) and Stavropol (2). Thirty-seven patients were referred for further=20 examination and treatment. For 16 patients, the treatment initiated at = the field=20 hospital was changed. Diagnoses were not made in three cases (one = patient died=20 and two consultations were not completed owing to the closure of the = hospital).=20 In terms of performance, there were 35 scheduled teleconsultations, 19 = deferred=20 and 10 urgent. In addition, five emergency consultations were carried = out for=20 critical care.

In summary, telemedicine was highly effective in = diagnosis,=20 choice of treatment and transportation of patients to specialized = medical=20 institutions in a complicated situation due to the military conflict in=20 Chechnya.

Monitoring during treatment and=20 rehabilitation

In large-scale disasters, disruption of the regional = health=20 care system and population migration often occur, which lead to = difficulties=20 with patient transfer and medical data recording. Monitoring of the = victims=20 during all stages of medical care is essential. In the Russian system,=20 information on the health condition of disabled persons is integrated = into a=20 special registry.7 In = the USA, the=20 TRAC2ES system is designed to control the handling of victims evacuated = from=20 military operations.8

The Russian registry was created for centres of = disaster=20 medicine. The users of the registry are health care and social security=20 authorities. Electronic medical records include personal data of a = child, data=20 about the parents/guardians, life history, diagnoses, treatment, = disability and=20 need for rehabilitation.

The registry was developed to support decision making = on the=20 scale and duration of rehabilitation of disabled children involved in = disasters,=20 to improve the monitoring of their health status, and rational planning = and=20 control of medical and social measures. The database includes:

assessment = of=20 functional capabilities, pathological conditions and social adaptation = of the=20 child

analysis = of the=20 child=92s level of disability

control of = rehabilitation at different stages of medical care

assessment = of the=20 nature of the child=92s disability

analysis = of the=20 social adaptivity of the disabled child

the need = for=20 prosthetics and special equipment.

Transfer of the information between the centres = providing the=20 care for the victims of disasters takes place through the Internet.

Discussion

The experience of regular telemedicine support for = physicians=20 at the Children=92s Field Hospital has demonstrated high efficiency in = diagnosis=20 and treatment, as well as in solving the problems of patient evacuation = to=20 specialized institutions. Unlike conventional mobile military hospitals, = the=20 Children=92s Field Hospital provided medical care for a wide range of=20 diseases.

It is interesting to compare the results of = teleconsulting in=20 the traditional practice of the telemedicine centre and in emergency = situations.=20 According to the data from the Moscow Research Institute for Paediatrics = and=20 Children=92s Surgery (2003=962007), transportation from the Russian = regions to=20 Federal (Moscow) clinics was required in 17=9637% of the consulted = patients,=20 depending on the type of pathology. In comparison, 58% of the = Children=92s Field=20 Hospital patients required transportation to specialized clinics in = Moscow and=20 other regions. This difference can be explained by the greater severity = of the=20 cases and the limited means of diagnosis and treatment at the = Children=92s Field=20 Hospital. Nevertheless, the treatment of 42% of patients was continued = in the=20 field hospital, while previously most such patients had to be = transported to=20 other medical institutions. The decrease in the need for patient = transportation=20 due to the use of videoconsultations has been mentioned previously.3,4

Our experience of teleconsultations in Chechnya was = somewhat=20 similar to the situation in Somalia during the United Nations = humanitarian=20 mission in 1993. During the long civil war in that country, the = communication=20 and transport infrastructure was almost completely destroyed. Medical = care was=20 limited, and not all medical specialties were represented on the staff = of the US=20 military field hospital. However, during 13 months of operation in = Somalia, 74=20 cases involving 248 images were transmitted. For several patients, air=20 evacuation or on-site surgical intervention was avoided because of the=20 teleconsultations.3

In other humanitarian operations, a teleradiology = (DEPRAD)=20 system was installed by the Georgetown Medical Center to support = PrimeTime=20 III.9,10 In = Russia,=20 specialists of the Russian Antarctic Expedition, the Institute of = Influenza of=20 the Russian Academy of Medical Sciences, the Baltic Technical University = and the=20 company SVIT developed a modular station for diagnosis, the = Ambulance-071=20 YS.11 The = station=20 enables distant delivery of urgent consultations. It enables:

automatic = and=20 semi-automatic recording of electrophysiological, tactile, descriptive = and other=20 data

= preparation and=20 transfer of documents

automatic = and=20 semi-automatic processing and analysis of the received data

expert = assessment of=20 patients=92 functional status

provision = of=20 recommendations for correction of patients=92 functional status based on = expert=20 assessment

monitoring = of=20 patients=92 functional status.

This station is used in Antarctica. The results = obtained=20 demonstrate the value of the approach,12 = which can=20 also be employed in emergency situations.

Although in Chechnya the satellite system provided a = relatively=20 simple and reliable connection, this was not mobile communication in the = full=20 sense of the term. Recently, fully mobile satellite equipment has become = available, and has been used successfully in military and disaster = medicine. For=20 real-time consultations, a personal digital assistant (PDA) equipped = with a=20 digital camera and telephone has been suggested.13 = Wireless=20 communication for PDAs enables communication between several sites and = the=20 centre in the case of multiple victims.14 = Such a=20 situation occurred occasionally in Chechnya, when multiple patients were = admitted to the field hospital. A full-scale decision support system for = a field=20 hospital could be based on a WiFi network. A wireless network would = allow data=20 transfer from the patient=92s bed, as well as interactive = videoconferences=20 directly from the operating room or intensive care unit. Mobile = telemedicine of=20 this kind would have been useful during our work in the field = hospital.

Limited on-site data collection was possible in the = field=20 hospital using a mobile ECG recorder. The American system PrimeTime = allowed US=20 physicians to establish video telemedicine sessions anywhere within a = war zone=20 and to connect with medical centres in the USA.4 = Direct=20 interactive contacts with rescue teams, using mobile telemedicine = systems, by=20 remote consultants would significantly increase the efficiency of = decision=20 making in emergency situations.

Prolonged and severe emergency situations often = require special=20 provision for psychological support and rehabilitation of the victims. = Such=20 support can be provided through telepsychiatry,15 = although this=20 was not available in the case of children treated at the field = hospital.

In summary, the challenges faced during the = implementation of=20 the telemedicine system in Chechnya were:

= insufficient=20 bandwidth for communications during the first stage of telemedicine work = (subsequently overcome by the use of another satellite)

occasional = difficulties in finding specialists in certain areas

absence of = an=20 intra-hospital telemedicine system in the Institute for solving medical = problems=20 during videoconsultations

satellite=20 limitations precluding observation of the dynamics of patients=92 = movements during=20 videoconsultations.

Future disaster telemedicine in = Russia

To increase the efficiency of teleconsultations = provided for=20 Russian field hospitals, the following are required:

= organization of=20 round-the-clock services in the telemedicine centre

= availability of=20 sufficient medical institutions to provide teleconsulting in emergency=20 situations

= development of the=20 requisite national telemedicine infrastructure and creation of local = information=20 systems in disaster medicine centres.

In 2006, successful training exercises of the = disaster=20 medicine service were conducted under field conditions using a new, less = expensive mobile telemedicine system. This accords with the = government=92s concept=20 of developing telemedicine technologies in the Russian Federation,16 = which=20 provides transition to a new level of information support in disaster=20 telemedicine to enable efficient control over medical care and = consultative=20 support for medical teams in emergency situations.

The process of equipping field hospitals with mobile=20 telemedicine units continues. A small Q-band satellite station, = developed by Web=20 Media Service, successfully passed testing in 2007. This allows data = transfer at=20 128 kbit/s, i.e. at almost the same rate as via ground communication = lines.5 = Mobile=20 telemedicine units have been developed for the needs of space = medicine.17 = During the=20 missions of the US Space Shuttle, a mobile set of medical devices for = ear, nose=20 and throat and skin imaging, electrocardiography, blood oxygen = saturation level,=20 and heart and lung sound auscultation was used.18 = Similar=20 equipment might be used by mobile teams for disaster medicine.

Conclusion

Telemedicine was highly effective in managing = paediatric=20 patients at the field hospital in a complicated situation due to the = military=20 conflict in Chechnya. The Russian satellite system HeliosNet provided = reliable=20 communication, and was not prohibitively expensive. The cost of the = equipment in=20 the telemedicine unit of the field hospital was approximately US$5000 in = 2001.=20 The cost of operating the satellite system (2008 prices) was = approximately=20 US$270 per month (for 10 videoconferences and 15 store-and-forward=20 consultations). In 2001=962002, the estimated cost was some three to = four times=20 higher. The costs of the telemedicine work in Chechnya were met by = charitable=20 donations from business concerns.

Telemedical support for physicians working in areas of = natural=20 disasters, local military conflicts or humanitarian disasters would = increase the=20 level of urgent and specialized medical care. An important factor in = realizing=20 this will be the presence of a satisfactory telemedicine infrastructure = in=20 neighbouring regions and appropriate organization to monitor patients=92 = health=20 during their transportation to hospitals or other specialized medical=20 centres.

References

1.=20 NASA satellite aids in Mexico City rescue effort. NASA News = Release=20 1985; 85: 133.

2.=20 Houtchens BA, Clemmer TP, Holloway HC et al. Telemedicine and = international=20 disaster response. Medical consultation to Armenia and Russia via a = Telemedicine=20 Spacebridge. Prehosp Disaster Med 1993; 8:=20 57=9666.

3.=20 Crowther JB, Poropatich R. Telemedicine in the US Army: case reports = from=20 Somalia and Croatia. Telemed J 1995; 1: = 73=9680.

4.=20 Calcagni DE, Clyburn CA, Tomkins G et al. Operation Joint Endeavor in = Bosnia:=20 telemedicine systems and case reports. Telemed J 1996;=20 2: 211=9624.

5.=20 Ehrlich AI, Kobrinsky BA, Petlakh VI et al. Telemedicine for a = Children=92s Field=20 Hospital in Chechnya. J Telemed Telecare 2007; = 13:=20 4=966.

6.=20 Kobrinskiy BA, Matveev NV. Teleconsultations at the Moscow Research = Institute=20 for Paediatrics and Children=92s Surgery. J Telemed Telecare = 2006;=20 12(Suppl 3): 110.

7.=20 Kobrinsky BA. Database of disabled children injured in disasters. = Prehosp=20 Disaster Med 1997; 12(Suppl 1): 90=961.

8.=20 Cook R, Woods D, Walters M, Christoffersen K. The cognitive systems = engineering=20 of automated medical evacuation scheduling and its implications. In:=20 Proceedings of the Third Annual Symposium on Human Interaction with = Complex=20 Systems, 25=9628 August 1996: 202=967.

9.=20 Levine BA, Cleary K, Mun SK. Deployable teleradiology: Bosnia and = beyond.=20 IEEE Trans Inf Technol Biomed 1998; 2: = 30=964.

10. Mun SK, = Levine B,=20 Cleary K, Dai H. Deployable teleradiology and telemedicine for the US = military.=20 Comput Methods Programs Biomed 1998; 57: = 21=967.

11. = Liaskovik AT,=20 Senkevich YuI, Chasnik VG, Yaschin AV. [The concept of health services = in=20 regions with low population density and computer stations in the = structure of=20 advisory help.] Inform Technol Publ Health Serv 2001;=20 8/9: 28=969 (in Russian).

12. = Senkevich YuI.=20 [Development of information technologies for medical maintenance of = polar=20 expeditions.] Ukr J Telemed Med Telematics 2004; = 2:=20 22=968 (in Russian).

13. Garshnek = V, Burkle=20 FM Jr. Applications of telemedicine and telecommunications to disaster = medicine:=20 historical and future perspectives. J Am Med Inform Assoc 1999; = 6: 26=9637.

14. Grasso = MA.=20 Handheld computer application for medical disaster management. AMIA = Annu=20 Symp Proc 2006: 932.

15. Mack D, = Brantley=20 KM, Bell KG. Mitigating the health effects of disasters for medically=20 underserved populations: electronic health records, telemedicine, = research,=20 screening, and surveillance. J Health Care Poor Underserved = 2007;=20 18: 432=9642.

16. = [Concepts of=20 Development of Telemedical Technologies in the Russian Federation.] = Moscow,=20 2001 (in Russian).

17. = Grigoriev AI,=20 Orlov OI. [Telemedicine in Russia.] Vestn Ross Akad Med Nauk = 2004;=20 10: 30=965 (in Russian).

18. Crump = WJ, Levy BJ,=20 Billica RD. A field trial of the NASA Telemedicine Instrument Pack in a = family=20 practice. Aviat Space Environ Med 1996; 67:=20 1080=965.

26 Web-based paediatric oncology information and=20 registries: An international perspective

Andr=E9 Nebel de Mello

Introduction

Cancer registration can trace its origins to the = first decade=20 of the 20th century, when surveys measuring the point prevalence of = cancer were=20 reported from a number of European countries. Permanent registration = systems=20 were implemented in Hamburg in 1926, Mecklenburg in 1937 =96 both = discontinued=20 during World War II =96 Massachusetts in 1927 and Connecticut in 1935. = The first=20 national survey on a significant sample of the US population was carried = out in=20 1937=9638. By the end of the late 1940s, population-based registries and = the=20 survey system (10 metropolitan areas in the USA) had solved most = technical=20 problems, and the concepts have been widely used ever since.

The first experiences of using nominal rosters of = cancer=20 patients for analytical studies or for linkage with other registries = occurred in=20 the late 1940s. Epidemiologists working on those registries realized = that=20 incidence and mortality statistics should not be considered as = alternatives: the=20 latter are generally valuable, but the former can also provide = information on=20 treatment and follow-up. An expert report for the World Health = Organization=20 (WHO) concluded that:1

the collection of accurate statistics of = cancer=20 incidence and mortality among different =85 people and =85 countries may = lead to=20 important indications for =85 studies =85 [whereas] the information = [provided by=20 mortality statistics] =85 is becoming increasingly inadequate, owing to = growing=20 numbers of patients successfully treated and thus not registered in the=20 statistics of death [Thus], we =85 make the following suggestions:

1. Great benefit would follow the collection = of data=20 about cancer patients from as many different countries as possible.

2. Such data should be recorded on an agreed = plan so as=20 to be comparable.

3. Each nation should have a central registry = to arrange=20 for recording and collection of such data.

4. There should be an international body whose = duty=20 should be to correlate the data and statistics obtained in each = country.

In 1950, the WHO created a Subcommittee on the = Registration of=20 Cases of Cancer. Within a few years, the Nordic countries, the UK and = Canada=20 launched programmes that led to national coverage of registration. The = model=20 followed in the USA was different: no national coverage was attempted, = and=20 instead a number of county- or state-based registries were created. The = surveys=20 on samples of the population were converted in the Surveillance, = Epidemiology=20 and End Results (SEER) programme, which produces incidence and survival = rates=20 broken down by ethnic groups.

The first worldwide analysis was published in 1966 = with the=20 title Cancer Incidence in Five Continents.2 This = marked the=20 beginning of a series of publications appearing at five-year intervals,=20 supervised by the International Union Against Cancer (UICC), the = International=20 Agency for Research on Cancer (IARC) and the International Association = of Cancer=20 Registries (IACR). The data were not simply and passively accepted, but = were=20 revised and controlled.2=964 Two = by-products=20 of this strategy have been a worldwide standardization of the activity = of=20 registration and the provision through the IARC of technical advice to=20 developing cancer registries.

In 30 years, the number of countries with cancer = registries=20 nearly doubled and there was a fivefold increase in both the number of = active=20 cancer registries and the total population served by registration (Table = 26.1).4 These = increases=20 were concentrated in industrialized countries, whereas in developing = countries=20 there was a substantial decrease in registration, attributable to the = political=20 and economic situation,5 = leading to the=20 inequalities reported in Table 26.2 = and=20 displayed in Figures=20 26.1 and 26.2.

In the early 1980s, it became apparent that = population-based=20 survival rates of cancer patients could be used as an indicator of the = quality=20 of cancer care in a given area and that registries could play a major = role. The=20 first large-scale international cooperative study, the EUROCARE project, = published its first results in 1995,6 and = aimed to=20 increase cooperation between epidemiologists and clinicians in = continental=20 Europe and to perform a systematic follow-up of the living status of the = registered individuals.

Cancer registries have benefited tremendously from the = use of=20 databases and electronic data transfer. The use of the Internet is thus = a=20 natural evolution. Most registries

Table 26.1 Coverage in eight = volumes of=20 cancer incidence in five continents4
Volume	Year of publication	Registries	Populations	Countries	Period = (approximate)
1	1966	32	35	29	1960=9662
2	1970	47	58	24	1963=9667
3	1976	61	79	29	1968=9672
4	1982	79	103	32	1973=9677
5	1987	105	137	36	1978=9682
6	1992	138	166	49	1983=9687
7	1997	150	183	50	1988=9692
8	2002	186	214	57	1993=9697

Table 26.2 Coverage by cancer = registries around 19923
Area	Number of registries	Population served by registries=20 (millions)	Total population = (millions)	Percentage of population=20 served
Africa	5	0.5	728	0.1
Central and Latin America	11	20.8	482	4
Canada and USAa	25	61.9	293	21
European Union	53	119.0	372	32
Other Western European countriesb	10	8.0	12	67
Other, Europe	10	45.6	344	13
Asia	24	71.4	3458	2
Oceania	9	18.5	29	64
aIncluding Surveillance, Epidemiology = and End=20 Results programme, covering approximately 10% of the = population.
bNorway,=20 Switzerland and Iceland.

3DImage=20

Figure 26.1 Individual countries: = coverage by=20 cancer registries 19974

were publishing information online in the early = 1990s, and=20 many have already switched to web-based data entry interfaces.

Cancer in children

Cancer is very rare in childhood =96 it is = predominantly a=20 disease of elderly people. In industrialized countries, about 1 in 200 = (0.5%) of=20 all cancers occurs in children aged under 15 years. The incidence rate = is=20 typically 110=96150 per million children per year, equivalent to a risk = of around=20 1 in 500 during the first 15 years of life. Nevertheless, cancer = accounts for=20 about 20% of all deaths in children aged 1=9614 years, making it the = second most=20 common cause of death in children in most of the world (the first is = death

3DImage=20

Figure 26.2 Cancer registry = coverage:=20 geographical coverage (percentage of total population) of cancer = registries by=20 region4

due to external causes) and the most common cause of = death by=20 disease, with the exception of Africa and some Asian countries.

Cancer in children is often not preventable. Prenatal = factors=20 are considered to affect the incidence of tumours in children under the = age of 5=20 years. It is generally accepted that cancer results from genetic = changes. The=20 carcinogenic process in children is much shorter than in adults. = Childhood=20 cancer incidence rates are highest during infancy, so it is reasonable = to assume=20 that many paediatric cancers result from aberrations in early = developmental=20 stages and in utero.

An increased risk of childhood cancers has been = reported to be=20 associated with certain genetic conditions or syndromes such as = chromosomal=20 abnormalities, DNA-repair disorders, congenital anomalies, hereditary = immune=20 deficiency states and other hereditary syndromes. Racial differences = have been=20 observed in childhood tumours, even within industrialized countries. A = peak=20 incidence in acute lymphoblastic leukaemia (ALL) usually occurs between = the ages=20 of 2 and 3 years in white American children and from 1 to 4 years in = European=20 children, but not among African=96Americans. Ewing=92s sarcoma is = another=20 well-established example of a cancer with racial differences, with the = lowest=20 incidence rate in black children (African or American).7

Overall, childhood cancer is about 20% more common = among boys=20 than among girls. The male predominance is greater for lymphomas, liver = tumours=20 and nasopharyngeal carcinoma, and less marked for leukaemia, brain = tumours,=20 neuroblastoma and soft tissue sarcomas. Boys and girls have a similar = incidence=20 of retinoblastoma and Wilms=92 tumour. The incidence in girls is only = greater for=20 extragonadal germ cell tumours, malignant melanoma, and adrenal cortex = and=20 thyroid carcinomas.

There are also marked variations between populations = in the=20 incidence of specific types of childhood cancers. Nearly one-third of = all=20 childhood neoplasms are leukaemias. International variation occurs in = the rate=20 of ALL, and the higher incidence of ALL in early childhood has usually = been=20 associated with higher levels of socioeconomic status, suggesting that=20 environmental factors play a role. Although a considerable=20 number of environmental or exogenous factors have been suggested as risk = factors=20 for childhood cancers, only a few have been proven, and they are mostly=20 infectious agents, including Epstein=96Barr virus, hepatitis B virus, = human=20 immunodeficiency virus and human herpesviruses. These infections are = probably=20 responsible for the international variation in the incidence of some = childhood=20 cancers, such as lymphoma, nasopharyngeal carcinoma, hepatic cancer and = Kaposi=92s=20 sarcoma. In addition, some parasitic infections have been implicated,=20 particularly malaria in tropical Africa, acting as a cofactor for = Burkitt=92s=20 lymphoma, and schistosomiasis in Egypt, causing bladder cancer.7

The EUROCARE collaboration has revealed considerable = variation=20 in survival between European countries,8 but, = unlike=20 those for adults, the survival rates of children with cancer in Western = Europe=20 are similar to those in the USA.9 In = the=20 developing countries, where 80% of the world=92s children with cancer = live, they=20 are often diagnosed too late or not diagnosed at all and, without access = to=20 life-saving treatment, more than one in two of these children diagnosed = with=20 cancer will die.

The increases in survival rates occurred during a = period of=20 great technical advances in childhood cancer treatment, but there were = also=20 major changes in referral patterns. At one time, most children with = cancer were=20 treated at local hospitals, there were few specialists in paediatric = oncology,=20 and opportunities for participation in collaborative studies of = treatment were=20 limited. Treatment has gradually become more centralized, and more = children have=20 been entered in national and international clinical trials and = studies.10 For = several=20 types of cancer, survival has been found to be higher among children who = were=20 treated at specialist centres or who were entered in national or = international=20 clinical trials.

As a consequence of the improved survival rates = described above,=20 the number of adult survivors of childhood cancer has increased = substantially=20 (Figure = 26.3). In=20 1961, there were only about 15 survivors in Britain aged 30 or above, = and none=20 above 40, while in 2000, there were over 26 000 survivors, of whom = almost 7000=20 (about 25%) were aged over 30 years. In 1971, there were 5500 survivors, = with=20 over 1000 above age 20 and 100 aged 30 or above. In 1981, there were = nearly 3000=20 survivors aged 20 and above, but fewer than 100 of them were aged over = 40 years,=20 while in 2000, almost 2500 (almost 20% of those aged 20 and above) were = aged=20 over 40 years. Eventually, more than 1 in 1000 adults of all ages will = be=20 survivors of childhood cancer.11

Cancer information on the = Internet

The Internet has become an increasingly common = source of=20 medical information for patients with cancer. For example, over 50% of = adults in=20 the USA have searched online for health information and 80% of all US = Internet=20 users have searched online for at least one major health topic.12

Use of the Internet to access cancer information is = related to=20 age (being more common in those aged under 60 years), higher income, = higher=20 education and being white.13 = However,=20 there has been little research on Internet cancer information use among = minority=20 racial/ethnic groups in the USA and Western Europe, or in populations of = developing countries, or on the appropriateness of the websites = available=20 to

3DImage=20

Figure 26.3 Number of (past or = current)=20 childhood cancer patients (by age group) alive at the end of each year = in the=20 UK, 1961=96200011

such populations.12,13 = Many cancer=20 organizations have created patient-centred web-sites to provide = comprehensive=20 information about specific cancers, but most of the information = available is in=20 English, limiting its use for non-speakers.

A study of cancer patients=92 self-reported attitudes = to the=20 Internet came to the following conclusions:14

Patients = are=20 comfortable giving as well as receiving cancer information and support = online;=20 they are also comfortable in evaluating it.

They are = interested=20 in the experiences of other patients and derive benefit by interacting = with them=20 directly, through venues such as discussion boards and email lists or,=20 indirectly, through activities such as reading biographies.

They = perceive better=20 outcomes after using online health information and support.

Cancer = patients have=20 a certain level of trust in online information, primarily for = information=20 obtained from established reputable sources such as studies in journals = and=20 advice given by medical doctors; they also trust websites endorsed by = health=20 authorities.

They are = confident=20 in their ability to evaluate information, including comprehension of = research=20 reports.

They = display a=20 healthy scepticism when presented with the option of divulging personal = health=20 information. However, some patients are willing to provide email = addresses and,=20 if they receive personalized information, they are comfortable in = disclosing=20 their identity.

Another study evaluating cancer patients=92 and = caregivers=92=20 interests about the Internet indicated that most patient and caregiver=20 respondents were interested in Internet-based cancer-related services = such as=20 information related to treatment (80%), conversations with physicians = via the=20 Internet (70%) and online support groups (65%). In addition, respondents = reported that they would be likely to use such services (70%) and were=20 interested in home health care services delivered via PCs (60%). No = differences=20 were found between ethnic groups, geographical settings or patient = status=20 (patient versus caregivers) on these variables. Minorities, older = individuals=20 and less-educated individuals were less likely to have knowledge of and = to have=20 used the Internet.15

In the last few years, there have been efforts to = improve online=20 cancer information quality. Good examples include the International = Cancer=20 Information Service (established in 2001), the American Society of = Clinical=20 Oncology (ASCO) website People Living with Cancer (launched in 2002) and = the=20 Oncopediatria.org = portal16 = (launched in=20 2004).

Online information about childhood cancer and = web-based=20 initiatives on the subject are less common, even in industrialized = countries.=20 This may be a reflection of the lower incidence of the disease on this = age group=20 or may be a misconception about the similarity of the disease between = adults and=20 children.

International initiatives

While most international initiatives that focus on = paediatric=20 oncology are from cooperative groups in Western Europe or North America, = there=20 are some good examples that focus on developing countries. These include = the=20 following.

SLAOP

The Latin American Society of Paediatric Oncology = (SLAOP)=20 provides information for general paediatricians and paediatric = oncologists by=20 publishing articles, news and presentations in paediatric and = evidence-based=20 oncology on its website.17 = SLAOP is also=20 developing a Latin-American Paediatric Oncology Registry, and has = launched the=20 Latin-American Paediatric Promyelocytic Leukaemia Registry, a web-based = registry=20 available through its website.

St Jude Children=92s Research = Hospital

The St Jude=92s Hospital in Tennessee has an = International=20 Outreach programme with the object to improve the survival rates of = children=20 with catastrophic illnesses worldwide, through the transfer of = knowledge,=20 technology and organizational skills. This is achieved through twinning=20 programmes and through two websites: Cure4Kids18 and = POND4Kids.19

The Cure4Kids website was launched in October 2002 and = provides=20 medical education for physicians, nurses, scientists and health care = workers in=20 countries with limited resources who treat children with catastrophic = diseases.=20 The main functions are:

online = education=20 about catastrophic childhood illnesses

= collaborative work=20 spaces for document sharing and online meetings; several countries, = including=20 Brazil, Lebanon, Morocco, Guatemala, El Salvador, Honduras and Mexico,=20 participate in these international meetings

access to=20 consultation and mentoring by staff of St Jude=92s Hospital

technology = and=20 training for better management of patient information.

The core of Cure4Kids is an online digital library = of=20 reference material, a discussion area for exchange of advice and = information=20 between doctors, and access to online seminars and lectures. The website = is also=20 used to host live meetings via web conferencing (video and = voice-over-IP).18 In = September=20 2007, there were 11 490 registered users in 157 countries.

The Paediatric Oncology Networked Database (POND4Kids) = is an=20 online, multi-lingual database for paediatric haematology/oncology = patients. The=20 aim is to improve the care of paediatric oncology patients in countries = with=20 limited resources by the exchange of information and experience among=20 oncologists who practise in a similar medical environment. The major = objectives=20 of POND4Kids are to:

store = patient data=20 for easy retrieval and analysis in a way that ensures quality = control

provide = uniform data=20 collection to facilitate comparison of information among centres

provide a = single=20 tool for data storage and retrieval to facilitate training of data = managers

develop a=20 multilingual online system that is available to users at no cost.

POND4Kids is hosted on a web server and is divided = into=20 several virtual sites. Clinicians at different POND4Kids sites can share = information about individual patients, groups of patients with the same = disease=20 or all patients. Shared records have personal identifiers removed, but = retain a=20 unique POND identification number. Information sharing facilitates = analysis by=20 colleagues of specific diseases treated at multiple centres in = low-income=20 countries. Information can also be shared with international experts to = assist=20 with analysis and quality improvement.

Ten centres in nine countries (seven in Central = America, two in=20 Morocco and one in Jordan) currently use the POND4Kids website. In the = first two=20 years of operation (2004=962006), over 9000 patient records were entered = into=20 POND4Kids.20 = Many=20 paediatric oncology services in developing countries have adopted these = websites=20 for registering and discussing their patients, instead of developing a = website=20 of their own.

SIOP

The International Society of Paediatric Oncology = (SIOP)=20 provides information for professionals by publishing best practice = guidelines on=20 its website21 and = by making=20 available the SIOP educational books and conference lectures on the = Cure4Kids=20 website.

International agencies

The IARC publishes the International = Classification of=20 Childhood Cancer,22 = currently in=20 its third revision, and adopted worldwide in childhood cancer = registries. The=20 IARC also publishes the Cancer Incidence in Five Continents = report that=20 is updated every 5 years,2=964 and = publishes=20 cancer registration manuals and papers on the social inequalities of = cancer.=20 Almost all publications are available at the agency=92s website.23

The IACR has designed a suite of computer programs to = meet the=20 needs of population-based cancer registries in developing countries. The = software is in its fourth version, named CanReg4, and can be used in a=20 Windows-based network environment. It is available in English, Spanish, = French,=20 Italian, Turkish, Chinese, Thai, Arabic and Farsi. The software is free = and is=20 available at the IACR website.24

Twinning programmes

Twinning programmes are partnerships between = institutions in=20 industrialized countries and those in developing countries with the goal = of=20 improving survival rates among children with cancer. These programmes = have=20 reduced the rates of abandonment of treatment, relapse and death due to = toxic=20 effects of treatment. The investments that they have attracted have led = to=20 improvements in access to treatment and hospital infrastructure. The = best=20 results have been obtained when local oncologists were recruited as = programme=20 directors and asked to promote the idea of a strong paediatric oncology = unit=20 among their peers and to coordinate the training of providers.25

Most twinning programmes have a telemedicine = component, usually=20 videoconferencing, web-based case report forms or continuing medical = education=20 (CME). Examples are the programme between the King Hussein Cancer Centre = (KHCC)=20 in Amman, Jordan and the Hospital for Sick Children in Toronto, Canada = in=20 paediatric neurooncology26 and = the=20 MISPHO Consortium initiatives in Central America.27

Online childhood cancer registries in developing=20 countries

Although online cancer registries have became more = common in=20 the last few years, only a few childhood cancer registries have been = implemented=20 by developing nations, and even fewer with a web-based interface. = Examples=20 include the following.

Brazil

The Oncopediatria portal was launched in 2004 and is = a=20 web-based system that offers services and information on paediatric = cancer.16 It = maintains=20 a secure online patient registry, a web-based bone marrow transplant = registry=20 tool and online cooperative treatment protocols for the Brazilian = Society of=20 Paediatric Oncology. It is part of a national telemedicine network of=20 universities, research institutes and medical institutions that has been = established in Brazil to support distance medical practice in oncology, = called=20 ONCONET.28=9630

<= A=20 id=3Dpage_282>

The main objectives are:

to improve = the=20 information flow in research programmes and cooperative treatment = protocols

to = disseminate and=20 harmonize treatments through the use of protocols that produce the = highest cure=20 rates

to = establish the=20 basis for a national demographic record of paediatric cancer

to make = available=20 statistics, demographic data and analyses of the results of treatments = using the=20 protocols.

The system is hosted on clusters of computers. It is = based on=20 open-source software, designed to provide high performance, fault = tolerance and=20 high availability.

Some of the Brazilian Society=92s cooperative = protocols have been=20 implemented. The first online treatment protocol targets the treatment = of=20 high-risk neuroblastoma.29 A = protocol=20 for multiple subtypes of non-Hodgkin=92s lymphoma and another for = paediatric bone=20 marrow transplantation 30 are = also=20 available. In these protocols, much of the data is textual, but parts of = the=20 record are medical images. The system allows images to be stored in = several=20 common image formats such as JPEG and DICOM (digital imaging and = communications=20 in medicine).

In June 2007, there were 310 registered paediatric = oncologists=20 from 53 out of 58 treatment centres in 23 states; there were 7000 = registered=20 patients.

Argentina

The Argentinean Paediatric Oncology Hospital = Registry (ROHA)=20 was established in 2000 using the WHO/IARC standards for cancer = registration. It=20 registers children with solid and haematological malignancies. = Registered data=20 can be consulted online at the ROHA website.31

Eastern Europe

The Automated Childhood Cancer Information System = (ACCIS) is a=20 project developed by the IARC and supported by the European Commission, = with the=20 objectives of collecting, presenting, interpreting and disseminating = data on=20 childhood cancer in Europe. The ACCIS database contains some 160 000 = records on=20 childhood and adolescent cancer cases registered over the last 30 years = in 78=20 European population-based cancer registries, covering 2.6 billion = person-years.=20 The Eastern European countries with information stored in this database = are=20 Belarus, Estonia, Hungary, Slovakia, Slovenia and Turkey.32

Belarus

The childhood population-based cancer registry of = the Republic=20 of Belarus was created in August 1999 and registered cases = retrospectively to=20 the year 1989. It was created as one of the international health care=20 initiatives after the Chernobyl disaster. Consolidated data can be = consulted=20 online at the registry=92s website.

Serbia

The Childhood Cancer Registry of Central Serbia was = created by=20 the Institute of Public Health of Serbia =91Dr Milan Jovanović = Batut=92. The=20 registry has consolidated data from 1997 to 2005, available online at = the=20 Institute=92s website.34

India

The non-governmental organization South Asian Marrow = Foundation =96=91Matchpia=92 =96 has a web-based initiative named = Project India,35 = which=20 launched the United South Asian Donor Registry (USADR), an online bone = marrow=20 donor registry. This is probably India=92s largest registry. The = foundation also=20 performs matching between donors and patients, including those with = paediatric=20 cancer.

Singapore

The Singapore Childhood Cancer Registry (SCCR) was = established=20 in September 1997 under the auspices of the Paediatric Oncology Group=20 (Singapore), and registers all children, aged 18 years and below, who = have been=20 diagnosed with haematological or solid malignancies. Physicians = voluntarily=20 register the patients through a secure web-based form on the = registry=92s=20 website.36

Paediatric oncology web-based = information

Most childhood cancer information websites from = developing=20 countries belong to parents=92 associations and support groups. The = information=20 content on these websites is usually focused on the activities and = objectives of=20 the organization, and there is limited information on the most common = types of=20 childhood cancer and only general information about therapy options. For = more=20 complete information, there are usually links to North American, local=20 governmental or international websites. There are a few exceptions to = this rule,=20 which are mentioned below.

Government websites usually offer general cancer = information=20 targeting adults with cancer. In Brazil and South Africa, local = childhood cancer=20 medical associations and some treatment centres have websites with more = detailed=20 cancer information for parents and professionals.

Latin America

The Brazilian National Cancer Institute (INCA) has a = subsection of its website37 = dedicated to=20 childhood cancer information for parents and professionals, including=20 statistics, treatment guidelines, early detection and an overview of the = cancer=20 types. There are also many cancer-related publications available for=20 download.

Over 20 childhood cancer support groups in Brazil = offer websites=20 with disease information for the general public. For example, the = Brazilian=20 Lymphoma and Leukaemia Association (ABRALE) has a website38 = that offers=20 detailed information on leukaemia and lymphoma for parents and health=20 professionals. It has a subsection dedicated to = cancer in=20 children. Distance learning tools, legal support information, forums and = downloadable information booklets are also available.

The Oncopediatria website16 = from Brazil=20 has an open information section for parents and health professionals = that=20 includes cancer information, articles, summaries of treatment studies = and a=20 biweekly newsletter.

The Organization of Parents of Children with Cancer = and Related=20 Diseases (OPNICER) from Colombia offers on its website39 = legal=20 information for parents and a roadmap of the challenges faced by = children and=20 parents from cancer diagnosis to cure.

The Natal=ED Dafne Flexer Association from Argentina = offers=20 detailed information for parents, patients, volunteers and = professionals, as=20 well as articles, downloadable booklets and other childhood cancer = resources on=20 its website.40

Eastern Europe

The Romanian Association of the Parents with Cancer = and=20 Leukaemia Ill Children (P.A.V.E.L.) has an information section on its=20 website41 = with=20 diagnostic information, nutritional orientation and support information = for=20 parents and professionals, as well as best practice guidelines for = doctors.

Asia

The Children=92s Cancer Foundation of Singapore = offers detailed=20 information and resources for parents and teachers, and downloadable = booklets in=20 three languages on its website.42

Africa

The South African Children=92s Cancer Group (SACCSG) = has a web=20 portal43 = with=20 information for general practitioners on early diagnosis of cancer. It = also=20 provides information and support for parents, in partnership with the = Childhood=20 Cancer Foundation of South Africa.

Conclusion

The field of oncology is vast, and knowledge is = increasing=20 rapidly. The main gap between industrialized and developing countries in = this=20 field is not the availability of the newest medications; rather, it is=20 differences in the information about the types of cancer afflicting the=20 population and on the best ways to treat them. The increases that have = occurred=20 in the cure rate of children with cancer are mainly due to the use of = better=20 combinations of existing drugs, rather than the use of new ones.

The Internet offers great potential for bridging the = knowledge=20 gap. The instant availability of up-to-date information for medical=20 practitioners can increase the speed of diagnosis. The availability of = accurate=20 cancer profiles in each country, resulting from work done by the = national=20 registries, can guide professionals to the most likely diagnosis, and help governments and private = initiatives to=20 direct their resources to treat cancer more effectively.

Acknowledgements

I thank Adilson Yuuji Hira, Marcelo Kn=F6rich Zuffo = and the=20 staff of the Telemedicine and Bioinformatics Unit from the Laboratory of = Integrated Systems of the University of S=E3o Paulo for their advice and = support.

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33. Child Health International Foundation. A = Childhood=20 Cancer Registry for Belarus. Available at:=20 www.pghfree.net/~chif/registry.html.

34. = Institute of=20 Public Health of Serbia =91Dr Milan Jovanović Batut=92. Available = at:=20 www.batut.org.yu/english.html.

35. = Matchpia.=20 Available at: www.matchpia.org.

36. = Singapore=20 Childhood Cancer Registry. Available at: sccr.pogs.org.sg.

37. = Instituto Nacional=20 de C=E2ncer (INCA). Available at: www.inca.gov.br.

38. = Associa=E7=E3o=20 Brasileira de Linfoma e Leucemia (ABRALE). Available at: = abrale.org.br.

39. = Organizaci=F3n de=20 Padres de Ni=F1os con C=E1ncer y Enfermedades Relacionadas (OPNICER). = Available at:=20 www.opnicer.org.

40. = Fundaci=F3n Natal=ED=20 Dafne Flexer. Available at: www.fundacionflexer.org.

41. Romanian = Association of the Parents with Cancer and Leukaemia Ill Children = (P.A.V.E.L.).=20 Available at: www.asociatiapavel.home.ro.

42. = Children=92s Cancer=20 Foundation. Available at: www.ccf.org.sg.

43. South = African=20 Children=92s Cancer Study Group (SACCSG). Available at: = www.saccsg.co.za.

27 E-health in international networks: New = opportunities=20 for collaboration

Shariq Khoja and Azra = Naseem

Introduction

In recent years, there has been a substantial = reduction in the=20 availability of health professionals in developing countries, which has = been=20 accompanied by a rise in the demand for high-quality health care. This=20 combination has forced health care institutions to collaborate and share = their=20 resources to provide comprehensive, high-quality and accessible health = care at a=20 reasonable cost.

The Aga Khan Development Network (AKDN) is an = international=20 network that comprises several institutions, working for the development = of poor=20 nations in Asia and Africa, in social development (health, education and = housing), disaster relief, economic development and preservation of = cultures.=20 Most of the development in the health sector is carried out through the = Aga Khan=20 Health Services (AKHS) and the Aga Khan University (AKU).

The AKHS operates a private, not-for-profit health = care system.=20 It includes more than 200 health care facilities, including 9 hospitals. = The=20 AKHS provides primary health care and curative medical care in = Afghanistan,=20 India, Kenya, Pakistan and Tanzania. It also provides technical = assistance to=20 governments in health service delivery in Kenya, Syria and Tajikistan. = The=20 community health programmes of the AKHS are designed to reach vulnerable = groups=20 in society, especially childbearing women and young children, through = low-cost,=20 proven medical technologies. Experience has confirmed the efficacy of = these=20 services in improving health status and their cost-effectiveness.1

The AKU is an international university with 11 = teaching sites in=20 8 countries: Afghanistan, Kenya, Pakistan, Tanzania, Uganda, Syria, = Egypt and=20 the UK. The AKU is also associated with university hospitals in Pakistan = and=20 Kenya. The largest of these is the Aga Khan University Hospital, Karachi = (AKUH,=20 K), which has 542 beds and provides services to 38 000 inpatients and = 500 000=20 outpatients annually. The Aga Khan University Hospital, Nairobi (AKUH, = N) also=20 provides tertiary- and secondary-level health care services in East = Africa.

The extent and scope of the AKDN=92s health activities = require=20 considerable networking between the different agencies. For decades, = this=20 networking was maintained by traditional means of=20 communication and extensive travel by health professionals between = various=20 institutions. In the last five years, some institutions within the AKDN = have=20 begun to adopt information and communication technology (ICT) to enhance = their=20 educational, research, information exchange and health provision = activities. All=20 these activities can be grouped under the umbrella of =91e-health=92. = Although,=20 e-health in the AKDN is still in its infancy, activities directed = towards=20 learning, care provision and information exchange have already = begun.

Benefits of e-health

Institutions within the AKDN have shown interest in = adopting=20 e-health to enhance their education, research, information exchange and = health=20 provision activities. The following benefits are anticipated:

= Improved=20 clinical care. An e-health network will encourage rapid adoption of = e-health applications that will facilitate improved clinical care. For = example,=20 common access to clinical practice guidelines will aid standardization = of care,=20 and use of specific e-health applications such as teleconsulting will = raise the=20 confidence and skills of clinicians in rural and remote locations.

= Greater=20 knowledge sharing. An e-health network, with an emphasis on = knowledge=20 rather than simply information, will ensure greater knowledge = sharing.

= Greater scope=20 for research. Interaction through an e-health network will enhance=20 partnerships and sharing of resources, which will in turn contribute to = a=20 greater scope for research.

= Greater capacity=20 building. Capacity building, in particular, will be strengthened = through an=20 e-health network. Institutions with a common focus (within or outside = the AKDN)=20 could join and contribute their respective skills and experiences.

= Administrative=20 resilience. A successful e-health network will strengthen = administrative=20 resilience.

Although, e-health in the AKDN is still at its = beginning,=20 activities directed towards learning, care provision and information = exchange=20 have already begun. These activities are described briefly below.

Learning

The AKU and the AKHS have worked in collaboration to = develop=20 asynchronous learning for medical and nursing students, and to develop=20 continuing medical education (CME) for health care providers. Efforts = are also=20 being made to introduce the use of live e-learning software at the AKU. = Two=20 distinct instructional settings can be identified where ICT is used for=20 learning:

In=20 technology-enhanced classroom teaching, teachers use PowerPoint slides = to=20 illustrate concepts in their face-to-face lectures and later distribute = them to=20 the class by email. Students submit word-processed assignments for=20 assessment.

In = distance=20 education, nurses and other health care providers, particularly in East = Africa,=20 complete formal educational programmes at remote locations. In such = programmes,=20 email messages are used, together with online discussions via = video-conferencing=20 or through web-conferencing.

There is also blended or distributed learning as a=20 combination of these two approaches, with an increasing emphasis on the = use of=20 online learning technologies. E-learning in blended courses can take = many=20 different forms. Examples include:

repository = of=20 learning objects

web-based = virtual=20 learning environment

a database = of=20 Internet links

= synchronous=20 e-learning through Elluminate

remote = access for=20 health professionals.

Repository of learning = objects

In 2003, a searchable Library of Images was = developed at the=20 AKU. The aim was to create a repository of learning objects, which could = be=20 searched, reused and shared over the network to avoid duplication of = effort in=20 developing learning resources. Initially, the pictures and other images = were=20 digitized and catalogued with appropriate metadata information. Later,=20 registered users, including students, faculty members, clinicians, = residents and=20 allied health staff, were also able to contribute images with associated = metadata information. A committee was set up to review each contribution = in=20 order to ensure its relevance and accuracy and to avoid redundancy and=20 duplication. Moreover, ethical issues such as concealing the identity of = patients were also considered. Currently, 1500 digitized items (clinical = photographs, radiological images, operative findings, microscopy slides, = ECG and=20 EEG charts, animations, and video-clips) are available2 for = AKU faculty=20 members, staff, students and other health care providers through the=20 Internet.3 The = images from=20 the Library of Images are used in class lectures, presentations and = assignments,=20 and are also linked with course materials available via AKUMed. The = material is=20 shared with other institutions within the network with access to the AKU = intranet.

Web-based virtual learning=20 environment

The need for a system that would allow access to = course=20 information, lecture notes and a discussion forum for students of the MB = BS=20 programme was felt by the faculty at the AKU Medical College, and led to = the=20 development of an asynchronous virtual learning environment (VLE) called = AKUMed.=20 VLE refers to the components in which learners and tutors participate in = online=20 interactions of various kinds, including online learning.4 With = growing=20 numbers of faculty members using AKUMed, its popularity has increased, = and=20 similar systems are being designed for the School of Nursing and the = Department=20 of Community Health Sciences, in order to offer courses with strong = online=20 components.

Database of Internet links

A portal with links to websites on various = health-related=20 topics has been developed. The portal is accessible through the AKU = intranet and=20 is regularly updated. It is used by the students and faculty members of = the=20 AKU.

Synchronous e-learning

Elluminate Live has been introduced as a live = e-learning tool=20 in all campuses of the AKU. It was chosen because it can be used from = areas with=20 low-bandwidth Internet connections. The software allows recording, and = permits=20 sharing of audio, video, text and image data. Elluminate also allows the = use of=20 white board and document sharing, to facilitate online discussions. = Finally, it=20 supports transfer of medical data and live teleconsultations, which may = be an=20 important feature for the AKU. Several pilot projects have been = initiated in=20 different campuses of the AKU in Asia, Africa and Europe. A summary of = the pilot=20 projects at each campus is given in Table = 27.1.

Remote access for health=20 professionals

Remote access for health staff was conceived as a = structured=20 educational programme for health care providers, which focused on = problem-based=20 learning via a web-based distance learning system. The purpose of this = programme=20 was to facilitate evidence-based practice of medicine and nursing at the = Aga-Khan Hospital in Dar-es-Salaam and its five affiliated primary care = centres=20 in Tanzania. A phased approach was planned, followed by the introduction = at=20 other AKHS institutions. The web interface allows multiple threaded = discussions=20 based on specific interest areas, including sub-specialties such as = paediatrics,=20 cardiology and nursing. This makes it possible for health professionals = in North=20 America to share journal articles, PowerPoint presentations, quality = assurance=20 tools and weblinks to various resources with staff in Tanzania. The = long-term=20 goal is to make this method of learning accessible to health care = professionals=20 associated with the AKHS in East Africa or with other private and public = sector=20 hospitals, to improve health care delivery in those countries.

Care provision

Two examples of telehealth in AKDN agencies are:

(1) email-based teleconsultations in Tanzania

(2) a teleradiology link in Afghanistan.

Email-based = teleconsultations

In 2004, a pilot telemedicine programme began that = allowed=20 communication between doctors working at the Aga Khan Hospital in = Dar-es-Salaam=20 and clinicians in North America. The goal was to create partnerships = that would=20 improve the delivery and quality of health care in the region. The = pre-defined=20 turnaround time for queries was 24=9672 hours.

Table 27.1 Summary of the = pilot=20 projects at each AKU campus
	AKU-IED, Karachi	AKU-CHS, Karachi	AKU-ISMC, London	AKU-SON, Karachi and AKU-EA,=20 Nairobi
Objective	Understand changing needs and plan = accordingly	Look into all possible options where Elluminate = will be=20 useful	Gain confidence with Elluminate	Pilot Elluminate use for continuing education = courses=20 offered from AKU-SON Karachi to East Africa, Afghanistan and=20 Egypt
Areas	Distance education courses Meetings with = Professional=20 Development Centres Other uses by faculty members in = teaching-related=20 activities	Work in progress (WIP) Online CME course = with East=20 Africa Web seminar on health problems in = Pakistan Postgraduate=20 education programmes	Meetings with different departments, e.g. = Finance, IT and=20 Provost=92s Office, once a month or more Lectures, cultural = hour and=20 lunch-hour seminars (Wednesday afternoons once a month) Faculty = Assembly (first Saturday), although time and day difference could = be a=20 problem Lectures organized by Research Department, Special = Lecture=20 Series and AKU-IED AKU 25th Anniversary Planning Committee=20 Meeting	Continuing education programme for practising = nurses=20 Online courses for nursing students Meetings and resource = sharing=20 between nursing faculty staff from different = locations
Expected outcomes	Identify problems relevant to the = implementation of=20 Elluminate Live in order to plan for wider implementation of = Elluminate=20 Live at AKU-IED	Skill enhancement of the faculty, staff and=20 students User satisfaction (through the help of feedback = forms)	Attendance at meeting, seminar or workshop that = would=20 otherwise have been missed Work closely with other AKDN = institutions to=20 share intellectual or material resources and strengthen the = relationship=20 with other AKDN entities Follow-up with students and distance=20 education	Number of online teaching sessions using live = teaching=20 tools Evaluation of online tools by moderators and participants = for=20 online learning Identifying problems with online learning in = different=20 locations

In practice, the programme was under-utilized by the=20 professionals in Dar-es-Salaam. Over a 3-year period, approximately 80=20 teleconsultations occurred, whereas the estimated number of = consultations at the=20 time of the launch was 2500. The main reasons for this underutilization = were=20 insufficient bandwidth for an effective Internet-based education = programme,=20 discomfort among Dar clinicians in Dar-es-Salaam due to inadequate = exposure to=20 the use of computers, and practice behaviours and the environment = preventing the=20 use of technology to its fullest capacity. The evaluation team found = that the=20 leadership at the Aga Khan Hospital in Dar-es-Salaam was very positive = with=20 respect to the use of technology for the training of health care = providers. This=20 led to the new programme of remote access for health care professionals = that has=20 been described above.

Teleradiology link

The AKUH in Karachi has a partnership with the = French Medical=20 Institute for Children (FMIC), which is an 85-bed paediatric hospital in = Kabul.=20 The primary aim of the telemedicine project was to provide access to=20 high-quality diagnostic services. As a first step, the project used = broadband=20 technology and wireless video consultation with digital image transfer = to=20 provide teleradiology services. CT scans and X-ray images can be = diagnosed and=20 interpreted and treatment can be suggested from Karachi. A combination = of=20 fibre-optic and radio links is used to transfer images from the FMIC to = the AKUH=20 in Karachi (Figure=20 27.1). Four or five images are transferred to the AKUH every day, = and=20 reports are sent back to the FMIC in less than 24 hours.

3DImage=20

Figure 27.1 Teleradiology link = between the=20 French Medical Institute for Children, Kabul and the Aga Khan University = Hospital, Karachi

Information exchange

Since its inception, the AKU has made patient = information=20 available to all care providers, while being careful to maintain the=20 confidentiality of patient records. Several programmes have been = introduced to=20 capture medical information electronically and make this available in = all=20 patient care areas. Laboratory records, radiology reports, nursing and = physician=20 records and order entries, and several types of administrative = information have=20 been computerized for rapid access by all care providers. There are = still=20 several missing elements, such as physician notes, outpatient records, = decision=20 support systems and sharing of patient records between campuses. The = university=20 has therefore developed a detailed plan to achieve this. The ultimate = goal of=20 electronic health records is to integrate computerized medical records = and=20 ordering systems with routine care, and avoid any duplication of work in = the=20 form of generating paper records. This will lead eventually to a = paperless=20 organization where all information will be available in electronic form, = guided=20 by policies to ensure privacy and confidentiality of patient data, yet = ensuring=20 rapid access to information for the care providers.

Opportunities and challenges

The above examples of e-health work show that the = AKDN has=20 increased the availability of learning resources, health care and = information=20 for its own institutions, with a view to making health services more = affordable=20 and accessible in the developing world generally. E-health also offers=20 opportunities for the network institutions to build on each other=92s = strengths=20 and expertise by sharing knowledge, expertise, best practices and = information.=20 For example, the doctors and nurses in East Africa possess specialist = knowledge=20 and skills in certain tropical diseases, which could be shared with = doctors and=20 nurses in other institutions of the network. Such collaboration is = likely to=20 encourage the development of a strong knowledge base founded on = indigenous,=20 culturally sensitive, e-health applications.

No innovation is free of challenges, especially if it = involves=20 bringing a change in the everyday practices, attitudes and beliefs of = people.=20 Stemming from the use of new technologies for e-health, there are = challenges=20 associated with the development, delivery and sustainability of such = programmes.=20 For instance, the above examples represent the efforts of small groups = of=20 doctors and nurses from the AKU and the AKHS who are enthusiastic about = the use=20 of ICT for learning and are also familiar with modern technology. = However, there=20 is a wide spectrum of technological access and expertise among other = potential=20 users. Likewise, expertise in teaching and learning, providing patient = care and=20 sharing information through technology also vary considerably between = the=20 network institutions. Moreover, since there has been no previous = experience of=20 such programmes among the participating institutions, there are no = formal=20 polices and procedures to guide the implementation. Furthermore, in most = cases,=20 no systematic evaluation has yet been conducted to assess the outcomes. = While=20 funding for the current projects has been provided through the AKDN, the = availability of funds for future research, = development and=20 evaluation of e-health applications could represent a problem. Clearly, = there is=20 a need for network-wide resource sharing, accountability and = coordination for=20 the development and implementation of e-health programmes, policies and=20 strategies for AKDN institutions.

Next steps

To enhance the use of e-health in the AKDN, it is = important to=20 develop a network-wide strategy for e-health. Such a strategy would = allow=20 collective learning and sharing of knowledge and experience among people = providing health care within the AKDN. To develop a network approach to=20 e-health, the following principles have been proposed:

E-health = initiatives=20 should increase access to health care information and services for = communities,=20 and enhance the quality of care among network institutions and partners = through=20 knowledge transfer and educational programmes.

E-health = initiatives=20 should address the needs of health care institutions, identified and = prioritized=20 using sound techniques. The prioritized needs should also guide external = institutions and health care professionals interested in working in the = field of=20 e-health to focus on interventions addressing the most important health = needs of=20 the community.

All = e-health=20 initiatives for the network and partners should ensure that knowledge = and=20 experience gained from these projects are measured, and that the results = are=20 disseminated to the broader community.

All = e-health=20 initiatives for the network and partners should ensure that knowledge = especially=20 public institutions, without compromising the quality of care or the = safety and=20 confidentiality of patients receiving services from AKDN = institutions.

All = e-health=20 initiatives should be standardized and planned to enhance networking = among AKDN=20 institutions and partners.

E-health = initiatives=20 for the network and partners should identify suitable platforms and = systems that=20 have universal applications. Proprietary software should be avoided = whenever=20 possible.

E-health = initiatives=20 should promote collaboration with other partner institutions, especially = public=20 institutions, without compromising the quality of care or the safety and = confidentiality of patients receiving services from AKDN = institutions.

All = e-health=20 projects should focus on the sustainability of the initiatives by = deonstrating a=20 return on investment and integration with the existing programmes.

To confirm the above principles, a process of needs = and=20 readiness assessment has been started in all the countries where the = AKDN=20 operates. This will:

identify = the current=20 and future needs of health care institutions that can be addressed by = using=20 e-health

define the = available=20 alternatives and provide justification for the use of e-health

determine = the=20 infrastructure, awareness, willingness, capacity, sociocultural = environment and=20 institutional polices required for e-health

define the = process=20 of e-health planning leading to enhanced readiness of health care = institutions=20 in the relevant countries

develop a = model for=20 e-health needs and readiness assessment for AKDN institutions and = partners in=20 other countries (and for other similar institutions).

The needs and readiness assessment exercise is = currently being=20 carried out in Tanzania and Afghanistan. These two countries were = selected based=20 on their needs and existing collaborations between network institutions. = The=20 readiness assessment is focusing initially on teleconsultations and=20 tele-education. However, the needs assessment will capture institutional = needs=20 in information and knowledge management as well.

The following activities are being conducted during = the needs=20 and readiness assessment exercise in the two countries:

1. Developing a stakeholder team in each = country.=20 Separate teams of key stakeholders are being formed in each country to = plan the=20 needs and readiness assessment in these countries. The stakeholder team = decides=20 on the process of needs and readiness assessment by identifying the = relevant=20 instruments, supervising data collection and compiling results for = guiding=20 e-health implementation in each country.

2. Training the stakeholder team in each = country. Once=20 the teams have been formed, the members will be exposed to e-health=20 terminologies and concepts. These are required to carry out the planning = of=20 needs and readiness assessment. The training programmes in each country = will=20 last for two days each.

3. Conducting the needs assessment in AKDN=20 institutions. Identifying the needs of AKDN institutions that could = be=20 addressed though e-health will be conducted using (i) discussions with = the=20 stakeholder team members to document their views and suggestions and = (ii) focus=20 group discussions with different groups of health care providers and = managers of=20 health care institutions. The participants for focus group discussions = will be=20 identified by the stakeholder team, and the sessions will be conducted = by team=20 members from AKU.

4. Identifying appropriate e-health solutions for = the=20 suggested needs. On the basis of the identified needs, appropriate = e-health=20 solutions will be selected by the stake-holder team. The process will be = carried=20 out in consultation with the team from the AKU and a consultant. Efforts = will be=20 made to identify simple, low-cost, low-bandwidth and culturally = sensitive=20 e-health solutions for AKDN institutions.

5. Prioritizing e-health solutions. In the = next step,=20 the stakeholder team will prioritize the e-health solutions. This step = will help=20 in assessing and building the readiness of health care institutions for = the=20 e-health applications that have been identified, and avoid wasting time = on=20 applications that may not be required in the short term.

6. Conducting readiness assessment of network=20 institutions. Finally, the stakeholder team will choose among the = existing=20 tools for e-health readiness assessment that have already been validated = and=20 tested in developing countries. The teams will also finalize the plan = for=20 analysing the information collected.

Conclusion

The AKDN represents an interesting example of = agencies and=20 institutions working in several different countries towards a common = development=20 goal. Health is a component of the overall = development of the=20 communities, which makes it necessary for the health care institutions = to build=20 strong relationships with institutions involved in other facets of = development.=20 Better coordination within, among and between these agencies, and with = the=20 communities, is necessary for provision of health care in these = countries.=20 E-health offers great potential to enable a network of this size to = achieve its=20 goals of better access and high quality of care, while operating within = the=20 available resource constraints.

The AKDN has developed a plan to move from pilot = trials to=20 routine operations, by developing a network approach guided by an = overall=20 strategy. The strategy is based on the principles of needs and readiness = assessment, community and community-centeredness, knowledge transfer,=20 networking, open platforms, standardization and evaluation. A = broad-based needs=20 and readiness assessment has already been started in two countries.

References

1.=20 Fort V, Obonyo B, Madhavan S. Strengthening the Institutional = Capacity of=20 Aga Khan Health Service, East Africa=92s Community Health Department to = Support=20 Organizations Working in Community Health Service. Available at:=20 pdf.dec.org/pdf_docs/Pdacf019.pdf.

2.=20 Aga Khan University. Available at: www.aku.edu.

3.=20 Library of Images, Aga Khan University. Available at: = loi.aku.edu/loi.

4.=20 Joint Information Systems Committee (JISC). Circular 7/00: MLE in = Further=20 Education: Progress Report. Available at:=20 www.jisc.ac.uk/news/stories/2000/07/circular700.aspx.

SECTION 5
THE FUTURE

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28 The future use of telehealth in the developing = world

Richard Wootton

Introduction

Much has been written about the potential for = telemedicine in=20 the developing world. However, after reviewing the literature, it is = clear that=20 the evidence base supporting its practical utility is rather slender, = and that=20 most of the material published to date has been in the form of comments, = letters, discussions, product reports, news items or case reports.1 None = the less,=20 in preparing this book, the implicit thesis was that telemedicine can = have a=20 positive effect on health care delivery in developing countries, and = that=20 ultimately it can reduce the global burden of disease. The latter could = perhaps=20 be regarded as the Holy Grail for workers in the field. How does the = experience=20 reported in the book reflect this ideal?

The examples in this book show unequivocally that = useful=20 services can be delivered in the developing world using telehealth. None = the=20 less, viewed from the perspective of telehealth activity in the world as = a=20 whole, it is clear that there has been relatively little use of = telehealth in=20 developing countries so far. One obvious reason is the information and=20 communication technology (ICT) environment, where there are evident = challenges=20 to the more widespread use of telehealth and to the use of e-health = generally.=20 These are, in fact, general problems concerning the use of ICT anywhere, = including:

the cost = of IT=20 hardware and software

the = limited=20 availability of fast broadband and mobile networks

the slow = development=20 of software in languages other than English.

These and other factors add up to the so-called = =91digital=20 divide=92 between the developing world and the industrialized world (see = Chapter 2).

ICT barriers

A useful framework for considering access to ICT is = provided=20 by the Real Access criteria.2 These = criteria=20 have been used to analyse the factors concerning access to ICT and its = use,=20 including the =91soft=92 aspects that are often overlooked. The criteria = are=20 designed to help understand the reasons why ICT development projects = fail to=20 achieve their goals, and to identify the reasons why such projects = succeed.=20 There are 12 criteria, which are inter-related:

(1) physical access to technology

(2) appropriateness of technology

(3) affordability of technology and technology = use

(4) human capacity and training

(5) locally relevant content, applications and = services

(6) integration into daily routines

(7) socio-cultural factors

(8) trust in technology

(9) local economic environment

(10) macroeconomic environment

(11) legal and regulatory framework

(12) political will and public support.

An understanding of these factors can be used to = improve the=20 way that ICT-based development policies and initiatives are planned, = monitored=20 and evaluated.

Other barriers

Telehealth, of course, is a complex matter. A = satisfactory ICT=20 environment is a necessary, but not sufficient, condition for the = successful=20 practice of telehealth. There are other barriers to the use of = telehealth, and=20 they apply in the industrialized world as well. The barriers = include:

= organizational=20 factors, e.g. changing the way in which hospitals and doctors work

human = factors, e.g.=20 lack of staff with the appropriate skills

= medicolegal matters,=20 including ethical concerns.

As the examples in this book show, it is possible = to overcome=20 all these obstacles and bring about successful, and in some cases = sustainable,=20 telehealth operations.

Telemedicine examples

In summarizing telehealth work, it is usual to = categorize the=20 applications under three headings: clinical, educational and = administrative.=20 These categories are not mutually exclusive.

Administrative

This book contains only a few examples of telehealth = work in=20 the administrative category. This is surprising, since facilitating=20 administrative work =96 conducting meetings at a distance, providing = web-based=20 data collection forms and supplying online reports, for example =96 are = all=20 perfectly proper forms of telehealth, and ones that are likely to = provide major=20 benefits in terms of avoided staff travel and improved information = flows.=20 Perhaps this is the unglamorous, and therefore under-reported, face of=20 e-health.

Education

Although relatively little mention is made of = administrative=20 telehealth work, this book contains more examples of education. One of = the most=20 successful educational projects, and one that appears to be sustainable, = is led=20 from Geneva by the organization R=E9seau Afrique Francophone de = T=E9l=E9m=E9decine=20 (RAFT), which provides services in French-speaking African countries. = Education=20 is delivered in real time using interactive web-casting.3 A = successful=20 example of the opposite modality, asynchronous education, is the Pacific = open-learning network of the World Health Organization (WHO).4 The=20 open-learning network provides online (web-based) courses, course = materials and=20 other resources to health professionals in the Pacific region. In = addition, 15=20 learning centres have been established in 11 Pacific Island countries to = increase access to online materials and resources.

Although they are not explicitly identified in this = book, there=20 are two other significant educational resources that deserve mention. = First,=20 there is the HINARI project (Health Internetwork Access to Research = Initiative),=20 which was established in 2002 by the WHO, when it secured agreement from = many of=20 the world=92s scientific publishers to make their journals available in = developing=20 countries at no cost to the reader.5

Over 3750 journal titles are now available to health = institutions in 113 countries. Second, the US National Library of = Medicine made=20 the Medline database freely available to the world via the Internet in = the=20 mid-1990s. Using the PubMed search engine, more than 17 million = citations and=20 abstracts of biomedical research articles can be searched via the web. = The ready=20 availability of the Medline database via PubMed, and free access to = several=20 thousand journals via HINARI, are splendid examples of how the = industrialized=20 world can assist less fortunate countries. The indirect health gains of = these=20 initiatives remain to be quantified, but can confidently be assumed to = be=20 substantial.

The educational projects described in this book are = undoubtedly=20 successful. None the less, they should be viewed in a global health care = context. Many countries face critical shortages of health service = providers,=20 such as doctors, nurses and midwives (Figure = 28.1).6 This = is=20 important because, unsurprisingly, the number of health workers and = their skills=20 are positively correlated with population health outcomes. The WHO has = set out a=20 framework for improving the global health workforce, by focusing on = strategies=20 related to the stage when people enter the workforce, the period of = their lives=20 when they are part of the workforce, and the point at which they make = their exit=20 from it. The strategy focuses on:

= entry:=20 preparing the workforce through strategic investments in education and = effective=20 and ethical recruitment practices

= workforce:=20 enhancing worker performance through better management of workers in = both the=20 public and private sectors

= exit:=20 managing migration and attrition to reduce wasteful loss of human = resources.

Telemedicine has an obvious role to play in = improving access=20 to education, and perhaps in allowing better supervision of a dispersed=20 workforce. One might expect

3DImage=20

Figure 28.1 Countries with a = critical shortage=20 of health service providers. There is an estimated shortage of almost = 4.3=20 million doctors, midwives, nurses and support workers worldwide. = (Reproduced=20 from World Health Report 2006;6 data = taken from=20 Global Atlas of the Health Workforce15)

that greater access to education could be achieved = at lower=20 cost by pooling of resources and by expanding the use of telemedicine = and=20 distance education. Clearly, education represents a fruitful potential = area for=20 telehealth in the developing world.

Clinical

In clinical telehealth, there has been little use of = videoconferencing in developing countries, for the obvious reasons of = the cost=20 of the requisite technology and the restricted availability of suitable=20 telecommunications. The Medical Missions for Children has a = videoconferencing=20 network to a number of hospitals in developing countries, although a = good deal=20 of the telehealth activity that takes place is educational in nature, = for=20 example mentoring of local doctors, rather than direct patient care (see = Chapter 10).

In practice, a substantial proportion of clinical = telehealth=20 work in developing countries is done by email or by web messaging (Table 28.1). = Successful=20 examples of the use of email include the Cambodia work managed from = Boston (see=20 Chapter 13) = and the=20 global e-referral network operated by the Swinfen Charitable Trust (see = Chapter 19). The = latter has=20 recently moved from a system based on plain email to one based on a = secure web=20 server. Long-running examples of the use of the web for delivering = clinical=20 consultations include the US Army=92s system in the Pacific7 (see = Chapter 15) and = the highly=20 regarded iPath system for case discussions among groups of = pathologists.8

Table 28.1 General-purpose=20 second-opinion telemedicine networks providing services in the = developing=20 world
Operator	Referring sites	Expert sites	Date of first = operation	Mechanism	Description
Partners Health care, Boston, Massachusetts, = USA	Rovieng Health Centre, Cambodia Rattanikiri = Hospital,=20 Cambodia	Sihanouk Hospital, Phnom Penh Harvard Medical = School,=20 Boston	2001	Email	Email consultations are used to support health = workers at=20 a rural clinic in northern Cambodia. The email advice comes from=20 specialists at a tertiary hospital in Phnom Penh and from the=20 Massachusetts General Hospital in Boston. In 2003, a second site = at a=20 small hospital in northern Cambodia began referring = cases
Tripler Army Medical Center, Honolulu, Hawaii, = USA	US-associated Pacific islands	Tripler Army Medical Center, Hawaii	1997	Web	A web-based teleconsulting system is used by = the main US=20 Army hospital in Hawaii to support referrers in hospitals (mainly = military=20 hospitals) around the Pacific
iPath Association, University of Basel, Basel,=20 Switzerland	Several (mainly telepathology), e.g. Cambodia, = Solomon=20 Islands, Bangladesh Also more recent teleconsultation work, = e.g.=20 Ukrainian Swiss Perinatal Health Project	Mainly Swiss, European	2001	Web	The iPath software was originally developed for = telepathology case conferences (for which it is an excellent tool, = and=20 several tens of thousands of case conferences have now been = conducted =96=20 technically by a number of different organizations who all use the = same=20 software). More recently, the software has begun to be used for = general=20 teleconsulting (i.e. non-pathology work)
Swinfen Charitable Trust, Canterbury, = UK	Global (34 countries)	Global (13 countries)	1999	Email and Web	A simple email teleconsultation system was = established at=20 a single hospital in Bangladesh by a UK-based charity. Specialist = opinions=20 were obtained from a small panel of volunteer consultants. The = operation=20 has now grown to service over 100 hospitals around the world, with = a panel=20 of nearly 400 consultants. An automatic message handling system is = employed, supplemented by a more recent web-messaging = system
Geneva University Hospitals, Geneva, = Switzerland	Africa (nine countries)	Geneva	2001	Web via satellitem	The RAFT project provides services from Geneva = to nine=20 French-speaking African countries. The core activity is distance = education=20 via webcasting of interactive courses. Some teleconsultation work = also=20 takes place, mainly involving specialists in=20 Geneva

Intermediate between the two poles of real-time=20 videoconferencing and store-and-forward messaging lies the VHF radio = network=20 installed in the Peruvian jungle to facilitate communications with = remote health=20 centres.9

Cost-effectiveness

Although the above examples should all be considered = to be=20 successful demonstrations of telehealth in the developing world, it has = to be=20 admitted that strict evidence for cost-effectiveness remains elusive. = Analysis=20 of cost-effectiveness is a health economics tool that enables = comparisons to be=20 made between alternative interventions in terms of their costs and = consequences.=20 For example, is it preferable to spend resources on a PACS system at the = national referral hospital, or to implement a programme of directly = observed=20 treatment of tuberculosis? To answer this question requires not only = that the=20 costs be known, but also that the consequences =96 the health gain =96 = can be=20 calculated. The latter may be done in terms of life-years gained, for = example;=20 if so, the situation is relatively straightforward. If the health gain = includes=20 other advantages =96 perhaps improved quality of life or reduced = incidence of=20 medical complications =96 then assigning a monetary value to the = benefits is=20 likely to be more difficult.

Telehealth research workers know only too well that it = is hard=20 enough to obtain evidence for cost-effectiveness in telehealth work in=20 industrialized countries; it is even harder to do so in developing = countries.=20 Yet the matter of cost-effectiveness remains a serious question hanging = over the=20 potential future use of telehealth. More than a decade ago, the question = was=20 posed whether it is ethical to devote significant resources to = telehealth in the=20 developing world if the costs and benefits are largely undocumented when = there=20 are health measures, such as vaccination, sanitation and clean drinking = water,=20 with characteristics that are well understood.10

The WHO has provided examples of interventions that, = if=20 implemented properly, can substantially reduce the burden of disease, = especially=20 among the poor, and do so at a reasonable cost (Table = 28.2).11 = What is=20 striking about this list is how little tele-health has yet been applied = in these=20 areas. Telehealth may have a place in directly observed treatment of=20 tuberculosis (DOTS),12 but = little is=20 yet known about its feasibility on a wide scale, never mind its=20 cost-effectiveness. It is true that telehealth has been used = successfully to=20 provide HIV/AIDS services (see Chapter 9), but = again it=20 remains to be seen how easy it will be to scale up the pilot = programmes.

In this connection, it is worth noting the Peruvian = telemedicine=20 network that is based on email transmission by VHF radio link. A recent = study=20 has documented fewer urgent patient transfers from health posts and = health=20 centres,9 and = there is=20 emerging evidence of cost-effectiveness.13

A strategy for telemedicine

Given the above, and the need to obtain quantitative = evidence=20 of cost-effectiveness, what is the right strategy for telehealth in the=20 developing world? The key aspects appear to be:

Table 28.2 Interventions with = a large=20 potential impact on health outcomes11
Examples of = interventions	Main contents of = interventions
Treatment of tuberculosis	Directly observed treatment schedule (DOTS):=20 administration of standardized short-course chemotherapy to all = confirmed=20 sputum smear-positive cases of tuberculosis under supervision in = the=20 initial (2=963 months) phase
Maternal health and safe motherhood = interventions	Family planning, prenatal and delivery care, = clean and=20 safe delivery by trained birth attendant, postpartum care, and = essential=20 obstetric care for high-risk pregnancies and = complications
Family planning	Information and education; availability and = correct use=20 of contraceptives
School health interventions	Health education and nutrition interventions, = including=20 anti-helmintic treatment, micronutrient supplementation and school = meals
Integrated management of childhood = illness	Case management of acute respiratory = infections,=20 diarrhoea, malaria, measles and malnutrition; immunization,=20 feeding/breastfeeding counselling, micronutrient and iron = supplementation,=20 anti-helmintic treatment
HIV/AIDS prevention	Targeted information for sex workers, mass = education=20 awareness, counselling, screening, mass treatment for sexually = transmitted=20 infections, safe blood supply
Treatment of sexually transmitted = infections	Case management using syndrome diagnosis and = standard=20 treatment algorithm
Immunization (EPI Plus)	BCG at birth; OPV at birth, 6, 10, 14 weeks; = DPT at 6,=20 10, 14 weeks; HepB at birth, 6 and 9 months (optional); measles at = 9=20 months; TT for women of childbearing age
Malaria	Case management (early assessment and prompt = treatment)=20 and selected preventive measures (e.g. impregnated bed = nets)
Tobacco control	Tobacco tax, information, nicotine replacement, = legal=20 action
Non-communicable diseases and injuries	Selected early screening and secondary=20 prevention

1. Concentrate on areas identified by the WHO as = being likely=20 to affect the disease burden.

2. Work with local staff.

3. Try and establish within-country telehealth = networks.

4. Evaluate the costs and consequences, to provide = evidence of=20 cost-effectiveness.

In 2006, Lord Crisp examined how the UK experience = and=20 expertise in health could best be used to help improve health in = developing=20 countries.14 He = made a=20 number of detailed recommendations, but pointed out that it was = necessary for=20 developing countries to take the lead and to =91own=92 the solutions, = which could be=20 supported by international, national and local partnerships based on = mutual=20 respect.14 = This surely=20 epitomizes any potential use of telehealth.

Conclusion

What then is the future for telehealth in the = developing=20 world? Clearly, telemedicine does not represent =91the answer=92 to all = public=20 health challenges in developing countries. However, it can provide = value,=20 particularly when it is employed to strengthen and support a local team, = rather=20 than simply being used to import expertise from outside to supplement or = supplant local efforts. One important role for telemedicine is in the = training=20 of local health professionals. The place of telemedicine in direct = patient care=20 delivery remains to be established, although there are promising = indications of=20 its success in certain circumstances. Consultations via email and the = web should=20 form an essential part of health partnerships.

The long-term goal of telehealth work must remain the=20 demonstration of its efficacy in comparison with well-understood = measures such=20 as the provision of safe drinking water and immunization (Figures 28.2 = and 28.3). One = unanswered=20 question is the future design of telehealth networks. Whether resources = should=20 be concentrated into a single network or into several, it is clear that = the=20 long-term aim should be to establish within-country telemedicine = networks=20 (supported from out of country where appropriate) that:

= demonstrably alter=20 health outcomes

can be = shown to be=20 cost-effective and sustainable

will act = as a model=20 for other countries to copy.

3DImage=20

Figure 28.2 People forced to use one = water=20 source for all daily chores =96 like this girl in Pakistan =96 face = increasing risks=20 of gastrointestinal infections and other waterborne diseases. Together, = these=20 diseases kill around 2.2 million people globally each year, mostly = children in=20 developing countries. (Photograph courtesy of WHO/Christopher = Black)

3DImage=20

Figure 28.3 Child immunization at = the Malipur=20 Maternity Home in Delhi, India. Immunization is considered to be one of = the most=20 cost-effective health interventions. There is a well-defined target = group;=20 contact with the health system is only needed at the time of delivery; = and=20 vaccination does not require any major changes of lifestyle. (Photograph = courtest of WHO/P Virot)

This will enable the success of the telemedicine=20 second-opinion work that has been performed to date to be exploited on a = global=20 scale.1 = Telemedicine is=20 a small but significant component of ICT in health care delivery. In the = future,=20 it is to be hoped that telemedicine will develop into a proven tool for=20 facilitating learning and for capacity building, in addition to its role = in=20 direct clinical care.

References

1.=20 Wootton R. Telemedicine support for the developing world. J Telemed=20 Telecare 2008; 14: 109=9614.

2.=20 Bridges.org. Real Access/Real Impact Criteria. Available at:=20 www.bridges.org/Real_Access.

3.=20 Geissbuhler A, Bagayoko CO, Ly O. The RAFT network: 5 years of distance=20 continuing medical education and tele-consultations over the Internet in = French-speaking Africa. Int J Med Inform 2007; = 76:=20 351=966.

4.=20 POLHN. Pacific Open Learning Health Net. Available at:=20 www.polhn.com.

5.=20 World Health Organization. HINARI Access to Research = Initiative.=20 Available at: www.who.int/hinari/en.

6.=20 World Health Organization. The World Health Report 2006 =96 Working = Together=20 for Health. Available at: www.who.int/whr/2006/en.

7.=20 Callahan CW, Malone F, Estroff D, Person DA. Effectiveness of an = Internet-based=20 store-and-forward telemedicine system for pediatric subspecialty = consultation.=20 Arch Pediatr Adolesc Med 2005; 159: = 389=9693.

8.=20 Brauchli K, Oberli H, Hurwitz N et al. Diagnostic telepathology: = long-term=20 experience of a single institution. Virchows Arch 2004;=20 444: 403=969.

9.=20 Mart=EDnez A, Villarroel V, Seoane J, del Pozo F. A study of a rural = telemedicine=20 system in the Amazon region of Peru. J Telemed Telecare 2004;=20 10: 219=9625.

10. Wootton = R. The=20 possible use of telemedicine in developing countries. J Telemed=20 Telecare 1997; 3: 23=966.

11. World = Health=20 Organization. The World Health Report 2000 =96 Health Systems: = Improving=20 Performance. Available at: www.who.int/whr/2000/en.

12. DeMaio = J, Schwartz=20 L, Cooley P, Tice A. The application of telemedicine technology to a = directly=20 observed therapy program for tuberculosis: a pilot project. Clin = Infect=20 Dis 2001; 33: 2082=964.

13. = Mart=EDnez A,=20 Villarroel V, Puig-Junoy J et al. An economic analysis of the EHAS = telemedicine=20 system in Alto Amazonas. J Telemed Telecare 2007; = 13:=20 7=9614.

14. Crisp N. = Global Health Partnerships: The UK Contribution to Health in = Developing=20 Countries (=91The Crisp Report=92). Available at:=20 www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolic= yAndGuidance/DH_065374.

15. World = Health=20 Organization. Global Atlas of the Health Workforce. Available = at:=20 www.who.int/globalatlas/default.asp.

Index

Acacia project 75=966

access to ICT services 17=9620

administrative barriers to borderless global = e-health=20 initiatives 63=965

and non-adoption of e-health 80=961

administrative telemedicine 300

Afghanistan

AKDN needs and readiness assessment exercise 295

AKDN teleradiology link 290=962

Africa

Acacia project 75=966

eastern and southern Africa IDRC projects 73, 74(table)

Millennium Development Goals (UN, 2000) 234

needs (vs industrialized world), WHO Report 232

obstacles to telemedicine 234=966

policy environment, potentially restrictive policy = development=20 63=964

sub-Saharan Africa 232=9641

telecommunication costs 235

Telemedicine Task Team, European Commission and = European Space=20 Agency 237

West Africa Doctors and Healthcare Professionals = Network 127see = also=20 South Africa; sub-Saharan Africa

Africa Teledermatology project 124=966

data flow 123(fig.)<= /EM>

African Medical and Research Foundation (AMREF) 237, 239, 240

African Union 236

New Partnership for Africa=92s Development (NEPAD) = 236

Aga Khan Development Network (AKDN) 287=9696

AKDN agencies 290=961

care provision 290=962

education and training 288=9690

email-based teleconsultations 290=962

future 294=965

information exchange 293

teleradiology link 292, 292(fig.)<= /EM>

Aga Khan Health Services (AKHS) 239, 287=9693

Aga Khan University (AKU) 287=9693, 291(table)=

continuing medical education (CME) programmes 288=969

Elluminate Live 290

Library of Images 289

remote access for health professionals 290

virtual learning environment (VLE) AKUMed 289

Alliance of Italian Hospitals Worldwide 170=9681

Alma Ata Declaration on Primary Health Care 44

American Assistance for Cambodia (AAfC) 13, 137, 145

Anaesthesia Overseas, Eritrea 238

Angola, trial store-andforward project 238

Antwerp, Institute of Tropical Medicine in Antwerp = (ITMA) 91=962

APEC Digital Opportunity Center, Taiwan 29

Argentina, online cancer registry 282

Asia

E-health projects in Sri Lanka 85(table)

Malaysia, potentially restrictive policy development = 64

Pan Asia Networking (PAN) 69=9670, 76=967

PANACeA project 76=967

Australia

Africa Teledermatology project 124=966

Centre for Online Health at the University of = Queensland 206

Swinfen Charitable Trust 128, 206

Austria, Africa Teledermatology project 124=966

Ayurveda medicine 47

Balkans, telemedicine collaboration in emergency = situations=20 263

Bangladesh, Centre for the Rehabilitation of the = Paralysed=20 (CRP), Swinfen Charitable Trust 204=966

barriers to ICT 299=96300

borderless global e-health initiatives 63=965

and non-adoption of e-health 80=961

Basel, iPath application and networks 126=968

Belarus, online cancer registry 282

Benin, histopathology store-and-forward service = with Paris 238

Bill and Melinda Gates Foundation, assets 60

Botswana=96Baylor Children=92s Clinical Centre of = Excellence 238

Brazil, primary health care 34=9642

BH Telemedicine Project 36

Family Health Programmes (FHP) teams 37

National Information Policy on Informatics in Health = (NIPIH/PNIIS) 35

National Telemedicine Programme (2006) 35

nurses and nurses=92 assistants, procedures 39

online cancer registry 281=962

PACOTAPS software 38=969

Primary Care Information System 36

PROESF study 39

use of computers for professional activities 37, 38(table)

Brazilian Lymphoma and Leukaemia Association = (ABRALE) website=20 283

Brazilian National Cancer Institute (INCA) 283

Burkina Faso, tele-epidemiology network with France = 238

Burundi, iPath programme 238

Ca:sh (Community Access to Sustainable Health) = programme,=20 India 45, = 49, 50

Cambodia and USA 135=9648

American Assistance for Cambodia (AAfC) 137, 145

demographics and case mix 140, 141(table)= , 142(fig.)<= /EM>

economic factors 145=966, 147

health indicators and resources, USA vs Cambodia 136(table)=

human factors 146=967

ICT indicators 137(table)=

local and consulting clinicians 144=965

map, sites of operation of telemedicine clinics 138(fig.)<= /EM>

proposed characteristics of programme success 143(table)=

Rattanakiri Referral Hospital 139=9640

Rovieng Health Centre 138

standardized template for history and physical = examination 145

technological factors 146, 147

telemedicine programme collaboration 137=9640

Canada

funding of Community Health Information Tracking = System,=20 Philippines 28

funding for UHIN project 47=968, 49, 52, 69

Information and Communication Technologies for = Development=20 (ICT4D) 68=9678

International Development Research Centre (IDRC) 68

cancer 273=9690

information on Internet 277=969 = see also=20 paediatric oncology

case studies, m-health (mobile e-health) 45=9650, 55=966

Cell-Life project, South Africa 46, 49, 51, 52, 97

Centre for the Rehabilitation of the Paralysed = (CRP)=20 Bangladesh 204=966

Chad, RAFT programme 238

Chechnya paediatric telemedicine 262=9672

Children=92s Field Hospital 263=9670

clinical aspects 267=968

disaster medicine 268=969

monitoring during treatment and rehabilitation 268=969

process 266

structure 263(fig.)<= /EM>

system architecture 264=965, 265(fig.)<= /EM>

teleconsultations 268(table)=

teleradiology (DEPRAD) system 269=9670

children, see also Medical Missions for = Children;=20 paediatric

Children=92s Hospital at Montefiore, Bronx, New = York 106=967

China 212=9621

absence of legislation and regulation 219

BYL Telemedicine Network 214

challenges for telehealth 218=9619

Fujian Province Telemedicine Network 214=9615

high cost and insufficiency of funds for development = 219

incomplete organizational structure 218

lack of evaluation of programmes 219

lack of human resources 218

lack of reimbursement for services 219

lack of standards 219

lack of understanding by society 218

pilot telemedicine project 212

policy recommendations for development of telehealth = 220

increase investment 220

legal and regulatory infrastructure 220

promote international collaboration 220

strengthen leadership and supervision 220

train health professionals and technical staff 220

Shanghai Medical University 212=9613, 215=9617, 216(fig.)<= /EM>

Shuang-wei (Satellite Health Education Network of = the Ministry=20 of Health) network 214

Sino-Japanese Telemedicine Collaboration 214

telehealth opportunities 217=9618

telehealth programmes 215=9617

telemedicine past and present 212=9613

Traditional Medicine Telemedicine Network 214

unbalanced development in different areas 219

citizen-centred care 14

Colombia, Organization of Parents of Children with = Cancer and=20 Related Diseases (OPNICER) 284

Commission on Science and Technology for = Sustainable=20 Development in the South (COMSATS) 242=963

Community Access to Sustainable Health programme, = India 45, 50

Community Health Information Tracking System = (CHITS)

Philippines, National Telemedicine Center 28=969 see = also=20 m-health (mobile e-health)

community-based health workers, m-health 43=9650

COMSATS Internet Services (CIS) 244

continuing medical education (CME) programmes 112, 288=969

costs for ICT 18, 23

return on investment (ROI) 58=969

Crisp report 4, 305

Cuban doctors, working in South Africa 228

cytology 152, 153

Democratic Republic of the Congo, trial = store-and-forward=20 project 238

dermatology 121=9634

diagnostic accuracy 128=969

financial aspects 131=962

future developments 132

integration and intercultural context 129=9630

legal aspects 129

outcomes 128

practical steps in setting up a teledermatology = project 131(table)=

telederm.org application and networks 122=964

digital divide 9, 10=9611, 299

disaster medicine 262=966

e-commerce and e-learning 61

e-governance 60

e-health, see also telemedicine

e-health in the developing world 299=96308

cost effectiveness 304, 305(table)=

information and communication technology (ICT) = barriers 299=96300

telemedicine examples 300=964

administrative 300

clinical 302=964, 303(table)=

education 301=962

health service providers shortage (map) 302(fig.)<= /EM>

telemedicine strategies 304=965, 306=967=20 (figs)

e-health promotion 79=9686

Eastern Europe

large-scale infrastructure investments 11=9612

online cancer registry 282

Ecuador 193=96202

Fundaci=F3n Cinterandes (Cuenca Ecuador) 193=968

health concerns 193=964

intermittent surgical services 194=96202

medical system 194=967

mobile surgery programme 194=967

operating room (truck) 195=966=20 (figs)

primary care 200=962

local area network (LAN) in Macas 200(fig.)<= /EM>

programme activity 197

telemedical support for surgeons

telemedicine support 197=969

connectivity modalities and bandwidths 198(table)=

laparoscopic cholecystectomy postoperative care = 198(fig.)<= /EM>

education and training 19, 91=96100, 288=9690

continuing medical education programmes 112

database of Internet links 290

e-learning 61

e-school project, Uganda 236

examples of projects 301=962

importance of e-health education 81

learning objects repository 289

remote access for health professionals 290

South Africa 229=9630

synchronous e-learning 290, 291(table)=

telementoring 109=9619

teleneurology and telemedicine 256=968, 258(fig.)<= /EM>

twinning 96=967

web-based virtual learning environment 289

EHAS (Hispano-American Health Link) programme = (Peru, 2000) 45=966, 49, 50

Eldoret, Moi University 239

email telemedicine 203=9611

Cambodia 204=965

disadvantages 204

first use, Bosnia 204

future use 299=96308

future work 209=9611

origin and numbers of cases referred 2002=962008 207(table)=

Partners Telemedicine, Cambodia 204=965

Swinfen Charitable Trust 204=966, 209=9611

Tanzania 290, 295

teleconsultations 290=962

web-based telemedicine 203

emergency situations 262=966

endocrine surgery, India 109=9619

epilepsy 254

Eritrea, Anesthesia Overseas 238

Ethiopia 238

EUROCARE project, paediatric oncology 274, 277

European Commission and European Space Agency, = Telemedicine=20 Task Team for Africa 237, 238

European eHealth Action Plan (Legally eHealth) 64

European Union (EU)

directive on protection of personal information, = potentially=20 restrictive policy development 64

Framework Programmes 14

expatriate experts 82

file transfer protocol (FTP) servers 249

French Medical Institute for Children, Kabul and = Aga Khan=20 University Hospital, Karachi 292(fig.)<= /EM>

future of e-health in the developing world 299=96308

impact on potential health outcomes 305(table)=

Gabon 238

Gates Foundation 60

Geneva, RAFT (R=E9seau en Afrique Francophone pour = la=20 T=E9l=E9m=E9decine) 97=968,=20 126=967, = 237, 301

Geneva University Hospitals 303(table)=

Ghana 238

global e-health 57=9660

3-dimensional policy matrix model 62(fig.)

breadth of policy issues 61=963

critical shortage of health service providers (map) = 302(fig.)<= /EM>

need for global e-health policy 55=966

policy development void 62

policy perspective 59=9662

potential benefits 58

potential impact from access to =91e=92 applications = 59(fig.)

relationship of major components 57(fig.)

return on investment (ROI) 58=969

stakeholders 60

global health, identification and eradication of = disease 56

global network, Italian hospitals

Global Video Library of Medicine 103

GlobalStar communication system, videoconferencing = 265

=91glocal=92 e-health policy development 63

governance 60

Governments as policy-making organizations 79=9680

importance of e-health education 81

Guinea-Bissau, Spacedream project 238

Haiti, community-based HIV treatment programme 97

Health Internetwork Access to Research Initiative = (HINARI) 301

health service providers, critical shortage (map) = 302(fig.)<= /EM>, 302(fig.)<= /EM>

Healthspan International, telemedicine projects 240

HeliosNet satellite system 264, 265(fig.)<= /EM>, 271

HINARI (Health Internetwork Access to Research = Initiative) 301

Hispano-American Health Link (EHAS) programme = (Peru, 2000) 45=966

HIV/AIDS care 91=96100

3 by 5 Initiative 91

AIDSPortal 97

best practice with ICT 74=965

call centre in Uganda 95

Cell-Life project, South Africa 46, 49, 51, 52, 97

community-based treatment programme in Haiti 97

database-supported telephone conferencing 96

HIV/AIDS TELEmedicine service 91=962

ITG telemedicine, Institute of Tropical Medicine = website 127

Johns Hopkins, biweekly HIV clinical case = presentations 238

online training modality (eSCART) 95

RAFT 97=968

Satellife (HealthNet) 95=966

sources of information on antiretroviral therapy 73(table)

TELEmedicine website discussion forum 93(fig.)

ICT see also ICT policy; index = entries starting=20 with =93tele=94

access to ICT services 17=9620

administrative telemedicine 300

advantages 3

barriers to ICT 299=96300

borderless global e-health initiatives 63=965

non-adoption of e-health 80=961

benchmark targets 23

challenges in global public health 12=9615

costs 18, 23

relative to per capita income 18

diffusion and mortality 11(fig.)

driving forces for adoption of ICT 12=9613

e-commerce and e-learning 61

e-governance 60

e-health promotion 79=9686

examples of use in health systems and services 13(table)

holistic approach to ICT development 22=963

legal framework, skills and protections for a = network economy=20 20=963

national social and economic goals 18

outlook for future 23=964

pilot projects 11

potential telemedicine, impact on health outcomes 305(table)=

private sector investment 18

problems 299

speed of ICT services 19=9620

store and forward technology study, Nepal 185=9690

trends, application to health 24(table)

ICT Diffusion Index 10, 17

ICT policy 15=9620, 16(fig.), 19(table)

access to ICT services 17=9620

achieving national social and economic goals 18

adjustment to meet local needs 22

administrative barriers to borderless global = e-health=20 initiatives 63=965

core content 17=9619

expatriate experts 82

infrastructure development 17

in low- and middle-income countries 21

in middle- and high-income countries 20=961

non-adoption of e-health 80=961

objectives and approaches 4=9621

options for global e-health 65

policy options for global e-health 65

policy reform processes 21=962

potentially restrictive policy development 63=965

private sector investment 18

promotion of market competition 18

restrictive ICT policy development 63=964

India

Ayurveda 47

Ca:sh (Community Access to Sustainable Health) = programme 45, 50

Community Access to Sustainable Health programme 45, 50

endocrine surgery 109=9619

Jiva TeleDoc 47, 49, 51, 52

Mumbai telepathology 149=9655

applications 151

constraints 150=961

telecytology consultations 153

telesurgical consultations 153

telesurgical pathology and telecytology 152

oncoNET India 110

online cancer registry 283

Pan Asia Networking (PAN) 69, 70(table), 71

resource availability 258=969

Sanjay Gandhi Postgraduate Institute of Medical = Sciences=20 (SGPGIMS) 109=9612

telemedicine 258

telementoring 109=9619

teleneurology and telemedicine 258

Indonesia, Pan Asia Networking (PAN) 69, 70(table), 71(fig.), 72

Information and Communication Technologies for = Development=20 (ICT4D, Canada) 68=9678

deficiencies 72

future work 77=968

projects supported 68=969, 70(table), 73=966

Acacia 75=966

AfriAfya survey 73

Pan Asia Networking 76=967

PANACeA project 76

information and communication technology = see ICT

INMARSAT satellite link 204

Institute of Tropical Medicine in Antwerp (ITMA) 91=962

Institute of Tropical Medicine website, ITG = telemedicine 127

international agencies 82=963

strategies to promote e-health 84=965

International Development Research Centre (IDRC), = Canada 68=9678, 243

international networks 287=9696 = see=20 also Aga Khan Development Network (AKDN)

International Telecommunication Union (ITU) 43

iPath application and networks 98, 126=968, 238, 302, 303

Mauritania 239

Sao Tome 239

Iraq and Middle East, Swinfen Charitable Trust 206=968

Italian Hospitals 170=9681, 171=962(ta= ble)

Alliance of Italian Hospitals Worldwide 170=9681

Alliance power-interest grid 173(fig.)<= /EM>

e-learning 175=967

manual of procedures 179

ontological definition 177, 178(fig.)<= /EM>

policy-making process 172

problems 179

task environment 172=963

teleconsultation 173=969

health equipment inventory 177

new learning courses 176=967

production of learning content 173=965

quality control 177=969

ITG telemedicine, Institute of Tropical Medicine = website 127

Japan, Sino-Japanese Telemedicine Collaboration 214

Jiva TeleDoc 47, 49, 51, 52

Johns Hopkins, biweekly HIV clinical case = presentations 238

Karachi, AKUH 292

Kenya, African Medical and Research Foundation = (AMREF) 237, 239

Latin American Society of Paediatric Oncology = (SLAOP) 279

legal aspects

dermatology 129

European eHealth Action Plan (Legally eHealth) 64

and protections for a network economy 20=963

telemedicine 259=9660

LT Telepatologija 126

m-health (mobile e-health) 43=9650

Africa 235

case studies 45=9650, 55=966

funding sources 49(table), 51

project funding sources 49(table)

social effects of m-health on work of CBHWs 50=961

technology summary 49(table)

teleneurology 256

WiFi networks, Ghana 238see = also=20 Community Health Information Tracking System (CHITS); e-mail = telemedicine

Malaysia, e-health policy, potentially restrictive = policy=20 development 64

Mali, e-well project 239

market competition 18

Markle Foundation 140

Mauritania, RAFT and iPath 239

Mauritius 239

Medical Broadcasting Channel 102

medical interventions, potential impact on health = outcomes 305(table)=

Medical Missions for Children 101=968

case report 104

Children=92s Hospital at Montefiore, Bronx, New York = 106=967

Giggles Children=92s Theatre 103

Global Video Library of Medicine 103

history 102

Medical Broadcasting Channel 102=963

Telemedicine Outreach Programme 102

television programmes 103=964

videoconferencing equipment 102

Medline database, US National Library of Medicine = 301

Middle East, Swinfen Charitable Trust 206=968

Millennium Development Goals (UN, 2000) 43=964

in Africa 234

Crisp report 4, 305

Goal 8, Target 18 9

Mindset Health, South Africa 229

Moi University, Eldoret 239

Moorfields Eye Hospital ophthalmology projects, = links to=20 South Africa 237

mountainous and remote areas, northern Pakistan 232-41CHECK
Mozambique 239

funding sources for UHIN project 52

Mumbai telepathology 149=9655 = see=20 also India

Namibia 239

National Aeronautics and Space Administration = (NASA),=20 emergency situations 262

Nepal 182=9692

HealthNet Nepal 127, 182=965

cardiology 183

compression 184

dermatology 183

digital photography guides 184

hospital referrals 184=965

image processing 183=964

pathology 183

pilot project 184=965

radiology 183

receiving and reviewing cases 184

security and confidentiality 184

software, data transfer and security 183=964

software development 182=963

Pan Asia Networking (PAN) 69, 70(table)

store and forward technology study 185=9690

telemedicine assessment study 185=968

neurology 252=9661

teaching, videoconferencing 257see = also=20 teleneurology

New Partnership for Africa=92s Development (NEPAD) = 236

Niger 239

Nigeria

and Children=92s Hospital at Montefiore, Bronx, New = York 106=967

national telemedicine association 239

non-adoption of e-health 80=961

non-governmental organizations (NGOs)

big international NGOs (BINGOs) 60

role and challenges 60

Norway, Tanzania store-and-forward project with=20 Rikshospitalet (Oslo) 240 Oslo 240

oncology see paediatric oncology

Pacific region 156=9668

open-learning network, WHO 301

Pacific Asynchronous TeleHealth system 164=968

challenges 167=968

differences from Pacific Island Healthcare = Project 165=966

distances involved, map 164(fig.)<= /EM>

future work 168

referrals and consultations 166=967

teleconsultation workload 166(table)=

Pacific Island Healthcare Project 157=9663, 158(table)=

clinical procedure 159=9661

Northern Mariana Islands 160(fig.)<= /EM>

Federated States of Micronesia, map 158(fig.)<= /EM>

results 161=963, 161(table)= , 162(fig.)<= /EM>, 163(figs)<= /EM>

second-opinion telemedicine networks 303(table)=

Tripler Army Medical Center 156=967 = see also=20 Philippines

PACOTAPS software, Brazil 38=969

paediatric oncology 273=9685

cancer incidence 274(table)=

cancer registries 275(table)=

individual countries (maps) 275=966=20 (figs)

international initiatives 279=9681

Cure4Kids website 279=9680

International Agency for Research on Cancer = (IARC) 281

International Society of Paediatric Oncology = (SIOP) 280

Latin American Society of Paediatric Oncology = (SLAOP) 279

Paediatric Oncology Networked Database = (Pond4Kids) 280

St Jude Children=92s Research Hospital 279=9680

online cancer registries in developing countries 281=963

Argentina 282

Belarus 282

Brazil 281=962

Eastern Europe 282

India 283

Serbia 283

Singapore 283

twinning programmes 281

web-based information 277=969, 283=964

Africa 284

Asia 284

Eastern Europe 284

Latin America 283=964

paediatric support, field hospital in Chechnya 262=9672

Pakistan 242=9651

Commission on Science and Technology for Sustainable = Development in the South (COMSATS) 242=964

computer operator training 249

connectivity problems 248(fig.)<= /EM>

Karachi, AKUH 292

map 243(fig.)<= /EM>

medical staff and physician shortage 249

patient information software 249

project experience 244=967

community trust and confidence in the service 246=967

earthquake effects 247

equipment 245(table)=

medical equipment 246

number of teleconsultations 247(fig.)<= /EM>

Skardu centre 246

recommendations 250

service methodology 250

Pan Asia Networking (PAN) 68=969, 70(table), 76=967

Pan Asian Collaborative for Evidence-Based eHealth = Adoption=20 and Applications (PANACeA) project 70, 76=967

Pan-African initiatives 236=967

Partners Telemedicine 204=965, 238, 303(table)=

Peru, Hispano-American Health Link (EHAS) programme = (2000) 45

Philippines, Pan Asia Networking (PAN) 69, 70(table), 76=967

Philippines, National Telemedicine Center 27=9633

Community Health Information Tracking System (CHITS) = 28=969

E-Learning for Health Project 29=9631

map, locations of educational sessions 30(fig.)

migration of doctors and nurses 31

SMS Telemedicine Project 32

sustenance factor 31=962

videoconferencing 30, 31

policy options for global e-health 65

potential telemedicine, impact on health outcomes = 305(table)=

primary health care, community-based health workers = 44

private sector investment 18

conglomerates/foundations 61

promotion of e-health 79=9686

PubMed search, telemedicine articles 252(fig.)<= /EM>

RAFT (R=E9seau en Afrique Francophone pour la = T=E9l=E9m=E9decine) 97=968, 126=967, 237, 301

Mauritania 239

Senegal 239

REACH (Remote Asynchronous Communication for = Healthcare) 238

restrictive ICT policy development 63=964

Romanian Association of Parents with Cancer and = Leukaemia Ill=20 Children (PAVEL) 284

Russia

Ambulance-071 YS 269=9670

Moscow Research Institute for Paediatrics and = Childen=92s=20 Surgery 263

satellite system HeliosNet 264, 265(fig.)<= /EM>, 271

support for Children=92s Field Hospital, Chechnya 263=9670

telemedical collaboration with NASA 262

Rwanda

funding sources for UHIN project 52

videoconferencing 239

St Jude Children=92s Research Hospital, Cure4Kids = website 279

Sanjay Gandhi Postgraduate Institute of Medical = Sciences=20 (SGPGIMS) 109=9612

conferences, CME and workshops held 112(table)=

telemedicine network partners 111(table)=

telementoring sessions 111=9614

teleneurology 257

Sao Tome, iPath 239

Satellife (HealthNet) 95=966, 238

satellite system

HeliosNet 264, 265(fig.)<= /EM>, 271

Q-band, Web Media Service 271

Senegal, RAFT 239

Serbia, online cancer registry 283

Sierra Leone 239

Singapore

Children=92s Cancer Foundation of Singapore 284

online cancer registry 283

Sino-Japanese Telemedicine Collaboration 214

SMS Telemedicine Project 32

Solomon Islands National Telemedicine Network 126

Somalia, United Nations humanitarian mission (1993) = 269

South Africa 222=9631

background 224=965

Cell-Life project 46, 49, 51, 52, 97

Childhood Cancer Foundation 284

common challenges associated with starting = telemedicine=20 services 226

Cuban doctors 228

disease burden 222

education and training 228=9630

governance 222=963

health provision 222

interactive satellite broadcast system (Sentech) 229

Internet access charges 223

legislation and guidelines 230

Mindset Health 229

and Moorfields Eye Hospital, ophthalmology projects = 237

Port St Johns, teledermatology 127

projects 225=968

Free State, teleradiology 227

Medical Research Council (MRC) 224=967

mobile phone technology, HIV patient medication = compliance=20 228

University of KwaZulu-Natal, telehealth and = telemedicine 226=967

University of Stellenbosch, primary health care = workstation=20 226

Walter Sisulu Medical School 224, 226, 229

Western Cape, email based store and forward = telemedicine 228

synchronous services, commencement 227

telepsychiatry services 228

Unit of University of Transkei (UNITRA) in Umtata 127

South African Children=92s Cancer Group (SACCSG) 284

South African Defence Force, with MRC 225

Spacedream project, Guinea-Bissau 238

speed of ICT services 19=9620

Sri Lanka, e-health projects 85(table)

stakeholders

collaboration between 20

global e-health 60

private sector conglomerates and private foundations = 61

store and forward technology study, Nepal 185=9690

age and gender of users 187=968

collaboration between doctors 188

consultation areas 188

disadvantages 189

breakdown between health professionals 189

organizational problems 189

economic evaluation 189=9690

telemedicine vs traditional health care services = 189(table)=

exposure to rural areas 188

findings, dermatology ROC analysis 187(table)=

future developments 190

organizational position 188

research findings 190

ROC (receiver operating characteristic) analysis 185=967

users=92 attitudes 188

willingness to participate 187

stroke 254=965

sub-Saharan Africa 232=9641

burden of disease 232

demographics 232

doctor/people ratio 233

health care funding 233

initiatives 236=9640

international 237

Pan-African 236=967

projects within countries 238=9640

Millennium Development Goals (UN, 2000) 234

needs (vs industrialized world), WHO Report 232

obstacles 234=966

plight of rural patients (Ethiopia) 234

population predictions 232=963

potential solution 233=964

telecommunication costs 235

Sudan 239

Surveillance, Epidemiology and End Results (SEER) = programme=20 274

Swedish International Development agency, and = Zambia 240

Swinfen Charitable Trust 128, 204=966, 209=9611, 238, 302, 303(table)=

Centre for the Rehabilitation of the Paralysed (CRP) = Bangladesh 204=966

growth of network (1999=962004) 206

referrals 205(fig.)<= /EM>

Iraq and the Middle East 206=968

origin and numbers of cases 207(table)=

referrals 208(fig.)<= /EM>

types of queries 208(table)=

U21 consortium 207=969

Memorandum of Understanding 209

referring hospitals 210(fig.)<= /EM>

Switzerland

Basel, iPath application and networks 126=968

Geneva, RAFT (R=E9seau en Afrique Francophone pour = la=20 T=E9l=E9m=E9decine) 97=968,=20 126=967, = 237, 301

Geneva University Hospitals 303(table)=

Taiwan, APEC Digital Opportunity Center 29

Tanzania

African Medical and Research Foundation (AMREF) 237

AKDN needs and readiness assessment exercise 295

email telemedicine 290

store-and-forward project with Rikshospitalet (Oslo) = 240

tele-CME (continuing medical education) programmes = 112, 288=969

teleconsultation

emergency situations 262

Italian Hospitals 173=969

telecytology 152, 153

teledermatology 121=9634

telemedicine

articles published (PubMed) 252(fig.)<= /EM>

categorization of medical specialties according to = their=20 maturity 253(fig.)<= /EM>

legal aspects 259=9660

synonyms 3see = also=20 e-health

Telemedicine Outreach Programme, World Bank 102

Telemedicine Sur 127

telementoring 109=9619

teleneurology and telemedicine 252=9661

acute stroke 254=965

categorization of medical specialities according to = maturity=20 253(fig.)<= /EM>

epilepsy 254

India, telemedicine 258

legal questions 259=9660

medical education 256=968, 258(fig.)<= /EM>

mobile phones 256

movement disorders 255

neurological outpatients 256

neurophysiology 255

resource availability 258=969

telemedicine articles in different specialities 252(fig.)<= /EM>

videoconferencing 257

telepaediatric support, field hospital in Chechnya = 262=9672

telepathology 139=9645

teleradiology (DEPRAD) system 269=9670

teleradiology link 292, 292(fig.)<= /EM>

television programmes, Medical Missions for = Children 103=964

The Gambia 238

TIER (Technology and Infrastructure for Emerging = Regions) 238

twinning programmes

paediatric oncology 281

sharing expertise 96=967

U21 consortium 207=969

Swinfen Charitable Trust 209

Uganda

call centre, HIV/AIDS care 95

e-school project 236

Uganda Health Information Network (UHIN) 47=968, 49, 52, 69

UNDP, funding of Community Health Information = Tracking=20 System, Philippines 28

United Nations Human Development Index 135

United Nations humanitarian mission (1993), Somalia = 269

US Department of Defense, IFOR and PrimeTime 263, 270

US National Aeronautics and Space Administration = (NASA)

emergency situations 262

telemedical collaboration with Russia 262

US National Library of Medicine, Medline database = 301

USA

and Cambodia 135=9648

TRAC2ES system, military operations 268see = also=20 Cambodia

videoconferencing

GlobalStar communication system 265

Medical Missions for Children 102

neurology teaching 257

Rwanda 239

technical difficulties 56

Walter Sisulu Medical School 229

voice-over-Internet protocol (VOIP) services 236

West Africa Doctors and Healthcare Professionals = Network 127

WHO

biennial budget 60

Pacific open-learning network 301

WHO Global Observatory for eHealth 83=964

report summary 83

WHO Report, Africa needs (vs industrialized world) = 232

WiFi networks, Ghana 238

World Bank, Telemedicine Outreach Programme 102

World Summit on the Information Society 9, 10

Zambia, and Swedish International Development = agency 240
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Telehealth in the Developing World

Contents

Contributors

Foreword

Preface

SECTION 1BACKGROUND

1 Introduction

What is telemedicine?

Scope of the problem

Crisp report

Aim of the book

References

SECTION 2POLICY

2 Bridging the digital divide: Linking health and = ICT=20 policy

Introduction

ICT in the health sector

Measuring the digital divide

Driving forces for ICT in health

Challenges in global public = health

Forces for change

An overview of ICT policy

Interested parties

Pivotal role of = governments

Linking health goals to ICT = policy

Linking health and ICT policy

Core content of ICT policy

Factors affecting ICT use in the health=20 sector

Costs for ICT

Access speed

Education

Collaboration between stakeholders

Legal framework, skills and protections for = anetwork=20 economy

ICT policy orientation in middle- and = high-income=20 countries

ICT policy orientation in low- and = middle-income=20 countries

Opportunities presented by policy reform=20 processes

Policy adjustment to meet local=20 needs

Opportunities for action

A holistic approach to ICT = development

Making the case for health

Outlook for the future

Conclusion

Acknowledgements

Further reading

References

3 Telemedicine in developing countries: = Perspectives from=20 the Philippines

Introduction

The human experience

Community Health Information Tracking=20 System

The technological opportunity

E-Learning for Health = Project

The sustenance factor

SMS Telemedicine Project

Conclusion

Further reading

References

4 Information technology for primary health care = in=20 Brazil

Introduction

IT in primary care in Brazil

National Telemedicine = Programme

National information = systems

Telemedicine

Computerized tools

PACOTAPS

Training

Survey results

Conclusions

Further reading

References

5 Community-based health workers in developing = countries=20 and the role of m-health

Introduction

Opportunities in m-health for addressing = globalhealth=20 problems

Primary health care

Case study summary

Technology interfaces

Social

Finance

Government

Conclusion

Further reading

References

SECTION 1
BACKGROUND

SECTION 2
POLICY

Legal framework, skills and protections for = a
network=20 economy

Opportunities in m-health for addressing = global
health=20 problems

Role of national governments in=20 promoting
e-health

SECTION 3
EDUCATIONAL