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,
China

Richard E Scott

University of Calgary, Calgary,
Canada

Kendall Ho

University of British Columbia, Vancouver,
Canada

© 2009 Royal Society of Medicine Press Ltd

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

Contributors

ix

Foreword

xiii

Preface

xv

SECTION 1: BACKGROUND

1. Introduction

3

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

SECTION 2: POLICY

2. Bridging the digital divide:
Linking health and ICT policy

9

Joan Dzenowagis

3. Telemedicine in developing
countries: Perspectives from the Philippines

27

Alvin B Marcelo

4. Information technology for
primary health care in Brazil

34

Elaine Tomasi, Luiz A Facchini, Elaine Thumé,
Maria FS Maia and Alessander Osorio

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

43

Adesina Iluyemi

6. Global e-health policy: From
concept to strategy

55

Richard E Scott

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

68

Laurent Elder and Michael
Clarke

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

79

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

SECTION 3: EDUCATIONAL

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

91

Maria Zolfo, Verena Renggli, Olivier Koole and
Lut Lynen

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

101

Philip O Ozuah and Marina
Reznik

11. Telementoring in India:
Experience with endocrine surgery

109

Saroj K Mishra, Puthen V Pradeep and Anjali
Mishra

SECTION 4: CLINICAL

12. Teledermatology in developing
countries

121

Steven Kaddu, Carrie Kovarik, Gerald Gabler
and H Peter Soyer

13. Cross-cultural telemedicine
via email: Experience in Cambodia and the USA

135

Paul Heinzelmann, Rithy Chau, Daniel Liu and
Joseph Kvedar

14. Telepathology and telecytology
in developing countries

149

Sangeeta Desai

15. Internet-based
store-and-forward telemedicine for subspecialty consultations in the
Pacific region

156

C Becket Mahnke, Charles W Callahan and
Donald A Person

16. Telehealth support for a
global network of Italian hospitals

170

Gianfranco Costanzo and Paola
Monari

17. Telemedicine in Nepal

182

Mohan R Pradhan

18. Telemedical support for
surgeons in Ecuador

193

Stephen Cone, Edgar J Rodas and Ronald C
Merrell

19. A low-cost international
e-referral network

203

Richard Wootton, Pat Swinfen, Roger Swinfen
and Peter Brooks

20. Telehealth in China:
Opportunities and challenges

212

Jie Chen and Zhiyuan Xia

21. Telemedicine in South
Africa

222

Maurice Mars

22. Telemedicine in sub-Saharan
Africa

232

Maurice Mars

23. Telehealth for mountainous and
remote areas of northern Pakistan

242

Hameed A Khan and Irfan Hayee

24. Teleneurology: Past, present
and future

252

Usha K Misra and Jayantee
Kalita

25. Telepaediatric support for a
field hospital in Chechnya

262

Boris A Kobrinskiy and Vladimir I
Petlakh

26. Web-based paediatric oncology
information and registries: An international perspective

273

André Nebel de Mello

27. E-health in international
networks: New opportunities for collaboration

287

Shariq Khoja and Azra Naseem

SECTION 5: THE FUTURE

28. The future use of telehealth
in the developing world

299

Richard Wootton

Index

309

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Contributors

Palitha Abeykoon Ministry of Health, Colombo,
Sri Lanka

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

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

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

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

Michael Clarke International Development
Research Centre, Ottawa, Canada

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

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

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

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

Joan Dzenowagis World Health Organization,
Geneva, Switzerland

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

Laurent Elder International Development
Research Centre, Ottawa, Canada

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

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

Irfan Hayee COMSATS Headquarters, Islamabad,
Pakistan

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

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

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

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

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

Hameed A Khan Pakistan Atomic Energy
Commission, Islamabad, Pakistan

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

Boris A Kobrinskiy Moscow Research Institute
of Paediatrics and Children’s Surgery, Moscow, Russia

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

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

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

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

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

C Becket Mahnke Tripler Army Medical Center,
Honolulu, USA

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

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

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

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

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

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

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

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

Paola Monari Alliance of the Italian
Hospitals Worldwide – Secretariat for Technical Assistance, Rome, Italy

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

Andre Nebel de Mello Laboratorio de Sistemas
Integraveis da Escola Polictecnica da Universidade de São Paulo, São Paulo,
Brazil

Alessander Osorio University Federal of
Pelotas, Pelotas, Brazil

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

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

Donald A Person Tripler Army Medical Center,
Honolulu, USA

Vladimir I Petlakh Moscow Research Institute
of Paediatrics and Children’s Surgery, Moscow, Russia

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

Mohan R Pradhan Health Net, Kathmandhu,
Nepal

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

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

Edgar J Rodas University of Azuay, Cuenca,
Ecuador

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

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

Pat Swinfen Swinfen Charitable Trust,
Canterbury, UK

Roger Swinfen Swinfen Charitable Trust,
Canterbury, UK

Elaine Thumé Department of Nursing,
University Federal of Pelotas, Pelotas, Brazil

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

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

Zhiyuan Xia Telemedicine Centre, Fudan
University, Shanghai, China

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

Foreword

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

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

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

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

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

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

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

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

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

Preface

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

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

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

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

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

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

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

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

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

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

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

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

background and
introductory material

a section on policy
matters

a section describing
educational applications

a section about
clinical applications

a view of the
future.

We hope that within the broad spectrum of ideas expressed in
this book everyone will find something of relevance. We also hope that you enjoy
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
Richard E Scott

What is telemedicine?

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

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

Scope of the problem

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

improve access to
health care;

enhance the quality
of service delivery;

improve the
effectiveness of public health and primary care interventions;

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

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

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

Crisp report

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

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

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

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

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

Aim of the book

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

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

References

1
Wootton R. Telemedicine and isolated communities: a UK perspective. J
Telemed Telecare 1999; 5(Suppl 2): 27–34.

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

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

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SECTION 2
POLICY

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2 Bridging the digital divide: Linking health and ICT
policy

Joan Dzenowagis

Introduction

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

Despite this encouraging progress, however, the uptake of ICT
globally continues at an uneven pace, and the ‘digital divide’ remains a
significant obstacle to achieving global development goals. The digital divide
is understood broadly to be the gap between those with access to ICT and its
benefits and those without. It is specifically acknowledged in the United
Nations Millennium Development Goals (MDGs). Goal 8, Target 18 of the MDGs
proposes ‘a global partnership for development to make available the benefits of
new technologies, especially information and communication technologies’.1

Recent events such as the G8 Summits and the World Summit on the
Information Society2 have continued
to promote this target and to highlight the striking gaps in access to ICT
worldwide. In some countries, both urban and rural regions remain isolated from
the knowledge society: infrastructure is non-existent, costs for basic services
are beyond average income levels and well-intentioned ICT pilot projects end
without ever scaling-up. While this can be disastrous for national economies
competing in a global environment, it is also a tragedy for the health sector,
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
effective services. In many countries, use of ICT within the sector continues to
grow, and the Internet in particular is driving significant change. For example,
in middle- and high-income countries, the Internet is dramatically changing the
way in which consumers interact with health services, including access to health
information and the ability to purchase pharmaceuticals and other health
products. The Internet also plays a key role in expanding the reach of health
services to remote areas. The spread of broadband networks and the development
of new e-health applications, defined as the use of ICT for health, have a
mutually stimulating effect on further developments. However, it is clear that,
despite the numerous creative and sometimes quite costly efforts to improve the
situation, access to these developments is not universal, and many countries do
not benefit as they might from advances in ICT in health.

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

Measuring the digital divide

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

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

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

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

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

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

Despite the difficulties, there have been major ICT investments,
particularly in countries such as those in Eastern Europe. These economies are
growing rapidly, and large-scale infrastructure investments supported by the
European Union include ICT for health institutions and universities. In
higher-income countries, there is spending in the areas of information systems,
electronic health records, e-prescribing systems, diagnostic tools and medical
imaging. In developing countries, ICT pilot projects are being funded by
international donors, leading to uncoordinated deployment of ICT in health
service delivery and incompatible systems at many levels. In addition,
investments are being made in applications that support ‘vertical’ health
programmes such as disease surveillance, management of drug
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
years, the fundamental conditions for health have not been achieved in many
countries. Most of the burden of premature death and illness among the poor is
due to problems for which solutions are known and prevention is possible, yet
the health of populations in developing countries continues to be at risk.
Today, the gap in health between the wealthy and the poor, both within and
between countries, continues to grow.

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

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

Forces for change

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

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

Table 2.1 Examples of the use of ICT in
health systems and services

Broad area

Examples

Access to information and knowledge

1. Improved access to health information, research,
literature and training materials, such as access to biomedical and social
sciences research. This supports the health research enterprise and
enables comprehensive, evidence-based management of acute and chronic
conditions

2. Improved access to resources on prevention, awareness
and education, for the general public as well as for health professionals,
researchers and policy makers

Networking and collaboration

1. Collaboration for the management and coordination of
care across different health providers, community health services and
health institutions

2. Better exchange of knowledge among policy makers,
practitioners and advocacy groups

3. Rapid and coordinated response to disasters and
disease events

Information for policy and action: measuring progress,
tracking quality and trend analysis

1. ICT for collecting, organizing and disseminating
public health evidence and information for advocacy, practice and
policy

2. Improved ability to describe, model, analyze and
monitor trends on health status, income, employment and service coverage,
and disaggregate by gender

3. Support for research on policy effectiveness

Health education and training

1. Direct support to education and training for health
professionals and workers, including both pre-service education and
in-service training and resources

2. Improved efficiency and effectiveness of education
delivery through strategic application of ICT and ICT-enabled skill
development

3. Improved availability of quality educational resources
through ICT

4. Outreach to special populations (girls and women)
using appropriate technologies

5. Enhanced delivery of basic and in-service
education

Public accountability through greater flow of
information

1. Greater transparency, accountability and accessibility
in delivery of public services

2. Improved enforcement of regulations and performance
monitoring of decentralized services

Delivery of health services

1. Prevention of disease, health education and promotion,
and support for diagnosis and treatment

2. Establishment of health registries and health
information systems

3. Extension of care to rural and remote areas through
telemedicine applications; increased access of rural health workers to
specialist support and consultation

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

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

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

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

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

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

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

An overview of ICT policy

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

Interested parties

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

Pivotal role of governments

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

Linking health goals to ICT policy

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

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

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

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

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

Linking health and ICT policy

The potential points of influence, or entry points, in a
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
objectives and approaches in order to be effective advocates for improving
infrastructure, access and affordability, or for obtaining concessions or aid
for the health sector. While every country is unique, national policies
generally set out goals and objectives for the development of the ICT industry,
development of the economy and support for key sectors of the economy. The list
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
the development, expansion, operation and increased efficiency of ICT networks
at the infrastructure level. This is an area of great interest to the health
sector, but not traditionally one where the sector has much influence. Those
involved include governments (ministries of information technology and
telecommunications), the private sector (multinational corporations),
independent bodies (regulators) and international organizations (International
Telecommunication Union).

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

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

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

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

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

Factors affecting ICT use in the health
sector

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

Costs for ICT

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

Access speed

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

Table 2.2 Policy areas related to
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
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
infrastructure

Services level

Trust and security – transactions that affect use of
services and applications

Policies that affect business, government and consumer
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,
and private sector and civil society access

User level

Capacity building

Policies that build the capacity to use ICT, including
curriculum and materials, and technical education. For the general public,
this also includes policies to ensure basic literacy, without gender
difference

Overall environment

General government environment

Government structure (transparency, independence of
judiciary and regulatory authorities), discrimination
policy

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

Education

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

Collaboration between stakeholders

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

Legal framework, skills and protections for a
network
economy

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

ICT policy orientation in middle- and high-income
countries

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

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

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

ICT policy orientation in low- and middle-income
countries

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

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

Opportunities presented by policy reform
processes

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

Policy adjustment to meet local
needs

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

Opportunities for action

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

A holistic approach to ICT development

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

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

Making the case for health

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

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

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

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

Outlook for the future

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

Table 2.3 Examples of ICT trends and
their application to health

Technology trends

Applications to health

ICT policy issues

Broadband Internet

Distance delivery of health care services: consultations,
transmission of prescription and purchase of medicines, using text, still
and mobile pictures, and voice

Technology
standards

Privacy
protection

Costs

Geographical
availability of broadband Internet

Digitization

Video and pictures

Technology
standards

Electronic databases and memory chips as patient record
archive

Privacy
protection

Wireless communications technologies

Mobile communications: health anywhere from
everywhere

Costs

Geographical
availability of wireless communication

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

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

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

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

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

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

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

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

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

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

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

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

Conclusion

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

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

Acknowledgements

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

Further reading

World Health Organization. World Health Assembly
Resolution WHA58.1: Health action in relation to crises and disasters, with
particular emphasis on the earthquakes and tsunamis of 26 December 2004.
Available at: www.who.int/gb/ebwha/pdf_files/WHA58-REC1/english/Resolutions.pdf.

World Health Organization. Connecting for Health:
Global Vision, Local Insight. Report for the World Summit on the
Information Society. Country Profiles 2006. Available at: www.who.int/kms/resources/wsis_country_profiles.pdf.

European Commission. E-health: Better Healthcare for
Europe. Available at: ec.europa.eu/information_society/activities/health/index_en.htm.

References

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

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

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

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

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

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

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

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

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

10. Ball MJ, Garets DE,
Handler TJ. Leveraging IT to improve patient safety. In: Yearbook of Medical
Informatics 2003. Stuttgart: International Medical Informatics
Association/Schattauer, 2003: 1–6.

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

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

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

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

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

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

17. Wolcott P, Press L,
McHenry W et al. A framework for assessing the global diffusion of the Internet.
J Assoc Inform Syst 2001; 2: 1–50.

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

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

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

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

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

3 Telemedicine in developing countries: Perspectives from
the Philippines

Alvin B Marcelo

Introduction

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

The approach to implementation consisted of three distinct
steps:

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

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

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

The human experience

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

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

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

Community Health Information Tracking
System

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

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

Currently, CHITS is in use in 12 health centres in two cities
and two provinces in the Philippines. It has made the work of village health
workers easier, since information is entered only once during a patient
consultation and can then be used to generate the different reports that need to
be submitted to the Department of Health. Since data are stored electronically,
it is now easier to access and consolidate information, and there is less risk
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
health centres presently using CHITS. The information is stored in databases
using simple data elements patterned after the Department of Health. Access is
limited to authorized personnel, who undergo a two-day electronic health record
training prior to using the system. In this training programme, the ethics of
health information management are taught with special attention to the
responsibility and security required for digital data. All data are owned by the
relevant health centre, which also controls access. The data can be extracted
using open-source software tools.

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

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

The technological opportunity

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

E-Learning for Health Project

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

community management
of accidental childhood poisoning

community management
of stroke

community management
of tuberculosis

community
introduction to the avian influenza threat.

These video modules last 7–10 minutes each and are narrated in
the vernacular with English subtitles. The audiences are community health care
volunteers in remote communities. After the video showing, an interactive
question and answer session is established between the expert in Manila and the
volunteers using the best available technology (ranging from videoconferencing
to mobile phone calls). Various telecommunication media have been employed for
the educational sessions which are held in various locations (Figure 3.1):

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

Figure 3.1 Locations of educational
sessions

Figure 3.2 An expert participating in a health
worker’s meeting via videoconferencing

stroke between
Manila and Nueva Vizcaya, using cellphones

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

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

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

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

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

The sustenance factor

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

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

In one high-profile government-funded project, the BuddyWorks
Community Partnership in Delivering Telemedicine Services, remote sites were
provided with workstations and broadband Internet connections to allow them to
refer difficult cases to experts in a central facility. A total of 10 facilities
in four provinces was involved. However, despite the substantial investment,
referrals from the remote sites did not occur. Analysis revealed a workflow that
prevented the users from assimilating desktop Internet technologies for
communicating clinical dilemmas. In the proposed system, the remote physician
needed to log on to a computer with Internet access, go to the agreed website
portal, enter the relevant clinical data and wait for the response of an expert
– who would probably be busy with his or her own patients at the time. The
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
communicate via SMS. Most doctors already owned a mobile phone. Using SMS, they
were able to communicate more effectively. It was then decided to supplement the
existing network by providing modest prepaid SMS allowances to the doctors and
offering them free conference call services for voice-based referrals. This
system has proved to be sustainable and effective. During a 6-month period, over
300 referrals were received from 44 doctors in remote areas.

Conclusion

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

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

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

Further reading

International Medical Informatics Association. IMIA
Code of Ethics for Health Information Professionals. Available at: www.imia.org/ethics.lasso.

Declaration of Alma-Ata. International Conference on
Primary Health Care, Alma-Ata, 6–12 September 1978. Available at: www.who.int/hpr/NPH/docs/declaration_almaata.pdf.

Heeks R, Mundy D, Salazar A. Why Health Care
Information Systems Succeed or Fail. Institute for Development Policy and
Management, 1999. Available at: unpan1.un.org/intradoc/groups/public/documents/NISPAcee/UNPAN015482.pdf.

University of Texas Medical Branch Web Education Courses.
Telemedicine 101: Basic Principles of Telemedicine. Available at: www.utmb.edu/teletraining/th101/index.html.

World Health Organization. Executive Board. eHealth:
Proposed Tools and Services. Available at: www.who.int/gb/ebwha/pdf_files/EB117/B117_15-en.pdf.

References

1.
Tolentino H, Marcelo A, Marcelo P, Maramba I. Linking primary care information
systems and public health information networks: lessons from the Philippines.
Stud Health Technol Inform 2005; 116: 955–60.

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

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

4 Information technology for primary health care in
Brazil

Elaine Tomasi, Luiz A Facchini, Elaine Thumé, Maria FS
Maia and Alessander Osorio

Introduction

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

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

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

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

Martinez et al10 analyzed
communication and information needs in primary health care in rural areas from
Peru and Nicaragua. They found three main factors related to the inefficiency of
the health systems: poor infrastructure, a lack of information systems and
deficiencies in the training of health professionals. Other authors have
emphasized the need to incorporate good-quality health care data from local
levels into national databases.11–14 Similarly,
Gething et al15 stated that
the value of information systems in health is to point out the
needs and priorities at both national and local levels, but the process of
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
system management and its shortage elsewhere, particularly in primary care.
There is often pressure for new data, increasing the time required for
collection, with no assurance about its analysis, dissemination and usefulness
in decision making. The great quantity of data about each patient, recorded by
health professionals, seems to have little meaning in their daily
activities.16 We believe
that all of these factors contribute to the current situation – but especially
the lack of motivation of most health care staff and the poor integration
between health care and IT professionals.

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

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

IT in primary care in Brazil

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

National Telemedicine Programme

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

National information systems

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

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

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

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

Telemedicine

Separate from the National Telemedicine Programme, the BH
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
Telemedicine network connects primary care centres to the Federal University of
Minas Gerais teaching units, with activities in the fields of medicine, nursing
and dentistry. The network uses videoconferences for continuing education, and
teleconsulting between specialists and staff at the primary care centres for
second opinions and for discussion of clinical cases. The videoconferencing
network operates at 128 kbit/s.

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

The project has been evaluated by two groups. The results showed
better outcomes for the cases discussed, with about 70% of patients staying in
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
Hospital of Belo Horizonte to be seen.

Computerized tools

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

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

Information about the 236 primary care centres was obtained by
questionnaire: 4749 health workers were studied. Among these, 11% were
physicians, 7% nurses, 8% professionals with another college degree, 18% nursing
assistants, 23% other professionals with a high school degree and 33% community
health agents. One-third of the primary care centres had a computer (35%): 40%
in the south and 29% in the north-east. Considering the care model, 39% of the
family health services had a computer, as opposed to only 25% of the traditional
services (Table 4.1).
Only 11% of the primary care centres had Internet access: 17% in the south
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
for professional activities. This use was almost 50% among physicians, nurses
and other professionals with a college degree, and a little more than 10% among
nursing technicians, community health agents and other members of the teams who
had a high school education. The use of computers in the primary care centres
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
centres was 14% in the south and 5% in the north-east. Depending upon the care
model, it was 10% in family health services and 6% in the traditional centres
(Table 4.4).

Table 4.1 Microcomputers in primary
care services according to the model of health care and geographical
region (n = 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
primary care services according to the model of health care and
geographical region (n = 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
workers according to location of access (n = 4749)

In home or primary health care unit
(%)

Only in primary health care unit
(%)

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
care health workers according to model of health care and geographical
region (n = 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
PACOTAPS software is to assist health managers and teams with information about
population characteristics and health demands.22 The software
provides a structure to receive data about the contacts and procedures performed
at primary care centres. The origin document is the Outpatient
Contact Form, which is completed by the health team and signed by the user. Once
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
that are standardized by the Outpatient Information System. For the
identification of the diagnosis, PACOTAPS provides the application PESQCID,23 which allows
a guided consultancy to the International Classification of Diseases
(ICD-10).24 Thus, using
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
proportion of referrals.

Training

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

Survey results

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

Every user can receive one or more procedures at each contact.
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
checked, have a medical consultation for back pain and receive his or her
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
receiving a benefit. Therefore, the number of procedures is usually higher than
the number of people attended to. In this sample, more than 37 000 procedures
were analysed.

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

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

Conclusions

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

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

potential for
innovation in the public network

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

improvements in the
assisting structure, with possibilities of reduced costs and better structuring
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
central levels of health system management.

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

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

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

Further reading

Araújo Novaes M, Pinto Barbosa AK, Soares de Araújo K et
al. Experiences on the use of a second opinion software for the primary care.
AMIA Annu Symp Proc 2005: 889.

Edworthy SM. Telemedicine in developing countries.
BMJ 2001; 323: 524–5.

Goodman KW. Ethics and health informatics: focus on Latin
America and the Caribbean. Acta Bioeth 2005; 11:
121–6. Available at: www.scielo.cl/scielo.php?pid=S1726-569X2005000200002&script=sci_arttext&tlng=en.

Hira AY, Lopes TT, de Mello AN et al. Establishment of
the Brazilian Telemedicine network for paediatric oncology. J Telemed
Telecare 2005; 11(Suppl 2): 51–2.

Rigby M. Impact of telemedicine must be defined in
developing countries. BMJ 2002; 324: 47–8.

References

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

2.
Magruder C, Burke M, Hann NE, Ludovic JA. Using information technology to
improve the public health system. J Public Health Manag Pract 2005;
11: 123–30.

3.
Kukafka R. Public health informatics: the nature of the field and its relevance
to health promotion practice. Health Promot Pract 2005;
6: 23–8.

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

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

6.
Mitchell E, Sullivan F. A descriptive feast but an evaluative famine: systematic
review of published articles on primary care computing during 1980–97.
BMJ 2001; 322: 279–82.

7.
Magalhães CAS. Análise da resistência médica à implantação de sistemas de
registro eletrônico de saúde. [Analysis of Medical Resistance to the
Introduction of Systems for Electronic Health Records]. Rio de Janeiro:
Fundação Getúlio Vragas, 2006.

8.
Nobel J. Changes in health care: challenges for information system design.
Int J Biomed Comput 1995; 39: 35–40.

9.
Branco MAF. Informação e tecnologia: desafios para a implantação da Rede
Nacional de Informações em Saúde. [Information and technology: challenges to
developing a national health information network.] Physis: Rev Saude
Coletiva 1998; 8: 95–123.

10. Martinez A,
Villarroel V, Seoane J, del Pozo F. Analysis of information and communication
needs in rural primary health care in developing countries. IEEE Trans Inf
Technol Biomed 2005; 9: 66–72.

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

12. Cohn A, Westphal
MF, Elias PE. Data and the process of formulating health policies. Rev Saude
Publica 2005; 39: 114–21.

13. Gladwin J, Dixon RA, Wilson TD. Implementing a new health
management information system in Uganda. Health Policy Plan 2003;
18: 214–24.

14. Viacava F, Dachs
JNW, Travassos C. Os inquéritos domiciliares e o Sistema Nacional de Informações
em Saúde. [Household surveys and the National Health Information System.]
Cienc Saúde Coletiva 2006; 11: 863–9.

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

16. Facchini LA,
Piccini RX, Tomasi E et al. Monitoramento e avaliação do Projeto de Expansão e
Consolidação da Saúde da Família: relatório final. Pelotas: UFPel, 2006.
Available at: www.epidemio-ufpel.org.br/proesf/index.htm.

17. Herman T, Marcelo
A, Marcelo P, Maramba I. Linking primary care information systems and public
health vertical programs in the Philippines: an open-source experience. AMIA
Annu Symp Proc 2005: 311–15.

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

19. Brasil, Ministério
da Saúde. PNIIS – Política Nacional de Informação e Informática em Saúde;
proposta versão 2.0; inclui deliberações da 12a
Conferencia Nacional de Saúde. Brasília: MS, 2004. Available at:
www.datasus.gov.br.

20. Brasil, Ministério
da Saúde. Portaria n° 35 de 4 de janeiro de 2007 que institui, no âmbito do
Ministério da Saúde, o Programa Nacional de Telessaúde. Brasília: MS, 2007.
Available at:
dtr2004.saude.gov.br/dab/docs/legislacao/portaria35_04_01_07.pdf.

21. Barbosa AK, de A
Novaes M, de Vasconcelos AM. A web application to support telemedicine services
in Brazil. AMIA Annu Symp Proc 2003: 56–60.

22. Tomasi E, Facchini
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public health actions.] Rev Saúde Publica 2003; 37:
800–6.

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Saúde). DATASUS: informações em saúde Brasília: MS, 2002. Available at:
www.datasus.gov.br.

24. OMS (Organização
Mundial da Saúde). CID 10. [International Classification of
Diseases, 10th revision.] São Paulo: EDUSP, 1996.

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

Adesina Iluyemi

Introduction

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

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

Opportunities in m-health for addressing global
health
problems

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

reduce child
mortality from childhood diseases

improve maternal
health

combat HIV/AIDS,
tuberculosis and malaria.

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

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

Primary health care

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

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

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

Case study 1

Background

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

Case description

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

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

Case study 2

Background

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

Case description

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

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

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

Case study 3

Background

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

Case description

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

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

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

In 2002, there were 6 CBHWs and 250 patients. At present,
there are about 46 CBHWs in 4 rural and peri-urban sites, managing about
3500 PLWHA. Recent indications are that the programme may not be sustained
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
mostly rural and poor population. Ayurveda, a 5000-year-old practice, is
an example. Ayurveda uses medicinal plants to create low-cost drugs for
managing chronic and acute diseases. These services are delivered by
traditional CBHWs, who provide home consultation to clients in rural
areas. In 2001, Jiva Health, an Ayurvedic health care provider, decided to
develop an m-health system known as Jiva TeleDoc for supporting the
homecare activities of its CBHWs. The aim was to develop a sustainable
solution that was appropriate for the primary health needs of villagers in
India.

Case description

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

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

Case study 5

Background

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

Case description

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

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

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

Case study summary

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

Table 5.1 Stakeholders involved in
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
(MIT), USA

2. All India Institute of Medical Sciences (AIIMS),
India

3. State Ministry of Health of Haryana, India

EHAS

1. Biomedical Engineering and Telemedicine Group of the
Technical University of Madrid (GBT–UPM), 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
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,
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
sources

Case

Funding organizations

Ca:sh

1. Media Lab India

2. Ministry of Information Technology, Government of
India

3. Fogarty International Centre, National Institutes of
Health (NIH), USA

4. Media Lab, Massachusetts Institute of Technology,
USA

EHAS

1. Spanish Agency for International Cooperation
(AECI)

2. Spanish Interministerial Commission for Science and
Technology (CICYT)

3. Latin American Program for Science and Technology for
Development (CYTED)

4. Supervisory Organization for Private Investments in
Telecommunication in Peru (OSIPTEL)

5. World Bank InfoDev program

6. Committee for Solidarity and Development of the UPM,
the Council of Madrid

7. Spanish Association of Engineers of the ICAI and the
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
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
work described in the case studies (Table 5.2). The source
of funding for these m-health programmes was mostly international not-for-profit
organizations (Table
5.3).

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

Technology interfaces

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

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

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

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

Social

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

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

Finance

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

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

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

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

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

Government

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

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

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

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

Conclusion

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

Further reading

Al-Hakim L, ed. Web Mobile-Based Applications for
Healthcare Management. Hershey: IRM Press, 2007.

Istepanian R, Laxminarayan S, Pattichis CS, eds.
M-Health: Emerging Mobile Health Systems. Berlin: Springer, 2005.

Bangert DC, Doktor R, Valdez M, eds. Human And
Organizational Dynamics in E-Health. Oxford: Radcliffe Publishing,
2005.

Latifi R, ed. Current Principles and Practices of
Telemedicine and e-Health. IOS Press, 2008.

Spil T, Schuring RW. E-Health Systems Diffusion and
Use: The Innovation, the User and the UseIt Model. Hershey: Idea Group
Publishing, 2005.

Xiao Y, Chen H. Mobile Telemedicine: A Computing and
Networking Perspective. Boca Raton: Auerbach Publications, 2008.

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Kekki P. Primary health care and the Millennium Development Goals: issues
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15. Graves M, Grisedale
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16. Graves M, Reddy NK.
Electronic support for rural health-care workers. In: Bhatnagar S, Schware R,
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Co-constructing local meanings for child health indicators in community-based
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Villarroel V, Seoane J, Pozo FD. Rural telemedicine for primary healthcare in
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S. Computer-based health information systems – projects for computerization or
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Medical Information Science Reference, 2008.

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Strategies for developing human resource capacity to support sustainability of
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Salazar A. Why Health Care Information Systems Succeed or Fail.
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the micro. Inf Soc 2007; 23: 327–44.

6 Global e-health policy: From concept to
strategy

Richard E Scott

Introduction

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

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

The rapid development of e-health is causing many changes, the
social outcomes of which will be mixed. Winners will be best placed to take
advantage of the changes. Losers will not only be left behind technologically,
but also be in danger of losing the expanded services capable of being provided
through e-health. In order to maximize the number of winners, many challenges
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
following ‘North–South’ scenario.

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

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

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

And the patient … ?

Global health

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

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

Global e-health

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

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

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

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

Relevance of global e-health

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

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

transportation. A potentially contagious person or product can
now travel to anywhere in the world within 1–2 days. Kaul and Faust4 noted the relevance of this in terms of political
boundaries – ‘In today’s world, globalization has brought about
interdependencies that blur the distinction between domestic and external
affairs’ – and noted that ‘the best way to ensure one’s own well-being is to be
concerned about that of others’.

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

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

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

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

Public –
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
opportunity exists to achieve benefits on a more widespread basis, but several
factors will influence this, particularly in regard to developing countries.
Some are health related, some are ICT related, and others touch on
socio-political matters, including cultural sensitivities, governance and
policy.

Global e-health and developing countries

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

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

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

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

Global e-health policy perspective

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

Borders and
boundaries

Some observers consider that national borders are becoming
less meaningful.6 Certainly, they are becoming more porous to
health threats as a result of international mobility.3 Global e-health has the ability – if developed
correctly – to transcend existing geopolitical, sociocultural and temporal
boundaries. By so doing, it could help to solve some of the health care problems
facing the world’s population. This potential also raises concerns, such as the
‘jurisdictional gap’ and fear of loss of control that must be addressed if
e-health is to have the desired global benefits.7–9

Stakeholders

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

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

Changing
‘governance’

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

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

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

The breadth of policy
issues

E-health has been practised in some countries for several
decades, and comprises health informatics and telehealth (see Figure 6.1). E-commerce
and e-learning are distinct but related elements. Although originally quite
localized in application, e-health solutions have became more national (crossing
domestic borders) and even global (crossing national borders) – referred to as
inter-jurisdictional e-health activity.12 Such activity is often performed on the basis of
‘good Samaritan’, intra-professional consulting, or specific and limited
inter-agency agreements. However, the need for broad policy to facilitate
unfettered inter-jurisdictional activity has been recognized for many
years.13–15

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

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

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

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

‘Glocal’ e-health policy development: cautionary
examples

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

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

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

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

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

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

The African policy environment

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

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

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

EU directive on protection of personal
information

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

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

Malaysia’s e-health policy

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

EU initiative

In support of the European eHealth Action Plan, a report
called Legally eHealth28 was intended to place e-health in a European
legal and regulatory context. The report focused on how EU legislation on data
protection, product and services liability, and trade and competition law
applies. The report correctly noted that ‘until these issues are tackled head-on
in real cases, we will not begin to change the legal landscape in order to
provide fertile ground for new developments’. However, if the resulting EU
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
least, such an approach will result in many years of retrospective policy
realignment with other jurisdictions, maintaining rather than removing
inter-jurisdictional barriers to global e-health practice. At the worst, it may
ostracize developing countries from the global e-health community. Such
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
realignment. This is the status quo. It maintains the confusion and
prevents streamlined global e-health, and will require years of retrospective
policy realignment to bring the many disparate approaches together. In the
interim, many potential benefits of global e-health may be denied to the world’s
population.

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

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

Conclusion

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

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

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

Further reading

Commonwealth Secretariat. Commonwealth Health
Ministers Book 2008 – E-health. London: Henley Media Group, 2008.

eHealth ERA. Database of European eHealth Priorities
and Strategies. Available at: www.ehealth-era.org/database/database.html.

World Health Organization. Building Foundations for
eHealth. Progress of Member States. Geneva: WHO, 2006.

References

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

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

3.
MacPherson DW, Gushulak BD. Human mobility and population health: new approaches
in a globalizing world. Perspect Biol Med 2001; 44:
390–401.

4.
Kaul I, Faust M. Global public goods and health: taking the agenda forward.
Bull World Health Organ 2001; 79: 869–74.

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

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

7.
Bettcher D, Lee K. Globalisation and public health. J. Epidemiol Community
Health 2002; 56; 8–17.

8.
Rigby M. The management and policy challenges of the globalisation effect of
informatics and telemedicine. Health Policy 1999; 46:
97–103.

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

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

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

12. Scott RE, Jennett
P, Yeo M. Access and authorisation in a glocal e-health policy context. Int
J Med Inform 2004; 73: 259–66

13. Bashshur RL. Health
policy and telemedicine. Telemed J 1995; 1: 81–3.

14. Gobis LJ. Licensing
and liability: crossing borders with telemedicine. Caring 1997;
16: 18–24.

15. White AW, Wager KA,
Lee FW. The impact of technology on the confidentiality of health information.
Top Health Inf Manage 1996: 16; 13–21.

16. Stanberry B. Legal
and ethical aspects of telemedicine. J Telemed Telecare 2006;
12: 166–75.

17. Khoja S, Durrani H,
Fahim A. Scope of Policy Issues for eHealth: Results from a Structured
Review. Available at:
ehealth-connection.org/files/conf-materials/ScopeofPolicyIssuesforeHealth_0.pdf

18. Scott RE.
Investigating e-health policy – tools for the trade. J Telemed Telecare
2004; 10: 246–8.

19. Varghese S, Scott
RE. Categorising the telemedicine policy response of countries and their
implications for complementarity of telemedicine policy. Telemed J E
Health 2004; 10: 61–9.

20. Scott RE, Chowdhury
MFU, Varghese S. Telemedicine policy – looking for global complementarity. J
Telemed Telecare 2002; 8(Suppl 3): 55–7.

21. Scott RE.
‘Glocal’ e-Health – A Conceptual Policy Development Framework.
Available at: www.mrc.ac.za/conference/satelemedicine/Scott3.pdf.

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

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

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

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

26. African Union.
Africa Health Strategy 2007–2015. Available at:
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.
Available at: www.parlimen.gov.my/actindexbi/pdf/ACT-564.pdf.

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

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

Laurent Elder and Michael Clarke

Introduction

In 1970, Lester B Pearson, then Prime Minister of Canada and a
strong proponent of international development, stated the need for ‘a new
instrument concentrating more attention and resources on applying technology to
the solution of … economic and social problems on a global basis’.1 In May 1970, the International Development
Research Centre (IDRC) was founded by an act of the Canadian parliament. One of
the Centre’s priorities was Information and Communication Technologies for
Development (ICT4D), since access to information and an effective means to
communicate are necessary for sustainable development. IDRC’s ICT4D programme
now supports projects in Africa, Asia, Latin America and the Caribbean at a cost
of nearly Can$20 million each year.

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

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

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

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

How do different
user groups access and use these programmes?

Early work

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

Telemedicine in Uganda

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

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

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

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

E-health applications in Asia

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

Table 7.1 Telemedicine and e-health
projects funded by the PAN Asia small grants programme

Country

Project

Organization

Grant
(US$)

India

ICT-enabled life skill and sexuality education for
adolescent girls

Centre for Women’s Development and Research

8911

India

Using ICT to build capacities of HIV/AIDS service
providers in India

SAATHII (Solidarity and Action Against The HIV Infection
in India)

29 786

India

Impact of remote telemedicine in improving rural health,
India

n-Logue Communications Pvt Ltd

29 313

Indonesia

Development of ICT-based telemedicine system for primary
community health care in Indonesia

Biomedical Engineering Program, Department of Electrical
Engineering, Institut Teknologi Bandung (ITB)

29 479

Indonesia

Development of ICT-based mobile telemedicine system with
multiple communication links for urban and rural areas in Indonesia

Biomedical Engineering Program, Department of Electrical
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
Pakistan

Sustainable Development Networking Programme,
Pakistan

28 500

Philippines

A community-based child injury surveillance system: rapid
data collection using SMS

Medical Informatics Unit, College of Medicine, University
of the Philippines

22 642

Philippines

Mobile telemedicine and information resource system for
community health workers

SynapseHealth Solutions, Inc

29 784

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

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

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

Figure 7.1 Indonesian mobile telemedicine
application being demonstrated

Figure 7.2 Indonesian mobile telemedicine
application

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

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

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

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

knowledge production
– any type of publication

research targeting,
capacity building and absorption – follow-on research, training of staff

e-health solution
adoption or integration – expansion or adoption of an e-health solution

informing policy –
policy documents, meetings with government officials

broader community,
institutional, or country benefit – including social and economic benefit

health benefits to
individuals or the population – more effective health care.

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

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

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

Present work

The early telemedicine projects that IDRC supported did not
achieve all that was expected of them and raised more questions than it
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
in conjunction with other African partners. The project was designed to study
the application of ICT in the HIV/AIDS response in Uganda, Kenya, Tanzania,
South Africa and Botswana. After conducting a literature review, the project
staff undertook an electronic survey of individuals and organizations involved
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
Tanzanians generally obtained their information on antiretroviral treatment
(ART) from traditional media, rather than new media (Table 7.2). However, a
surprisingly high proportion (30%) of South Africans obtained information from
mobile phones and SMS. The assumption is that, as access to mobile telephony and
the Internet rises in Africa, so will the number of people accessing health
information from mobile phones.

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

Table 7.2 Sources of information on
antiretroviral therapy.10 Values
shown are percentages of sample (n = 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
ICTs for the fight against HIV/AIDS.10 Values
shown are percentages of sample (n = 990)

Factor

South Africa
(%)

Tanzania
(%)

Inappropriate language

81

58

Inappropriate and embarrassing messages

73

49

Lack of information, education and communication
materials

80

81

Lack of feedback mechanism

82

67

Lack of enabling ICT policies

82

63

Poor infrastructure/physical access

86

80

People’s attitudes

85

75

Traditional/cultural beliefs

87

80

Cost

85

68

Illiteracy

90

81

Table 7.4 Effectiveness of ICTs.10 Values
shown are percentages of sample (n = 990)

ICT

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

Finally, according to the AfriAfya study, the best practices for
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
‘modern’ ICT is still very limited, but that there is huge potential; that
institutions and health workers remain reliant on ‘conventional’ ICT and that
there is therefore a need to integrate both ‘modern’ and ‘conventional’to obtain
the best results; and, perhaps most important, that to change perceptions and
behaviours requires careful planning and patience.

Acacia project

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

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

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

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

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

maintenance of
patient records for HIV-positive patients’ lifelong drug treatments;

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

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

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

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

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

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

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

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

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

The questions that PAN would like to answer are:

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

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

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

PANACeA project

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

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

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

a disaster/emergency
telemedicine system;

a cost–benefit
analysis of hospital information management system data mining and data
warehousing;

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

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

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

use of mobile phones
for referral of pregnant women.

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

Future work

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

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

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

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

Further reading

AED-Satellife. Uganda Health Information
Network. Available at: pda.healthnet.org/.

Dansky KH, Thompson D, Sanner T. A framework for
evaluating eHealth research. Evaluation and Program Planning 2006;
29: 397–404.

E-health. Interview with Michael Clarke.
Available at: www.ehealthonline.org/inter-view/interview-details.asp?interviewid=161.

IDRC. Acacia Initiative. Available at: www.idrc.ca/en/ev-5895-201-1-DO_TOPIC.html.

IDRC. Telemedicine/Health. Available at: www.idrc.ca/en/ev-22782-201-1-DO_TOPIC.html.

References

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

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

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

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

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

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

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

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

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

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

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

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

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

14. IDRC. PAN
Prospectus 2006–2011. Available at:
www.idrc.ca/en/ev-9622-201-1-DO_TOPIC.html.

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

16. Gauld R. Public
sector information system project failures: lessons from a New Zealand hospital
organization. Government Information Quarterly 2007;
24: 102–14.

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

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

Introduction

Logic suggests that employing information and communication
technology (ICT) to deliver health care at distance (i.e. telehealth or
e-health) would be useful to address at least some of the problems in developing
countries. There is a growing body of literature to attest to this argument.1–3 In the early
1990s, there was a general expectation that e-health would solve the main
problems in health care in developing countries. However, the progress actually
made with e-health in developing countries has been rather limited to date. It
is also true that the use of e-health in industrialized countries is limited.4

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

Role of national governments in
promoting
e-health

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

Most developing countries in recent years have recognized the
importance of ICT in their economic development and social progress.6–8 A number of
countries in the developing world have initiated national policies towards
integrating ICT into their economic plans.9–12 However, it
is surprising that, in most cases, these national ICT initiatives have not considered the health sector as an important
sector.

We believe that the exclusion of the health sector in national
ICT initiatives is a major cause of the slow progress of e-health in developing
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
the benefits among policy makers

lack of evidence for
the benefits

limited finance

prejudice

lack of
expertise

health system
inertia.

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

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

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

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

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

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

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

Strategies at national level

Strategies to promote e-health at national level include:

raising awareness of
policy makers

expanding e-health
education

changing the
attitude of policy makers

using expatriate
communities.

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

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

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

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

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

Role of international agencies

International agencies such as the World Health Organization
(WHO), the United Nations (UN), the World Bank and certain regional
organizations (e.g. the African Union and SAARC) have recognized the value of
ICT in development.20–22 In fact the
WHO has been instrumental in promoting e-health in a number of ways.23 Some of these organizations have been involved
in e-health projects in different parts of the world.24

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

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

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

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

Key findings

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

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

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

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

Proposed action

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Strategies at international level

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

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

Table 8.1 E-health projects in Sri
Lanka

Date

Project

Description

2001

Three-day course on basic and specialist skills in
general surgery

The course was conducted by the Royal College of
Surgeons of England and was delivered by distance education11

2001

Feasibility study in partnership between the WHO and the
Norwegian Centre for Telemedicine

This aimed to examine the potential for telemedicine in
addressing problems of the health care sector in Sri Lanka12

2003

Pilot e-health project funded by the WHO in
collaboration with the Ministry of Health of Sri Lanka

This low-cost, store-and-forward telemedicine system was
designed to connect doctors in remote hospitals with specialists for
consultation13

2003

WHO-initiated pilot programme

This was designed to create a national telemedicine
system, paying attention to wireless communication technologies in
telehealth14

2005

‘E-health Emergency Hospital’ project

The objectives of the project were to improve recording
and reporting, improve communication via the Internet and email, and
improve access to specialist advice in cases of emergency14

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

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

Conclusion

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

Further reading

Eysenbach G. Poverty, human development, and the role of
e-health. J Med Internet Res 2007; 9: e34.

Khoja S, Scott RE, Casebeer AL et al. E-health readiness
assessment tools for health-care institutions in developing countries.
Telemed J E Health 2007; 13: 425–31.

Latifi R. The do’s and don’t’s when you establish
telemedicine and e-health (not only) in developing countries. Stud Health
Technol Inform 2008; 131: 39–43.

Wootton R, Youngberry K, Swinfen P, Swinfen R.
Prospective case review of a global e-health system for doctors in developing
countries. J Telemed Telecare 2004; 10(Suppl 1):
94–6.

References

1.
Al-Shorbaji N. WHO EMRO’s approach for supporting e-health in the Eastern
Mediterranean. East Mediterr Health J 2006; 12 (Suppl
2): S238–52.

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

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

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

5.
Kumaranayake L, Mujinja P, Hongoro C, Mpembeni R. How do countries regulate
health sector? Evidence from Tanzania and Zimbabwe. Health Policy Plan
2000; 15: 357–67.

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

7.
Wang EH. ICT and economic development in Taiwan: analysis of the evidence.
Telecommunications Policy 1999; 23: 235–43.

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

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

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

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

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

13. World Health
Organization Regional Office for the Eastern Mediterranean. Intercountry Meeting
on Tele-medicine (Riyadh, Saudi Arabia, 7–9 February 1999).Conclusions and
Recommendations. Available at:
www.emro.who.int/HIS/ehealth/Meetings-TelemedicineSAA1999.htm.

14. Drury P. The
eHealth agenda for developing countries. World Hosp Health Serv, 2005;
41: 38–40.

15. Metaxiotis K,
Ptochos D, Psarras J. E-health in the new millennium: a research and practice
agenda Int J Electron Healthc 2004; 1: 165–75.

16. Edirippulige S,
Marasinghe RB, Smith AC et al. Medical students’ knowledge and perceptions of
e-health: results of a study in Sri Lanka. In: MEDINFO 2007. Amsterdam:
IOS Press, 2007: 1406–9.

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

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

19. Edirippulige S,
Smith AC, Young J, Wootton R. Knowledge, perceptions and expectations of nurses
in e-health: results of a survey in a children’s hospital. J Telemed
Telecare 2006; 12(Suppl 3): 35–8.

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

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

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

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

24. Marasinghe RB,
Edirippulige S, Smith AC et al. A snapshot of e-health activities in Sri Lanka.
J Telemed Telecare 2007; 13(Suppl 3): 53–6.

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

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

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

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

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

30. World Health
Organization Regional Office for the Eastern Mediterranean. Fourth Regional
e-Health Conference: Building the Electronic Health Record (Teheran,
Islamic Republic of Iran, 7–9 September 2004).Conclusions and
recommendations. Available at:
www.emro.who.int/his/ehealth/meetings-iran2004-recommendations.htm.

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

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SECTION 3
EDUCATIONAL

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

Maria Zolfo, Verena Renggli, Olivier Koole and Lut
Lynen

Introduction

In December 2003, the World Health Organization (WHO) and the
Joint United Nations Programme on HIV/AIDS launched the ‘3 by 5’ initiative to
help low- and middle-income countries provide treatment to three million people
living with HIV/AIDS. Although the target date of December 2005 was not met, the
global efforts to scale up access to antiretroviral therapy (ART) have brought
positive changes worldwide. At the end of 2006, more than two million people
living with HIV were being treated with ART in low- and middle-income
countries.1

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

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

The HIV/AIDS TELEmedicine service

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

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

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

Service usage

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

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

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

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

Figure 9.1 TELEmedicine website3

Figure 9.2 TELEmedicine website discussion
forum

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

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

User satisfaction

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

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

Computer skills

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

At the end of the short courses in 2004 and 2005, we assessed
physicians’ access to the web and their abilities to use computers while working
in the field. Out of the total of 84 trained physicians, who were mainly African
and Asian nationals working for international organizations or for the ministry
of health, 75 completed the questionnaires. While 11% of the
physicians stated that they did not have access to the web, almost all of them
(74/75) said that they had their own email account. Of the respondents, 69%
preferred to access the Internet in the evening (17:00–midnight). A connection
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
a sound card on their computers. Two-thirds of the users reported that they were
able to download files and to use software such as Acrobat, Excel, PowerPoint,
WinZip and Word.

Online course

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

The eSCART content is structured into 13 different modules and
uses a problem-based learning approach with clinical cases, tutorials,
additional readings and self-assessments. At a workload of 4–5 study hours per
week, the 3-week face-to-face course requires a minimum of 3 months’ online
training. To expand the availability of the eSCART course, we intend to work
with appropriate international organizations and offer adaptations for HIV/AIDS
programmes in low-resource settings.

Other telemedicine approaches

Consultations

Some HIV/AIDS programmes in low-resource settings have
developed a consultation system that allows newly trained providers to ask
questions of an expert through direct telephone calls, email and call centres.
Telephone contact is usually set up so that health care workers and patients can
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
Disease Institute (IDI) of Makerere University in Kampala hosts a call centre
that responds to providers’ treatment questions. The centre operates during
normal office hours.10 It is staffed
by clinical pharmacists, who are supported by the IDI faculty. The call centre
automatically records the caller’s telephone number, and the staff return the
call at no cost to the caller. The centre automatically develops a database of
the most frequently asked questions.11

Satellife (HealthNet)

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

Case conferences

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

Twinning

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

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

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

Other web-based collaboration and telemedicine
systems

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

AIDSPortal

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

Community-based HIV treatment programme in
Haiti

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

Cell-Life

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

RAFT (Réseau en Afrique Francophone pour la
Télémedecine)

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

iPath

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

Conclusions

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

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

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

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

Acknowledgements

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

Further reading

Latifi R. Establishing Telemedicine in Developing
Countries: From Inception to Implementation. Amsterdam: IOS Press,
2004.

Norris AC. Essentials of Telemedicine and
Telecare. Chichester: Wiley, 2002.

Sørensen T. Guidelines for a country feasibility
study on telemedicine. Norwegian Centre for Telemedicine, 2003. Available
at: www.telemed.no/guidelines-for-a-country-feasibility-study-on-telemedicine.64916-7398.html.

Swinfen Charitable Trust Website. Available at: http://www.swinfencharitabletrust.org/.

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

References

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

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

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

4.
Zolfo M, Lynen L, Dierckx J, Colebunders R. Remote consultations and HIV/AIDS
continuing education in low-resource settings. Int J Med Inform 2006;
75: 633–7.

5.
Zolfo M, Arnould L, Huyst V, Lynen L. Telemedicine for HIV/AIDS care in low
resource settings. Stud Health Technol Inform 2005;
114: 18–22.

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

7.
Zolfo M, Koole O, Renggli V et al. Online consultations for HIV/AIDS care in
resource-limited settings. In: Proceedings of the 11th Congress of the
International Society for Telemedicine, 26–29 November 2006, Cape Town,
South Africa.

8.
Zolfo M, Renggli V, Koole O et al. Telemedicine survey on users’ satisfaction.
In: Proceedings of the 11th Congress of the International Society for
Telemedicine, 26–29 November 2006, Cape Town, South Africa.

9.
Zolfo M, Lynen L, Renggli V et al. Computer skills and digital divide for
HIV/AIDS doctors in low resource settings. In: Proceedings of Med-e-Tel, 5–7
April 2006, Luxexpo, Luxembourg.

10. AIDS Treatment
Information Centre Website. Available at:
www.idi.ac.ug/index.php?m=menu&i=170.

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

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

13. Clevenbergh P, Van
der Borght SF, van Cranenburgh K et al. Database-supported teleconferencing: an
additional clinical mentoring tool to assist a multinational company HIV/AIDS
treatment program in Africa. HIV Clin Trials 2006; 7:
255–62.

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

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

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

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

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

19. Skinner D, Rivette
U, Bloomberg C. Evaluation of use of cellphones to aid compliance with drug
therapy for HIV patients. AIDS Care 2007; 19:
605–7.

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

21. Geissbuhler A,
Bagayoko CO, Ly O. The RAFT network: 5 years of distance continuing medical
education and tele-consultations over the Internet in French-speaking Africa.
Int J Med Inform 2007; 76: 351–6.

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

23. Brauchli K,
Oberholzer M. The iPath telemedicine platform. J Telemed Telecare 2005;
11(Suppl 2): 3–7.

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

Philip O Ozuah and Marina Reznik

Introduction

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

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

There have been many reports suggesting the potential advantages
and benefits of telemedicine as a useful technique for delivering health care in
the developing world.5–8 However, few
authors have described the actual clinical experience of using telemedicine
there.9–13 The reported
use of telemedicine for children in developing countries is even more limited.14–17 Medical
Missions for Children (MMC) is a US not-for-profit organization that operates a
global videoconferencing network. It delivers expertise from medical specialists
and technicians based in hospitals in the USA to children needing care in
developing countries by using telemedicine.18

Medical Missions for Children

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

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

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

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

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

History

MMC was founded in March 1999 by Peg and Frank Brady at St
Joseph’s Children’s Hospital in Paterson, New Jersey, as a way of screening ill
children from developing countries prior to doctors travelling to treat them.
After eight years of operation, MMC serves children in over 100 countries
throughout Latin America, the Caribbean, Europe, Africa, Asia, the Pacific and
the Middle East. At least three patient consultations or diagnostic sessions are
held by videoconference each day, with 1000–1200 direct consultations conducted
every year. Since its inception, MMC has provided diagnostic consultations to
almost 25 000 children, using the expertise of more than 600 physicians from 27
mentoring hospitals via telemedical support.

Programmes

MMC’s work is accomplished through five programmes.

1. Telemedicine Outreach Programme

MMC operates a distance medicine network in more than 100
countries, called the Telemedicine Outreach Programme. This programme, a
partnership with the World Bank, allows physicians to be electronically linked
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
November 2005. It was developed as a means of helping physicians and other
health care professionals to stay abreast of the latest developments in the
medical field. High-quality, up-to-date medical education is delivered to
physicians and allied health care workers around the world by satellite
broadcasting and Internet streaming. The Intelsat 903 satellite is used to
broadcast medical content to an area that encompasses 9 million physicians, 14
million nurses, 5 million health care workers, 89 000 hospitals, and 16 000
universities and medical schools.18

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

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

3. Global Video Library of Medicine

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

4. Giggles Children’s Theatre

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

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

5. MMC-produced television shows

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

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

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

Figure 10.1 A Giggles Children’s Theatre
presentation of Aesop’s Fables

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

Case report

The first child helped by MMC, Yordano, was an 11-year-old boy
from rural Panama who was born with a cranial deformity resulting in the absence
of one eye, difficulty in swallowing and learning difficulties. Yordano comes
from a family of six. His father is a painter and his mother is a seamstress. He
has an 18-year-old brother, a 5-year-old brother and a healthy twin brother.
Yordano was the first child to use the MMC telemedicine network. He was examined
by the physicians at St Joseph’s Children’s Hospital in New Jersey, and it was
decided that he could be helped. A computer model of his head was created with
the help of interactive telemedicine to collect the measurements. Then, using a
computer, physicians designed titanium implants to correct his deformity. A
physical model was made to confirm that all the parts fitted properly. Yordano’s
doctors in Panama were involved with the preparation. However, it was decided
that his surgery should be performed at St Joseph’s. Yordano and his mother
arrived in the USA in November 2001 for the initial surgery. Subsequently,
Yordano had 11 surgical procedures performed at St Joseph’s to reconstruct his
skull and jaw, to create an eye socket for a prosthetic eye and to receive a new
titanium jaw (Figures
10.2–10.4).
After this surgery was completed, educational sessions were held by the surgeons from the USA, who used the MMC network to review
the procedure with 50 physicians from Panama. The plan is for Yordano to have
one more operation in Panama to align his jaw. He is now 17 years old and doing
well.

Figure 10.2 Yordano with Dr Hillel Ephros

Figure 10.3 Yordano, post surgery

Figure 10.4 Yordano, seven years after the
first operation

MMC and the Children’s Hospital at Montefiore

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

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

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

Conclusion

There are many potential benefits of using telemedicine to
deliver health care in the developing world.7–9 However, there
are few reports that describe the use of telemedicine for children in developing
countries. MMC, a non-profit-making organization, has a well-established
telemedicine network between mentoring hospitals in the USA and hospitals in
developing nations. Since its inception, the programme has provided direct
medical consultation and services to some 25 000 children in developing
countries.

Further reading

Reznik M, Marcin JP, Ozuah PO. Telemedicine and
under-served communities in developing nations. In: Wootton R, Batch J, eds.
Telepediatrics: Telemedicine and Child Health. London: Royal Society of
Medicine Press, 2005: 193–8.

Swinfen Charitable Trust Website. Available at: http://www.swinfencharitabletrust.org/.

References

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

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

3.
Edworthy SM. Telemedicine in developing countries. BMJ 2001;
323: 524–5.

4.
Zhao Y, Nakajima I, Juzoji H. On-site investigation of the early phase of Bhutan
Health Telematics Project. J Med Syst 2002; 26:
67–77.

5.
Einterz EM. Telemedicine in Africa: potential, problems, priorities.
CMAJ 2001; 165: 780–1.

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

7.
Groves T. SatelLife: getting relevant information to the developing world.
BMJ 1996; 313: 1606–9.

8.
Kastania AN. Telemedicine models for primary care. Stud Health Technol
Inform 2004; 104: 89–98.

9.
Wootton R. The possible use of telemedicine in developing countries. J
Telemed Telecare 1997; 3: 23–6.

10. Wootton R.
Telemedicine and developing countries – successful implementation will require a
shared approach. J Telemed Telecare 2001; 7(Suppl 1):
1–6.

11. Vassallo DJ,
Swinfen P, Swinfen R, Wootton R. Experience with a low-cost telemedicine system
in three developing countries. J Telemed Telecare 2001;
7(Suppl 1): 56–8.

12. Patterson V, Hoque
F, Vassallo D et al. Store-and-forward teleneurology in developing countries.
J Telemed Telecare 2001; 7(Suppl 1): 52–3.

13. Latifi R, Muja S,
Bekteshi F, Merrell RC. The role of telemedicine and information technology in
the redevelopment of medical systems: the case of Kosova. Telemed J E
Health 2006; 12: 332–40.

14. Lee S, Broderick
TJ, Haynes J et al. The role of low-bandwidth telemedicine in surgical
prescreening. J Pediatr Surg 2003; 38: 1281–3.

15. Person DA, Hedson
JS, Gunawardane KJ. Telemedicine success in the United States Associated Pacific
Islands (USAPI): two illustrative cases. Telemed J E Health 2003;
9: 95–101.

16. Graham LE,
Zimmerman M, Vassallo DJ et al. Telemedicine – the way ahead for medicine in the
developing world. Trop Doct 2003; 33: 36–8.

17. Qaddoumi I,
Mansour A, Musharbash A et al. Impact of telemedicine on pediatric
neuro-oncology in a developing country: the Jordanian–Canadian experience.
Pediatr Blood Cancer 2007; 48: 39–43.

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

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

11 Telementoring in India: Experience with endocrine
surgery

Saroj K Mishra, Puthen V Pradeep and Anjali
Mishra

Introduction

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

Intraoperative assistance has been described by several
authors.1,2 At the Sanjay
Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS) in Lucknow, we have
developed telementoring further, so that a mentor’s input is continuously
provided for the overall clinical care of the patient, to assist in diagnosis,
preoperative treatment planning and postoperative care.3 Telementoring
has been incorporated into the training and teaching programme of the Department
of Endocrine Surgery at the SGPGIMS. This department is one of only two in India
that provide curriculum-based training in this relatively new subspecialty.
Hence, the short-course training given in house to general surgeons is further
consolidated with telementoring. This model may be relevant to other developing
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
the state or province. The health system has a three-tiered structure: the
primary health care centres cover a group of villages, secondary level health
centres are at district level and medical colleges, located in big cities,
provide tertiary care. Private sector hospitals account for almost 60% of health
care.

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

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

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

SGPGIMS infrastructure

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

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

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

Partners

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

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

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

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

Telementoring and tele-education at the
SGPGIMS

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

Table 11.1 National telemedicine
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
benefited, since he had the operation performed locally, without having to
travel to a distant specialist centre. In fact, the general condition of this
patient was so poor that he could not have travelled to the specialist endocrine
surgical unit. For the telementoring session, both institutions were provided
with dedicated 512 kbit/s VSAT connectivity. Video and audio quality was good
enough for the expert at the SGPGIMS to guide the remote team
satisfactorily.

We have also used telementoring as a tool in subspecialty growth
in general4 and in
reinforcing endocrine surgical training.5 This has been done to meet local requirements,
since there is a lack of specialist endocrine surgical centres in India. As far
as structured endocrine surgical training is concerned, only two centres in
India provide the MCh (Master of Surgery) degree. They have an annual intake of
three candidates. In addition to the MCh training, short-course training (1–3
months) is also provided by the department at the SGPGIMS. The short-course
training is reinforced by the use of telemedicine. During a short training post
of three months, the trainees rotate through clinical and laboratory services
and attend all the academic sessions conducted by the department. Following
their return to their parent institute, telementoring is used to monitor their
endocrine surgical practice and to guide them in solving diagnostic problems, in
treatment planning and postoperative care.5 The trainees also receive mentoring from experts
in associated specialties such as nuclear medicine, endocrine pathology and
interventional radiology.5

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

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

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

Table 11.2 Conferences, CME and
workshops held

Year

No. of hours
of
transmission

5th Postgraduate Course in Endocrine Surgery (5
days)

2001

37

6th Postgraduate Course in Endocrine Surgery (5
days)

2003

40

Indian Thyroid Society Conference

2004

9

7th Postgraduate Course in Endocrine Surgery (5
days)

2005

36

8th Postgraduate Course in Endocrine Surgery (5
days)

2007

34

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

Figure 11.2 (a) Tele-CME session in
progress

Figure 11.2 (b) Tele-education session in
progress

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

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

Other telementoring and tele-education in
India

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

Telementoring and tele-education in other
developing
countries

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

Publications in the field of telementoring in endocrine surgery
from the developing world are very few in number. Even though there is paucity
of telementoring applications in the field of endocrine surgery in developing
countries, there are reports in other specialties. Lee et al13 reported
telementored laparoscopic varicocelectomy and nephrectomy in Bangkok, Thailand,
which was 17 500 km from the mentoring location at the Johns Hopkins Hospital in
Baltimore, USA. This experiment was conducted using ISDN lines at a bandwidth of
384 kbit/s. The authors concluded that transfer of knowledge and
teaching–learning were achieved and that the video pictures transmitted had
acceptable resolution and clarity. Similarly, transcontinental telementored
procedures (laparoscopic bilateral varicocelectomy and a percutaneous renal
access for a percutaneous nephrolithotomy) were carried out in collaboration
between surgeons in Baltimore and Sao Paulo and Recife in Brazil.14

Telementoring has been conducted using low-bandwidth mobile
telemedicine applications to support a mobile surgery programme in rural
Ecuador.15 This
involved a mobile operating room, which was taken to a remote region of Ecuador
(see Chapter 18). Using
a laptop computer equipped with telemedicine software, a videoconferencing
system and a digital camera, surgical patients were evaluated and operative
decisions were made via ordinary telephone lines. The surgeons in the mobile
unit in Ecuador were telementored by an experienced surgeon located at Yale
University in the USA. Apart from five preoperative evaluations, a laparoscopic
cholecystectomy was successfully telementored from the Department of Surgery at
Yale University School of Medicine to the mobile surgery unit in Ecuador. The
use of real-time surgical telementoring to teach complex ophthalmological
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,
Hawaii, to ophthalmologists at the Makati Medical Center in Manila, Philippines,
more than 8000 km away.16

Telemedicine has also been used asynchronously
(store-and-forward) for consultations and patient management by practitioners at
remote location. Vassallo et al17 reported the
establishment of a telemedicine link by the Swinfen Charitable Trust in July
1999, to support a lone orthopaedic surgeon practising in Savar, near Dhaka,
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
medical students pursuing elective study at a remote location in the developing
world and specialists at a central location was established between Gizo
Hospital in the Solomon Islands and Emory University Hospital in Atlanta, USA. A
visiting medical student used this facility to relay images and investigation
reports to specialists in Atlanta. This was used for telemedicine-aided
learning, thus providing expert support to medical students in remote
locations.18 A pilot
study at the Patan Hospital, Kathmandu, Nepal by the Swinfen Charitable Trust
has shown that a low-cost telemedicine link is technically feasible and can be
of significant benefit for diagnosis, management and telemedicine based
education in a developing world setting.19 Remote
monitoring of paediatric patients at the Children’s Field Hospital in Gudermes,
Chechnya, not only allowed significant number of patients to
be treated locally but also enabled the doctors at the peripheral location to
receive advice about operative techniques20 (see Chapter 25).

Problems concerning telementoring and tele-education
in
developing countries

Common health care delivery problems faced by developing
countries are infrastructural and organizational in nature. Infrastructural
problems include unreliable electricity supplies, poor telephone services, lack
of transport and lack of medical supplies. Organizational problems include a
lack of CME for health staff, poor training and supervision of health care
workers, shortage of doctors and health care workers, and too many patients.
Telemedicine may be useful in assisting with many of these difficulties. The
major challenges with telemedicine in developing countries are unrealistic
expectations, unsustainable funding models, lack of trials and evaluation data,
and lack of published results and sharing of expertise.

During the audit of the telemedicine programmes at the SGPGIMS
(2001–2005), it was found that only 61% of the scheduled sessions were held
successfully, i.e. 39% of sessions could not be conducted owing to technical or
human resource problems. Technical problems (23%) included power failure at the
remote end, disconnection of the VSAT link and shifting of the VSAT service
(Indian National Satellite System) to a new transponder. Human resource problems
(77%) included non-availability of doctors at the expert end (36%) or at the
remote end (35%), non-availability of technical staff at the remote end (7%) and
others.21

The legal and ethical barriers that are commonly cited in
telemedicine generally are also relevant in developing countries. These include
questions about medicolegal liability and recommendations for good clinical
practice, for which guidelines and protocols are still evolving. This is
especially true for cross-border practice.22 Other
concerns include standards, interoperability, product liability, intellectual
property rights and sharing of health information. Ethical and political matters
need to be addressed.23

At present, professional boundaries are definitely barriers to
the practice of telementoring both within and between countries. This may be
assisted by national health care regulatory bodies or by international agencies
such as the World Health Organization, which in consultation with its member
countries has the potential to develop a global regulatory framework. In the
meantime, accreditation of telementoring-based programmes needs to be carried
out by appropriate agencies in each country or at a global level.
Standardization of equipment, networks, technique, professional competence and
process needs to be worked out. Legal questions regarding the sharing of
responsibility as a result of the consequences of actions taken during
telementoring must be addressed. There are as yet no guidelines on these
matters. The health care regulatory body within each country needs to develop
legislation for safe practice via telemedicine.

Conclusion

Telemedicine has the potential to improve the utilization of
available resources for health care in developing countries. Our experience in
the specialty of endocrine surgery in India has demonstrated the effectiveness
of telemedicine applications in training, education and skills development. We
have successfully used telementoring for continuous reinforcement of endocrine
surgical training and also in the operating theatre for guided tumour removal.
Even though telemedicine-enabled applications are being explored in India and
other developing countries, few published reports have yet appeared. Deploying
and sustaining telemedicine and telementoring requires the commitment and
support of all those involved if success is to be achieved.

Further reading

Anvari M, Durst L. Development of a new telementoring
program. Healthcare Q 2000; 3(3): 26–30. Available at:
www.longwoods.com/product.php?productid=16718.

NASA. NEEMO 9 Mission Journal. Available at:
www.nasa.gov/mission_pages/NEEMO/NEEMO9/mission_journal_4.html.SGPGIMS.
Telemedindia.

References

1.
Rosser JC, Wood M, Payne JH et al. Telementoring. A practical option in surgical
training. Surg Endosc 1997; 11: 852–5.

2.
Bruschi M, Micali S, Porpiglia F et al. Laparoscopic telementored adrenalectomy:
the Italian experience. Surg Endosc 2005; 19:
836–40.

3.
Mishra SK, Mishra A, Pradeep PV. Telementoring in endocrine surgery. In: Kumar
S, Marescaux J,eds. Telesurgery. Heidelberg: Springer-Verlag,
2008.

4.
Pradeep PV, Mishra A, Kapoor L et al. Surgical sub-specialty growth in
developing country: impact of telemedicine technology; a case study with
endocrine surgery. In: Proceedings of the 8th International Conference on
E-Health Networking, Application and Services (Healthcom 2006), New Delhi:
34–9.

5.
Pradeep PV, Mishra A, Mohanty BN et al. Reinforcement of endocrine surgery
training: impact of tele-medicine technology in a developing country context.
World J Surg 2007; 31: 1665–71.

6.
Ministry of Communications and Information Technology. Recommended
Guidelines & Standards for Practice of Telemedicine in India. Available
at:
www.mit.gov.in/telemedicine/Report%20of%20TWG%20on%20Telemed%20Standardisation.pdf.

7.
Mishra SK, Gupta SD, Kaur J. Telemedicine in India: initiatives and vision. In:
Proceedings of the 9th International Conference on E-Health Networking,
Application and Services (Healthcom 2007), 19–22 June, Taipei, Taiwan:
81–3.

8.
SGPGI. Telemedicine. Available at: www.sgpgi-telemedicine.org.

9.
Pradeep PV, Mishra SK, Vaidyanathan S et al. Telementoring in endocrine surgery:
preliminary Indian experience. Telemed J E Health 2006;
12: 73–7.

10. Pradeep PV, Mishra
A, Kapoor L et al. Applications of tele-health technology in endocrine surgery:
Indian experience. In: Proceedings of the Telemedicine 2007 Conference,
31 May–1 June 2007, Montreal, Canada.

11. Ganapathy K.
Telemedicine and neurosciences in developing countries. Surg Neurol
2002; 58: 388–94.

12. Wootton R.
Telemedicine and developing countries – successful implementation will require a
shared approach. J Telemed Telecare 2001; 7(Suppl 1):
1–6.

13. Lee BR, Bishoff J
T, Janetschek G et al. A novel method of surgical instruction: international
telementoring. World J Urol 1998; 16: 367–70.

14. Rodrigues Netto N
Jr, Mitre AI, Lima SV et al. Telementoring between Brazil and the United States:
initial experience. J Endourol 2003; 17: 217–20.

15. Rosser JC Jr, Bell
RL, Harnett B et al. Use of mobile low-bandwith telemedical techniques for
extreme telemedicine applications. J Am Coll Surg 1999;
189: 397–404.

16. Camara JG,
Rodriguez RE. Real-time telementoring in ophthalmology. Telemed J 1998;
4: 375–7.

17. Vassallo DJ,
Swinfen P, Swinfen R, Wootton R. Experience with a low-cost telemedicine system
in three developing countries. J Telemed Telecare 2001;
7(Suppl 1): 56–8.

18. Mukundan S Jr,
Vydareny K, Vassallo DJ et al. Trial telemedicine system for supporting medical
students on elective in the developing world. Acad Radiol 2003;
10: 794–7.

19. Graham LE,
Zimmerman M, Vassallo DJ et al. Telemedicine – the way ahead for medicine in the
developing world. Trop Doct 2003; 33: 36–8.

20. Ehrlich AI,
Kobrinsky BA, Petlakh VI et al. Telemedicine for a children’s field hospital in
Chechnya. J Telemed Telecare 2007; 13: 4–6.

21. Kapoor L, Basnet
R, Chand RD et al. An audit of problems in implementation of telemedicine
programme. In: Proceedings of the 9th International Conference on E-health
Networking, Application and Services, 19–22 June 2007, Taipei, Taiwan:
87–9.

22. Stanberry B. Legal
and ethical aspects of telemedicine. J Telemed Telecare 2006;
12: 166–75.

23. Kapoor L, Basnet
R, Pradeep PV et al. Integrating telemedicine in surgical applications.
Comput Soc India Commun 2007; 30: 17–20.

SECTION 4
CLINICAL

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12 Teledermatology in developing countries

Steven Kaddu, Carrie Kovarik, Gerald Gabler and H Peter
Soyer

Introduction

The inherent visual nature of dermatology makes it suitable
for telemedicine. Several teledermatology projects have recently been initiated
in developing countries, and the number is gradually increasing.1–7 Preliminary
results underline a number of potential benefits to patients, remote health care
workers and health care systems of host countries. These benefits (Box 12.1) include easy
extension of specialized dermatological services to geographically remote areas
with few dermatologists, reduction of patients’ waiting time for appointments,
faster screening for skin diseases, promotion and coordination of scientific
health projects, and education of health workers and lay people.1–6,8 Local
physicians benefit from the mentoring and educational aspects of the
consultations, as well as the access to improved research facilities and
professional

Box 12.1 Potential benefits of
teledermatology

Benefits to patients

Enhanced
access to a trained dermatologist

Prompt
specialist opinion, leading to more accurate diagnosis and treatment
outcomes

Reduction of
patient’s waiting time

Reduction of
travel expenses

Benefits to local health care
workers

Improved and
efficient access to specialized dermatology care

Improved
management of patients with skin problems

New
opportunities for continued medical education

Enhanced
professional collaboration

Enhanced
collaboration in research

Access to
online atlases and databases

More efficient
screening of patients with skin problems

Better
follow-up of patients with selected skin problems

Benefits to local health care
system

Reduction in
health care costs

Reduction in
patient’s and physician’s travel costs

Reduction in
total number of hospital admissions, as well as faster
discharges

Increase
efficiency in the use of human resources

Increased and
effective support for local health professionals

Compilation of
online databases

interactions. Consulting experts also get special
opportunities to review rare or unusual dermatological cases.

As in other telemedicine systems, teledermatology employs both
store-and-forward methods (asynchronous) and real-time approaches
(synchronous).9 Both
modalities have previously been shown to be quite reliable and accurate when
compared with traditional face-to-face consultation.9–13
Store-and-forward systems are more widely used, owing to their lesser
technological requirements and affordability. Images are submitted by email or
presented on a web-based system. Although the real-time approach represents a
reasonable substitute for in-person consultation and has the advantage of
enhancing patient–doctor interaction, it is more time-consuming and
expensive.

Teledermatology may involve providing assistance, follow-up or
teaching. Tele-assistance models aim at teleconsultation, telescreening and/or
second opinion.7,14 The majority
of teledermatology projects in developing countries deal with dermatology
consultations. Telescreening projects have been used to manage waiting lists for
treatment of dermatoses with different healing times or to support prevention
programmes such as those surveying skin tumours.15
Telefollow-up systems deal with transmission of medical information regarding
follow-up and treatment progression of patients from remote centres (e.g. to
follow up patients treated for certain chronic skin conditions such as leg
ulcers and leprosy) and for postoperative evaluation.5,16
Tele-education is proving to be a versatile model, helpful in staff development
such as by tutoring and assessing medical and paramedical workers.7 Most
teledermatology collaborative projects also involve some degree of
tele-education in addition to tele-assistance. Thus, in addition to
long-distance consultation, they also provide continuing medical education (CME)
for physicians who submit cases. Applications for tele-education mainly
integrate text and images (static or dynamic) and/or virtual reality models to
achieve health education.

The use of web applications for discussion forums represents
another application of teledermatology. The main objective of such applications
is to create a quick and easy method for teleconsultation from a pool of expert
consultants. The philosophy behind these ‘DermOnline’ communities is open access
teleconsultation in dermatology, which means that these platforms are free to
all users and that the users themselves generate the content by sending and
answering the teleconsultations. These communities have moderators who check
both the subscribers and the content of the requests in order to guarantee
friendly and orderly virtual interaction.

Teledermatology in developing countries

There are several teledermatology networks and projects in
developing countries.

The telederm.org application and
networks

The telederm.org application was initiated by
the Department of Dermatology of the Medical University of Graz, Austria, in
2002. The primary goal was to develop a software application
that would facilitate worldwide exchange of knowledge and expertise in
dermatology and dermatopathology. The application is now used by several
teledermatology networks, some of which are active in developing countries,
including the telederm.org project and the Africa
Teledermatology Project.7,17–19 Versions of
the application are available in German, Italian, Chinese, Turkish languages,
Serbian and Hebrew.

The program provides the functionality to store and forward
medical cases with attached images. Within a particular network, users are
categorized as either clients or experts. Clients can only submit cases to
selected experts, whereas experts have the right to review cases, write comments
and suggest a diagnosis, or further forward cases to other selected experts
within the system (Figure 12.1). All users
can subscribe for notifications so that they get an automatic email if, for
example, a new comment is added to one of their cases or if a new case is
entered on the site. Every network has at least one administrator who is able to
register users and/or reassign consultations to preferred experts.

Figure 12.1 Africa Teledermatology project
data flow

All requests are archived in a database with a personal archive
for each user. A client can choose to send a request for consultation only to a
selected expert, or he or she can submit a request to an open forum as a
‘discussion case’. In the former situation, the user receives a personal answer
and interactions remain private. Cases submitted as ‘discussion cases’ are
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
the aim of creating an easy-to-use platform for teleconsultation services where
physicians could seek diagnostic advice in dermatology from a pool of expert
consultants and discuss challenging cases.18 An online
discussion forum was included in October 2003. At present, more than 1300
physicians are subscribed to the telederm.org project from over 90
countries worldwide. Through this application, participants from different
medical specialties are matched with dermatologists with a range of experience
in diagnosis and management of various skin diseases. By providing a platform
for interactive discussion between physicians at the point of care and experts
from different countries, the telederm.org project seeks to raise the
level of competence of physicians and dermatologists at the point of care on a
worldwide level.

The telederm.org project is a non-profit
venture under the auspices of the International Society of Teledermatology. The
main academic institutions involved are the Department of Dermatology, Medical
University of Graz, Graz (Austria) and the Dermatology Group, School of
Medicine, University of Queensland, Brisbane (Australia). Moderators of the
telederm.org
community come from a range of different countries, including Turkey, Croatia,
Romania, China, Pakistan, USA and India. The telederm. org project has 1024
users, with an average of 38 new users per month. It handles about 27 new cases
per month.

The Africa Teledermatology project

The Africa Teledermatology project20 was
initially conceived as the ‘Uganda Tele-Dermatology- and E-Learning-Project’ in
February 2007, with sponsorship from the Kommission für Entwicklungsfragen (KEF)
der Österreichischen Akademie der Wissenschaften. Its main objective was to
facilitate improvement of the treatment of skin diseases in Uganda by
establishing an Internet channel for long-distance dermatological consultation
between the medical Universities of Makerere and Mbarara in Uganda and the
Department of Dermatology, University of Graz. In collaboration with the
Department of Dermatology at the University of Pennsylvania, USA, the scope of
the project was expanded, with the eventual inclusion of a number of other
medical centres in eastern, central and southern Africa, which led to the
formation of the Africa Teledermatology project. The main purpose of this work
is to support African health workers in the diagnosis and management of patients
with skin diseases, especially those having skin conditions related to
HIV/AIDS.

The Africa Teledermatology project uses the telederm.org application
(Figure 12.2). There
are links on the application homepage to educational resources and a dermatology
curriculum. An online archive of tropical skin conditions should emerge

Figure 12.2 Dematologists and medical staff at
Mbarara university hospital, Uganda selecting and processing difficult cases of
skin diseases for teleconsultation

that will serve as an Internet source of educational material
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
aspects of teledermatology and teledermatopathology into health care systems of
developing countries.

In the first 12 months, 160 teledermatology-supported patient
encounters have been processed. Of these, 35% of cases were children and 25%
represented HIV-associated skin conditions. A number of Internet learning
facilities for medical personnel have been set up on the project website,
including an online case presentation with discussion, dermatology lectures and
an international forum of physicians with an interest in tropical dermatology.
Through this initiative, scientific cooperation has been established with a
number of specialists from well-known medical/dermatology centres worldwide, who
have contributed their experience in management of difficult skin conditions
submitted by colleagues in Africa.

iPath application and networks

The iPath software was developed by the Department of
Pathology of the University Hospital Basel as an open source framework for
building web- and email-based tele-medicine applications.21–23 iPath
provides the functionality to store medical cases with attached images and other
documents in closed user groups. Within these groups, users can review cases,
suggest diagnoses and submit comments. In addition, users can subscribe for
notifications so that they receive an automatic email message if, for example, a
new comment is added to one of their cases or if a new case is entered in a
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
group and who can delete erroneous data.

At present, iPath hosts several telemedicine networks active in
developing countries, several of which involve teledermatology. These include
the following.

Solomon Islands National Telemedicine Network

This is a joint project of the National Referral Hospital in
Honiara, South Pacific Medical Projects and the University of Basel.24 It aims to
use telemedicine to improve health care delivery in provincial hospitals in the
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
specialists in the Baltics, based on the iPath platform.25 Its purpose
is to support clinicopathological case discussions, consultations and CME.

RAFT-Forum (telemedicine platform of the Réseau de
Télé-enseignement et de Télémédecine en Afrique Francophone)

The main activity of this forum is the webcasting of
interactive courses for physicians and other health care workers in
French-speaking countries of Africa, including Mali, Mauritania, Senegal,
Morocco, Tunisia and Madagascar.26 The main
goal is to encourage knowledge sharing across medical
institutions in the various participating countries. Topics for discussion are
proposed by the partners of the network. The technology used for the webcasting
works with an Internet connection, a Java-enabled web browser (e.g. Internet
Explorer or Mozilla) and the free software RealPlayer.

Telemedicine Sur

This is a telemedicine platform for medical discussions, CME
and consultations for medical specialists and health practitioners in Latin
America.27 Specialties
involved include mainly pathology, dermatology and venereology, as well as
paediatrics.

West Africa Doctors and Healthcare Professionals
Network

This is a West African telemedicine network, again based on
the iPath software.28 Its goal is
to enhance the communication capabilities of doctors, particularly in the areas
of information access, distance learning (CME), telemedicine- and
knowledge-based support of diagnosis, and management of patients in various
specialties.

HealthNet Nepal

This is a health information and communication network in
Nepal that provides low-cost email, Internet access and a wide range of medical
and public health resources to the Nepalese health community.29 The network
began in 1994, and is subscribed to by over 230 health institutions and
organizations, including hospitals, clinics, university departments, research
sites and non-governmental organizations (NGOs) in both urban and rural areas.
The network enables health professionals throughout Nepal to communicate and
exchange knowledge.

Teledermatology project in Port St Johns, South
Africa

This project was initiated in 1999 at Port St Johns, a small
and poor provincial town on the east coast of South Africa, with the aim of
improving access to dermatological care for patients and family practitioner
clinical skills.30,31 The scope of
the project was to connect general practitioners from Port St Johns to a network
with dermatology specialists. The project started with email-based
store-and-forward teledermatology, but, since 2002, it has been using the iPath
software. In the first year, the server in Basel was used, but, since 2003, the
project has been connected to a telemedicine network run by the Telemedicine
Unit of the University of Transkei (UNITRA) in Umtata.

ITG telemedicine – the Institute of Tropical Medicine
website

The project was begun in 2003 by the Department of Clinical
Sciences at the Institute of Tropical Medicine, Antwerp, Belgium.32 Its aim was
to facilitate the introduction of antiretroviral therapy (ART) for patients
affected by HIV/AIDS in developing countries by providing training, distance
support and education to health care providers working in these settings. Advice
is given through email messages from a server list, and afterwards through a
discussion forum on a telemedicine website. Details of the patient’s history,
physical examination, images, laboratory findings and questions to be answered
have been received from a number of different countries.

Swinfen Charitable Trust

The Swinfen Charitable Trust was set up in 1998 by Lord and
Lady Swinfen to ‘assist poor, sick and disabled people in the developing world’
by providing access to expert medical advice from consultants all around the
world.33 It offers
provincial hospitals in developing countries the opportunity to submit cases to
specialists worldwide. Communication is via a simple email telemedicine system
using an automatic email messaging service developed by the Centre for Online
Health at the University of Queensland, Brisbane, Australia. The core of the
network is an automatic email routing system that directs the messages about
each case to the parties concerned (i.e. the referring doctor and the
specialists being consulted). The Swinfen Charitable Trust has been able to
establish telemedicine links between remote hospitals in the developing world
with international medical consultants in order to receive advice free of
charge. The remote hospitals and clinics are supplied with high-resolution
digital cameras and tripods, and medical staff are taught how to use the
equipment. The Swinfen Charitable Trust operates in over 30 countries, including
Afghanistan, Cambodia, East Timor, Iraq, Nepal, Papua New Guinea and Sri Lanka,
and offers specialist advice in a wide range of fields including dermatology,
dentistry, paediatrics, obstetrics and gynaecology, oncology, orthopaedics,
ophthalmology, neurology, plastic surgery and trauma (see Chapter 19).

Teledermatology outcomes

There have been few previous studies focusing on
teledermatology outcomes, and these have mainly involved projects in
industrialized countries.34–36 Generally,
diagnostic accuracy and clinical effectiveness represent the most popular
clinical outcome measures. The possible explanation for their repetitive
evaluation is the rapidly changing technology, especially that of the digital
cameras used in teledermatology.

As far as developing countries are concerned, there have not yet
been any large studies focusing on the clinical outcomes of teledermatology,
despite general consensus supporting the increased diagnostic accuracy and
clinical effectiveness possible using the technique. Problems in assessment of
clinical outcomes in projects in developing countries include mainly patient
loss to follow up and inadequate medical record systems, although similar
problems may also apply to traditional face-to-face consultations in this
setting.

The economic value, clinical benefits and sustainability of
teledermatology in developing countries remain to be formally proved. This is
primarily because evaluations of these economic outcomes require complex
analysis of the direct and indirect costs to national health providers and
patients, as well as assessment of the impact of teledermatology services on
earlier diagnosis and expert management.

Quality

A number of factors may lower diagnostic accuracy in
teledermatology. These include poor-quality images, insufficient clinical
information supplied, intrinsic difficulties of cases
submitted, interference of technology in the perception of three-dimensional
images, lack of ability to palpate or physically examine the patient, and lack
of proper training of physicians who submit cases or who give opinions, among
others. Poor-quality images may be of low resolution or may have a high level of
compression. Clinical information may be confusing owing to image files from
similar patients being separately sent or inconsistently coded. It is necessary
that medical workers be adequately trained to take good images and instructed
how to properly send cases before being involved in teledermatology projects. It
is also advisable to include a link to working instructions on the homepage of
teledermatology web applications; for example, see the Africa Teledermatology
project website.20

Legal problems

The increasing availability of health information about
individuals in electronic databases and through online networks has offered
tremendous benefits to physicians, health care workers and patients. However, it
has also created new legal challenges. There are presently extensive discussions
concerning the potential risks and complex legal problems associated with
telemedicine health care services provided to patients from remote locations
using telecommunication. Legal problems relate generally to problems concerning
the privacy of identifiable health information, and the reliability and quality
of health data, as well as medical liability. Since telemedicine in developing
countries is mainly practised across state borders, providers must be aware of
the potential risks concerning medical liability in the respective countries
where the patients are located. There is a need for developing countries to
adopt rules and regulations to address legal aspects involved in the use of
telemedicine in order to safeguard the rights of patients. Matters that need to
be considered include mainly safeguards about data forwarding, security of the
patient’s data (including images), confidentiality and the responsibilities of
health workers involved in telemedicine.

Generally speaking, local physicians are directly responsible
for treatments deriving from teleconsultations in dermatology. The medico-legal
position of remote expert dermatologists is similar to that when the telephone,
fax, email or letter is used for consultation, since all these methods amount to
the provision of advice from a distance, and normal standards of care and skill
should therefore apply. In teledermatology, there is an obligation to practise
to a reasonable level of skill. The referring doctor must give accurate clinical
information and submit representative images of reasonable quality. Complicated
treatment procedures recommended by remote experts need the patient’s permission
before being carried out.

Integration and intercultural context

Preliminary studies have confirmed the feasibility and
benefits of integrating teledermatology into the medical care systems of
developing countries. However, there are major challenges to sustainability,
including political, economic, technical as well as cultural barriers. Many
governments in developing countries are gradually recognizing
the potential of telemedicine to improve health care delivery and reduce
national health care budgets. Obviously, dermatology is not a main focus of
government and NGO health policies in developing countries, since available
resources are normally allocated to medical conditions with more serious
consequences, such as malaria, tuberculosis and HIV/AIDS rather than to
non-lethal skin disorders.

As a basis for introducing and sustaining teledermatology
services in developing countries, it is crucial that the relevant national
governments modernize internal communication in hospitals and remote medical
centres. Internet services need to be widely accessible, even in rural parts of
the developing world. The availability of email services in remote areas has
potential benefits for poor countries. It is cheap, requires relatively simple
hardware and software, and can easily deliver stored information. The deployment
of fixed or mobile telecentres promises to be valuable in bringing telemedicine
services to remote areas.

Cultural barriers may play a negative role in the sustainability
of teledermatology programmes, and may be based on individual, institutional or
societal attitudes. Individual patients may feel uncomfortable or refuse to be
involved in teledermatology owing to a lack of trust in the ability of the
technology to improve their health. This attitude may be based on inadequate
information as a result of political and economic differences, cultural
attitudes, language barriers and differences in perceptions of ‘health and
wellness’. Studies have shown that patients who are well acquainted with
computers and the Internet tend to be more open to the use of telemedicine.37 There is a
need for proper explanation in advance, together with information for patients
about teledermatology, such as what it is and what its benefits are, before
patients are offered teledermatology.

Local physicians and health workers may also adopt a negative
attitude to the use of teledermatology services for a number of reasons. They
may be uncomfortable about sending consultations in English, feel that
teledermatology cannot improve the health of their patients, distrust the safety
and privacy of the systems used, prefer the option of transferring patients, or
feel that teledermatology services cannot lower their health care costs.
Moreover, because of the limited number of doctors in developing countries,
local physicians and health workers may be concerned that teledermatology
systems will be time-consuming and generate unnecessary extra work. It is
therefore crucial that leaders at local hospitals and medical centres be engaged
early enough in the process of introducing teledermatology services and be made
aware of the potential and relative advantages of the technique. Participating
local physicians and health workers should also receive comprehensive education
and training packages, as well as support to improve their technical and media
skills, prior to their involvement in teledermatology projects. It is an
advantage to add formal guidelines and protocols of instructions on the
homepages of web applications. In order to facilitate faster adoption, local
health workers selected to participate in teledermatology projects should
preferably have prior experience in the use of the Internet.

In summary, consideration of a range of economic, political and
technical factors in the host country or institution during the planning and
early stages of implementation of teledermatology projects should help to ensure
the viability and sustainability, as well as the integration, of teledermatology
programmes (Box
12.2).

Box 12.2 Practical steps in setting up a
teledermatology project

1 Review prior telemedicine and teledermatology
activities in the region of interest.

2 Assess current technologies and telecommunications, as
well as human resources available.

3 Assess clinical, educational and administrative needs
and priorities.

4 Assess the ability of teledermatology to meet the
needs and willingness of health professionals to use the
technology.

5 Review the current policies (or lack of policies) that
may affect the practice of teledermatology in both the remote sites and
the referral centres.

6 Plan and distribute information and educational
packages to all individuals potentially involved.

7 Find out about available technology and
telecommunications links at all potential sites, and make sure that the
technology is available at remote sites.

8 Identify teledermatology technology that best meets
the needs of the communities, technical requirements and security, and is
compatible with the referral centres.

9 Establish contacts with potential remote
centres.

10 Establish a team of individual to help in strategic
planning, implementation and evaluation of the initial phases of the
project.

11 Contract and choose a vendor to install the required
IT infrastructure at each of the remote sites.

12 Identify the telecommunications options and work with
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
the technology

15 Educate the administrators/managers at the
teledermatology sites about how it may affect current workflow.

16 Initiate and conduct a preliminary evaluation of
design, implementation and technical performance, as well as clinical
staff and patient satisfaction

17 Develop an ongoing education and training programme
focused on individuals who are not part of the original
rollout.

Financial aspects

Most teledermatology activity in developing countries
represents pilot projects receiving subsidized funding from external governments
and NGOs, or from foreign universities and hospitals. There is very little
available information concerning the cost-effectiveness and sustainability of
these services. Economic analyses of the viability of teledermatology projects
are also complicated owing to the rapidly declining cost of hardware and
telecommunications, and the presence of a number of hidden costs and benefits,
such as the opportunity cost of a patient’s time and the intangible benefit of
an earlier correct diagnosis, which are hard to quantify. Nevertheless, for the
adoption of teledermatology services in countries with low resources, it is
necessary to obtain reasonable estimates of the financial consequences,
including the costs of implementation and subsequent operation. Proper prior
financial planning will help to ensure success and sustainability.

Implementation expenses in teledermatology projects mainly
comprise the costs for equipment (in a store-and-forward system, these include
digital camera and accessories, computers, image editing programs, a back-up
system and a printer), equipment maintenance, telecommunication and staff
training. Sustainability expenses tend not to depend on the
number of users/patients served. They include costs related to the operation and
running of the project, acquiring the physical space, supplies and travel.

Future developments

The number of medical centres using teledermatology in
developing countries is increasing, and the technique could soon become an
integral part of the health care system in some countries. Future technical
developments may improve the delivery of teledermatology consultations in
developing countries. For instance, the use of mobile phones with built-in
cameras represents a potential alternative to bulky digital cameras and
computers in more remote areas.16,38,39
Teledermatopathology, a related field to teledermatology, could refine
dermatology teleconsultation by providing a channel for confirming diagnoses as
well as for training and supervision and collaborative research. Until now,
establishing teledermatopathology services has been mainly hampered by the high
implementation costs.

There is an urgent need for physicians and health policy makers
in the developing world to establish standards and regulations concerning the
practice of telemedicine and teledermatology. Future studies should define the
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
patients. Studies focusing on teledermatology outcomes should be conducted to
confirm its clinical benefits and cost-effectiveness.

Finally, the global increase in the number of teledermatology
networks implies a need to establish a common international teledermatology
forum. Such a forum could serve to educate and assist users and policy makers in
different parts of the developing and industrialized world on how to optimize
teledermatology services, especially through identification of proven low-cost
technology approaches.

Further reading

FreeMedicalJournals.com.
Available at: http://www.freemedicaljournals.com/.

I Do Imaging: Free Medical Imaging Software. Available
at: www.idoimaging.com/index.shtml.

Krupinski E, BurdickA, Pak H et al. American
Telemedicine Association’s Practice Guidelines for Teledermatology.
Available at: www.liebertonline.com/doi/abs/10.1089/tmj.2007.0129.

Pak H, Burg G. Store-and-forward teledermatology.
eMedicine. Available at: www.emedicine.com/derm/topic560.htm.

Wootton R, Oakley A, eds. Teledermatology.
London: Royal Society of Medicine Press, 2002.

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Dermatol 2006; 141: 1319–20.

39. Massone C, Lozzi
GP, Wurm E et al. Personal digital assistants in teledermatology. Br J
Dermatol 2006; 154: 801–2.

13 Cross-cultural telemedicine via email: Experience in
Cambodia and the USA

Paul Heinzelmann, Rithy Chau, Daniel Liu and Joseph
Kvedar

Introduction

The Khmer empire was once the largest and most powerful in
South-East Asia. The descendant country of Cambodia is now home to over 14
million people. The Vietnam War and the violent reign of the Khmer Rouge in the
1970s left millions dead or traumatized. The collapsed health system was left
with an enormous burden of infectious diseases, malnutrition and psychological
trauma. In 1979, there were thought to be fewer than 50 doctors left in the
entire country.1

The average annual rate of 0.3 medical contacts per person
remains the lowest in the region. This may be primarily due to a lack of access,
as Cambodia has the lowest ratio of physicians to population in the region.2 Despite the
fact that 85% of Cambodians live in rural areas, only 13% of government health
workers work there.2 The problems
associated with the lack of access are compounded by frequent misuse of
prescription drugs and indigenous health practices that are at times
dangerous.3 For example,
animist healers may sometimes treat open fractures with a splint and a topical
application called ‘ma’lou’. This compound is made from chewed betel nut and
lime paste, and has been known to result in serious infection or even
death.

Poor health system performance has led to poor health outcomes.
One out of 12 children never lives to reach the age of five years,4 and among
antenatal clinic attendees, HIV is estimated at 2.2%, the highest reported for
any country in Asia.5 The
tuberculosis case rate (508 per 100 000 persons) is approximately 100 times that
of the USA and is the highest rate in Asia.6 Malaria
remains endemic, and has a prevalence of 5 per 1000 persons.7 Meanwhile,
there is a growing prevalence of chronic non-communicable disease, and traumatic
injuries and deaths from landmines and road traffic accidents continue
steadily.

Cambodia ranks among the lowest countries on the United Nations
Human Development Index (it was ranked 129 of 177 countries in 2006)8 and among the
highest in poverty. Forty percent of Cambodians live on less than US$10 per
month, and some 45% of the population has to borrow money to pay for health care
services, which in turn has become the main cause of indebtedness and loss of
land ownership.9 Table 13.1 compares
Cambodia’s health indicators and resources with those of the USA.

Table 13.1 Health
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
year)

5

114

2005

Mortality rate for non-communicable diseases (per 100 000
population per year)

460

853

2002

Mortality rate for cardiovascular diseases (per 100 000
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
expenditure on health)

44.7

25.8

2004

Private expenditure on health (% of total expenditure on
health)

55.3

74.2

2004

Out-of-pocket expenditure (% of total private expenditure
on health)

23.8

85.4

2004

Per capita total expenditure on health (US$)

6096

23.6

2004

Gross national income per capita
(purchasing power paritya)
(US$)

41950

2490

2005

aPurchasing power parity is a currency
conversion rate that both converts a common currency and equalizes the
purchasing power of different currencies. It eliminates the differences in
price levels between countries in the process of
conversion.

Telecommunications

During the 1990s, the advent of the Internet and the growth of
mobile phone technology dramatically changed the way that people communicate and
share information on a global scale. Disparities in access to these networks
inadvertently left Cambodia and many other regions isolated by a ‘digital
divide’. None the less, broad public access to the Internet within Cambodia was
boosted by foreign investment in the late 1990s from countries such as Canada
and Australia via a link through Singapore.10 Like many
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
distinction of being the first country in the world where mobile phone
subscribers outnumbered fixed line subscribers. By 2000, four out of five
telephone subscribers were using a mobile

Table 13.2
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
three factors: connectivity, which is based on the number of
Internet hosts, PCs, telephone main lines, mobile subscribers per capita;
access, which is based on the estimated number of Internet
subscribers, adult literacy rate, cost of a local call and GDP; and
policy, which is based on the presence of Internet exchanges,
level of competition in telecommunications, level of competition in the
Internet service provider market.

phone – the highest ratio in the world.10 Various
information and communication technology (ICT) indicators in Cambodia and the
USA are compared in Table 13.2.

Humanitarian non-profit organizations and social entrepreneurs
have begun to recognize the opportunity to use these growing communications
networks for social change. The non-profit organization American Assistance for
Cambodia (AAfC) and its founder provide one example. Bernard Krisher formed the
AAfC in 1993 with the aim of rehabilitating Cambodia. Since that time, the AAfC
has built over 300 elementary schools throughout rural Cambodia and has provided
approximately one-third of them with access to the Internet.12 This growing
Internet infrastructure established by AAfC has become the backbone for a
cross-cultural, multi-organizational telemedicine project that allows physicians
at the Harvard Medical School in Boston and clinicians at the Sihanouk Hospital
Centre of HOPE in Phnom Penh to support patient care in under-served regions of
Cambodia.

Telemedicine programme

The telemedicine programme is a collaboration between the
AAfC, Operation Village Health (a project of the Center for Connected Health of
the Partners HealthCare system in Boston) and the Sihanouk Hospital Centre of
HOPE in Phnom Penh. The aim is to provide remote consultation and supporting
tools to build capacity and improve local care for those living in rural
Cambodia.

The local health care providers (Cambodian nurses and doctors)
play a central role in the work. After assessing the patient (i.e. history and
physical and diagnostic tests), they transcribe a document of their findings
into English and transmit this, together with attached images, via email to the
consulting clinicians in Boston and Phnom Penh for review. Coordinators at each
facility direct the cases to the appropriate medical specialist. After reviewing
the medical cases, the offsite clinicians return their recommendations. The
supportive guidance delivered in this way not only enhances the quality of care,
but also provides a unique educational opportunity.

Figure 13.1 Sites of operation of the
telemedicine clinics in Cambodia

The programme currently operates at two sites in northern
Cambodia (Figure
13.1). In the first seven years, approximately 1000 telemedicine-supported
patient encounters were completed at the two sites.

Site 1: Rovieng Health Centre

The Rovieng district is located in the Preah Vihear province,
and is home to 6493 families (approximately 32 000 people). The region is served
by two health centres, which are located 15 km apart. The region is primarily an
agricultural community, and the estimated average annual income is less than
US$50. Indigenous medical practices are still commonly used, and include
techniques that involve direct skin contact (i.e. cupping, pinching and
coining), animistic healing practices and the use of various herbal
remedies.13 Most
visitors to the health centre have never met a Western-trained physician in
person.

The pilot telemedicine programme began in February 2001 at one
of the health centres in Rovieng. Each month, 25–40 people gather there to have
their medical conditions assessed and, if appropriate, triaged for telemedicine
consultation. Typically, 15–20 of these cases are documented in English and sent
via email to Western-trained clinicians located in Phnom Penh and Boston. To
date, telemedicine patients have come from 35 of the 57 villages in the
district. On many occasions, those living near the health centre provide
accommodation for people who have travelled longer distances by allowing them to
stay for several days in their homes.

This site is 235 km and about 6 hours by road from the major
hospitals in the capital city of Phnom Penh. It is also about 4 hours from the
nearest referral hospital. Despite the existence of these
more sophisticated facilities, cost, uncertainty and time constraints prevent
most village inhabitants from seeking care outside the village.

To facilitate improved local care, a nurse from Sihanouk
Hospital Centre of HOPE travels by road from Phnom Penh to Rovieng each month.
Those patients who cannot be easily diagnosed and treated by the nurse have
their cases sent by email to consulting physicians using the satellite Internet
connection at the adjacent elementary school. The local nurse must assess each
patient and transcribe the details of the encounter before these recommendations
are provided. Once received by the relevant consultant, recommendations for
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
Rovieng.

Day 2:

Nurse assesses patients, performs local laboratory
tests, photographs patients and sends transcribed cases in English to
consultants for review via email. Consulting clinicians in the USA and
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
recommendations.

Day 5:

Blood samples for any off-site testing are collected;
nurse and driver return to Phnom Penh with blood samples in a
cooler.

To enhance local diagnostic capacity, five point-of-care
laboratory tests were introduced in October 2004. The availability of these
tests has decreased the need for more expensive off-site laboratory testing,
allowing quicker and more accurate diagnosis. The five tests were:

(1)

blood glucose

(2)

haemoglobin

(3)

urine analysis (glucose, ketones, pH, specific gravity,
protein, leucocyte esterase, nitrites)

(4)

urine chorionic gonadotrophin (pregnancy test)

(5)

faecal occult blood.

The choice of these tests was based on several factors,
including the prevalence of local disease, ease of use, storage requirements,
low cost, and the ability to use them without reliance on running water or
electricity. Simple algorithms for using these tests were also created so that
the nurse could use them independently. Several manufacturers kindly donated
test kits to launch the service.

Site 2: Rattanakiri Referral
Hospital

Based on the success of telemedicine in Rovieng, a second site
opened in April 2003 at the Rattanakiri Referral Hospital (RRH) in Banlung, the
capital of the Rattanakiri province. This province is home to a mixture of 13
ethnic and tribal groups, and is generally considered to be the poorest of the
provinces. Non-Western indigenous health practices are widely practised. Unlike
the cases from Rovieng, these referrals are initiated by
Cambodian physicians working at the RRH, who have greater access to local
resources, including ECG measurement, laboratory tests and basic X-ray imaging.
Accordingly, the cases tend to be more complex, although there is usually more
information for consulting physicians to consider in formulating their
recommendations. As with the Rovieng site, the cases are sent each month as
email messages using a satellite connection to the Internet. Turnaround time for
receipt of consultant recommendations is also less than 12 hours. The
telemedicine clinic operates as follows:

Day 1:

Patients in need of teleconsultation are selected by
local physicians.

Day 2:

Cases are transcribed into English; relevant images
(e.g. skin, ECG, X-ray or ultrasound) are attached and sent via email to
consulting clinicians; consulting clinicians in USA and Phnom Penh review
cases and return their recommendations within 12 hours.

Day 3:

Local physicians review and implement the
recommendations

Day 4:

Any remaining arrangements for off-site testing or
referral are made.

This site received its initial financial support from the
Markle Foundation and is now largely supported by private individual donations,
most notably from Edward and Laurie Bacharach.

Effects on local care

Retrospective reviews of the telemedicine work have been
completed by staff at the Center for Connected Health and the Harvard Medical
School. These studies have examined the types of patients participating in the
telemedicine programme, the clinical impact on the community, and the utility
and cost savings associated with the portable point-of-care laboratory. To date,
the majority of these formal evaluations and reviews have focused on operations
at the Rovieng site. The results are summarized below.

Demographics and case mix

A retrospective review evaluated all cases completed at the
Rovieng site from January 2005 to May 2006.13 There were
196 teleconsultations for 106 patients. The majority of patients were female,
and two-thirds of all patients sought telemedicine care on more than one
occasion (Table
13.3). Most visits for new patients were for non-communicable chronic
diseases (Table
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
were reviewed.14 The mean
duration of the chief complaint among first-time clinic visitors was 37 months
for the first 6 months of the study period. By the last six months of the study
period, this had dropped to 8 months (Figure 13.2). The
proportion of patients referred for care at offsite
facilities decreased by 51% per year of clinic operation (95% confidence
interval 27–75%; p < 0.001) (Figure 13.3). These
data suggest that longstanding chronic conditions among villagers are now being
addressed and that appropriate care can be delivered locally.

Table 13.3 Patient utilization and
demographics: Rovieng, January 2005–May 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): 0–14

7

8

15–64

65

76

≥65

14

16

Table 13.4 Most frequent complaints
among new patients: Rovieng, January 2005–May 2006 (n =
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:
Rovieng, January 2005–May 2006. There were 196 consultations for 106
patients, some of whom had multiple diagnoses.

Diagnosis

Visits,
including
this
diagnosis

Patients

Dyspepsia

45

30

Hypertension

73

27

Anaemia

40

22

Diabetes (type 2)

48

15

Thyroid disease

23

12

Total

229

106

Figure 13.2 Duration of patients’ primary
chief complaint at initial visit, during three phases of the study period.
(Reproduced with permission from Telemed J E Health 2005;
11(1), published by Mary Ann Liebert, Inc.)

Figure 13.3 Proportion of patients referred
off-site for care during the study period. (Reproduced with permission from
Telemed J E Health 2005; 11(1), published by Mary Ann
Liebert, Inc.)

Point-of-care testing

Comparisons were made between the 57 patient encounters
occurring after the introduction of the laboratory tests and 119 encounters
occurring in the year before, which served as historical controls. Overall, the
proportion of patient cases receiving laboratory testing did not increase
(Fisher’s exact test, p = 0.71). Meanwhile, the proportion of cases
requiring off-site referral for the completion of laboratory testing decreased
significantly from an average of 69% to 35% (p < 0.001). The costs
associated with laboratory testing also decreased, from an estimated average of
US$41 to US$17 per month.15

Lessons learned

Several valuable lessons have been learned during seven years
of operation. The project has demonstrated the feasibility of using
store-and-forward telemedicine across time zones, socioeconomic strata and
cultures. More specific observations have also been made, and can be categorized
as human, economic or technology factors (Table 13.6).

Human factors

Human factors are arguably the most important for success.
This requires not only commitment at the organization level, but also adoption
by the users: the patients, local care providers and consulting physicians.

Patients

Demand by patients for telemedicine services at the Rovieng
Health Centre has remained high, particularly among women aged 15–64 years. The
sustained patient volume and rate of return visits suggest that cross-cultural
telemedicine can compete successfully with conventional and local indigenous
practices. This is probably due to several factors.

The willingness of families to accommodate one another during
the monthly tele-medicine clinics signals a high degree of ‘social capital’
within this community. The monthly schedule of the clinics encourages adherence
among patients through frequent opportunities to educate, inform and reinforce
the benefits of the prescribed medication. The social nature of these monthly
gatherings brings community members together, and may also play a role in
adherence – much like that of a support group or

Table 13.6 Proposed characteristics of
programme success

Factor

Characteristics

Human

Willingness to participate/collaborate, adoption,
satisfaction, cultural competence, supportive political
environment

Economic

Sustainability, affordability, marketability,
profitability

Technological

Usability, interoperability, scalability,
transferability

‘group visit’ (a model of chronic care management gaining
popularity among US primary care physicians). The significance of this is most
evident in instances where patients are asked to begin long-term medication
regimens that may have little effect on their sense of wellbeing – or even
produce undesirable side effects. For example, antihypertensive medications are
now frequently prescribed to treat the surprisingly high prevalence of high
blood pressure in this community. The high return rate among villagers and the
apparent adherence to modern drug regimens suggests that the concept of chronic
disease management is being incorporated into the local culture.

It is important to note that, at present, there is no direct
cost to patients for telemedicine visits or for the prescribed medications
recommended in the consultations, which undoubtedly encourages a high return
rate. To better understand patient expectations, their satisfaction and
willingness-to-pay were assessed in 2003 using a verbally administered
survey.7 All patients
surveyed (n = 63) were either ‘satisfied’ or ‘very satisfied’ with the
use of telemedicine as an alternative to the seeking of care within the
traditional Cambodian health system. Of those surveyed, 78% were willing to pay
for these services. Of those willing to pay, the mean amount was US$0.63 per
visit.

Local providers

Initially the dialogue between local and consulting clinicians
was a fairly unstructured exchange, akin to an instant messaging Internet
‘chat’. However, as the telemedicine programme has matured, this has evolved
into a structured format using a standardized template for history and physical
examination (Box
13.1).

The visiting telemedicine nurse in Rovieng is part of the SHCH
staff, and participation is mandated in the job description. In contrast,
telemedicine at the RRH depends on the interest and willingness of the local
physicians to participate. Patients that are managed using telemedicine require
more local physician time, although there is no additional physician
remuneration. It could be argued that the inherent opportunity cost to
physicians who participate under this arrangement might ultimately become a
barrier to sustainability. Possible methods of maintaining the participation of
local Cambodian physicians include reducing lengthy translation/transcription
times and improving cultural competence among US consultants to ensure that
their recommendations are relevant to the local context and available
resources.

Consulting physicians

Informal inquiries of consulting clinicians in the USA and
Phnom Penh have revealed several potential areas for quality improvement. To
maximize the value of the consulting physician’s recommendations and avoid a
‘garbage-in–garbage-out’ situation, measures should be taken to ensure the
completeness of the initial clinical data collected and documented by the local
provider. Convenient and reliable web access to patient medical records could
enhance continuity of care for those with recurring or chronic conditions.

Overall, a high degree of cultural competence among consulting
and local clinicians has been important to the successful introduction of
Western-based medical concepts such as chronic disease (i.e. diabetes and
hypertension) and prevention.

Box 13.1 Standardized template for
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,
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
such as the Asia Development Bank and Japanese corporate sponsors have funded
the efforts of AAfC. Satellite services (estimated cost US$285 per site per
month) have been secured as corporate gift-in-kind donations from a Thai
telecommunications company. By ‘piggy-backing’ the telemedicine programme onto
this existing Internet infrastructure, large capital investments have been
avoided.

None the less, certain problems remain, such as the cost
implications of telemedicine. As mentioned above, the local physician time
required per patient is greater than for traditional care in cases originating
at the RRH. Furthermore, strict adherence by local clinicians to the
recommendations of US consulting physicians who are uninformed about local
resource constraints could result in increased utilization and, therefore,
cost.

At present, the programme continues to rely on volunteers and
donations from charitable organizations. As a result, alternative economic
schemes (i.e. fee-for-service or a pooled payment model) may
eventually need to be introduced if this model of care is to be transferred to
other regions or implemented on a broader scale. Some revenue has been generated
via the online sales of locally produced products such as coffee, scarves and
other handicrafts, but, to date, this has contributed little to the overall
operating budget.

Technological factors

Reliable electrical power and Internet connectivity are
central to the operation of the programme. The use of solar panels supplemented
by portable generators has proven to be feasible for the operation of computers
and satellite communications equipment. Telecommunication employs a
low-to-moderate range of bandwidth and uses a store-and-forward, asynchronous
email mode of communication. These characteristics contribute to the potential
for scalability, especially as the use of email and familiarity with computers
among Cambodians grow. Expansion of Internet connectivity, however, has been
restricted by poverty, the lack of a rigorous academic community to nurture
networking, the complexity of using the Khmer language with computing and
application development, a shortage of dial-up telephone lines and restrictive
government regulations.10

In terms of laboratory technologies to support remote
consultations, the point-of-care laboratory tests appear to be feasible,
clinically useful and likely to reduce the need for slower, more expensive
offsite testing.

Future directions

The data from the retrospective reviews and lessons learned
have helped to plan a strategy for the future.

Human factors

As there is a high level of demand for management of chronic
illnesses such as diabetes and hypertension, an increased emphasis on continuity
of care is planned for patients at the Rovieng site.

Recently, the non-governmental organization HealthNet
International has been contracted by the Cambodia Ministry of Health to reform
health care delivery in several provinces, including Rattanakiri. As a result,
the telemedicine component at the RRH is also being restructured. Expected
benefits include greater local ownership and accountability of the programme
through stronger administrative oversight and physician participation. This
change is expected to integrate telemedicine more formally into the hospital’s
service and enable a greater measure of evaluation and quality control. In
addition, it is hoped that this new arrangement will facilitate a stronger
relationship with the Ministry of Health and potentially enable broader use of
tele-medicine to support government-sponsored public health initiatives.

To build local capacity, an increased emphasis on clinician
education is anticipated. Linking educational content directly to patient care
recommendations is being considered as one way to enhance the experiential
learning that already occurs. Skills training in the use of
computers, project management and administration would also enable greater local
ownership of the programme.

Economic factors

To date, the programme has successfully enlisted the voluntary
participation of highly skilled medical specialists and clinicians whose time
would otherwise not be affordable. This approach will continue to be crucial for
the future sustainability of the programme, as will philanthropic and
gift-in-kind contributions from socially minded individuals and
corporations.

Technology factors

A more sophisticated clinical information management system is
required. This would facilitate continuity of care through web access to patient
records and enable more robust data analysis for population tracking and
research. Several web-based platforms or electronic medical records are being
explored. Examples include the system created by the Swinfen Charitable Trust
(see Chapter 19) and
open-source formats (i.e. OpenMRS and OpenVista).

To improve the efficiency and completeness of local clinician
assessment and transcription, digital pen technology combined with standardized
clinical forms is being explored. This may be an improvement over keyboard data
entry.

Conclusion

Cambodia’s health system faces a significant disease burden,
as well as provider shortages and limited resources. The low-bandwidth,
store-and-forward telemedicine programme that began in 2001 has expanded to a
second site. Experience suggests that this model of care is not only feasible,
but also acceptable to patients and care providers, and has positive clinical
effects. Continued challenges to its operational efficiency and effectiveness
remain, as do methods of data collection to assess the clinical effects. With
stakeholders in the USA and Cambodia, this collaborative project seeks to become
a sustainable, scalable and transferable model of cross-cultural telemedicine
for low-resource settings.

From a broad perspective, the process of globalization will
undoubtedly have an impact on the health of populations in both the
industrialized and the developing world.16 Telemedicine
and telehealth applications are likely to emerge as future tools to transform
the way care is delivered across cultures, geography and time zones. It is clear
that utilizing communication technologies to decrease health disparities is
possible in places such as rural Cambodia, but large-scale deployment of
telehealth in the developing world will depend on the positive convergence of
human, economic and technological factors.17

Acknowledgements

We thank Kathy Fiamma, Dr Kavitha Reddy, Dr Sherene Idriss,
Heather Bello, Nedialka Douptcheva and Marco Senelly.

Further reading

King H, Keuky L, Seng S et al. Diabetes and associated
disorders in Cambodia: two epidemiological surveys. Lancet 2005;
366: 1633–9.

Telemedicine in Low Resource Settings (Discussion Group).
Available at: www.dgroups.org/groups/telemedicine/index.cfm.

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Zimmerman M, Vassallo DJ et al. Telemedicine – the way ahead for medicine in the
developing world. Trop Doct 2003; 33: 36–8.

18. Heinzelmann PJ, Lugn NE, Kvedar JC. Telemedicine in the
future. J Telemed Telecare 2005; 11: 384–90.

19. World Health
Organization. WHO Statistical Information System (WHOSIS). Available
at: www.who.int/whosis.

20. World Health
Organization. The Digital Divide: ICT Development Indices 2004. New
York and Geneva: United Nations, 2005.

14 Telepathology and telecytology in developing
countries

Sangeeta Desai

Introduction

The field of surgical pathology and cytology involves a
cascade of operator-dependent technical, scientific and medical processes. The
preparation and interpretation of surgical pathology and cytology material
requires trained technical personnel, excellent technical support, skill,
experience and some basic infrastructure. Developing nations such as India are
typically flawed by vast socioeconomic differences. In India, there is a truly
heterogeneous and uneven development of health care facilities, which results in
major disparities: some medically privileged areas have expertise on par with
the industrialized world, while other remotely located, rural, under-served
populations are almost totally deprived of any medical facilities. Telemedicine
provides a method of bridging this gap.1–5

Telepathology for the developing world

Telepathology is the practice of pathology at a distance using
telecommunications. It involves viewing images on a video monitor rather than
directly through a microscope. The minimum requirements for telepathology
are:

a light microscope
(motorized for dynamic telepathology);

a high-resolution
camera (either a digital camera or a video camera with a frame grabber
card);

a workstation for
the telepathologist;

access to a
telecommunications network.

Telepathology can be performed using a static, or
‘store-and-forward’, approach; it can also be conducted using a dynamic, or
real-time, approach; or it may employ a hybrid of the two.1,2 There are
obvious disadvantages associated with static telepathology, the major one being
sampling error, which reflects the passive nature of this exercise. In contrast,
dynamic telepathology overcomes the basic drawback of static telepathology,
although techniques such as ultra-rapid virtual slide processing6 are
prohibitively expensive in a developing country setting. Sampling error in
static telepathology consultation could be reduced by the referring pathologist
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
judiciously selected digital images. It has been our observation that mutual
trust, rapport and close interaction between referring pathologist and
telepathologist, and adequate training of the referring pathologist, are very
important to achieve successful teleconsultations.2

The quality of the images is largely dependent on the quality of
the basic starting material, which is the stained slide. The mode of
transmission and the image compression will not compromise the quality of images
if chosen carefully. It has been suggested that successful telepathology
diagnoses can be achieved using adaptive colour reduction algorithms to reduce
image file size, thus facilitating transmission without sacrificing
quality.7

The single most important factor that influences selection of
the system in the developing world is the cost. The potential customer, in
addition, also faces the problem of commercial pressure by the vendors. Dealing
with single-vendor proprietary systems, i.e. buying the camera, software and
microscope in a package, implies an inability to negotiate costs. However, it is
heartening to note that the costs of most of the components of telepathology
system are declining.

Constraints

There are a number of constraints that limit the introduction
of telepathology in the developing world. These include the following.

Inadequate infrastructure

The essential components of any telepathology system, i.e. the
microscope, a camera with software and a computer, may not available in rural
areas of developing countries. Procurement of these items may be difficult.
Telecommunication facilities may not be developed at all, or they may be so
poorly developed that it may be difficult or impossible to transmit cases.
Moreover, the development and availability of telecommunication facilities may
be non-uniform.3,4,8,9

Non-uniform processing of pathology
material

The limiting step in telepathology is availability of a
well-processed histology or cytology glass slide. In the developing world, the
lack of infrastructure, equipment and uniform standards makes for poor pathology
material or suboptimal technical material.

Lack of accreditation

Telepathology is a combination of surgical pathology,
information technology and imaging. All three processes lack defined standards.
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
for success in telepathology. Lack of trained manpower for histopathology
processing has a very negative effect on the subsequent quality of a
telepathology consultation. As training is required for surgical pathology and
cytology specimen processing, it is also required for information technology and
handling of camera and computer. The natural tendency of the staff to initially
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
telepathology or to staff a telemedicine department. The staff are expected to
perform multitasking, especially in a low-volume centre.

Applications of telepathology

Intraoperative consultation between pathologist and surgeon
requires rapid and accurate diagnosis, which is rendered on a frozen section and
provides the necessary guidance to the operating surgeon. For interpretation of
intraoperative frozen sections, transmission of live images is required using
dynamic telepathology. The same also holds true for primary diagnosis of routine
surgical pathology. Although this technique is well developed in certain parts
of Europe and the USA,5,10 in
developing countries, the constraints of cost mean that intraoperative
consultation is rare.

However, telepathology has proven its merit in developing
countries where dynamic teleconsultation is not required, for example to obtain
second opinions,3,4,8,9
expert-to-expert consultations, quality assurance, distance education, consensus
diagnosis for pathology review in clinical trials and proficiency testing. In
the USA, ultra-rapid turnaround time in surgical pathology has recently been
demonstrated in breast cancer clinics. These combine digital mammography imaging
and interpretations, the latest advances in rapid specimen processing (microwave
and automated immunostaining), and biopsy diagnosis by telepathology, producing
a ‘one-stop shop’ for patients being investigated.6 Although this
is attractive, promising and useful for the industrialized world, it is not
practical in the developing world because of the high costs.

Another potential use of telepathology is for consultations
generated in the industrialized world to be outsourced to experts in developing
countries. This is currently practised in the field of radiology at some
centres. However, credentialing requirements, issues related to licensure and
malpractice coverage need to be resolved for this approach.11 If these
factors are dealt with appropriately then this model of tele-pathology may have
potential.

Telepathology is not yet validated in the field of exfoliative
cytology, which involves microscopic examination of cells that are shed from the
lesion. Most cytologists would agree that telecytology is not a preferred mode
for reporting exfoliative cytology. However, it is worth noting that there have
been a few studies of telecytology involving fine-needle aspiration cytology
(FNAC).9

Tele-surgical pathology and telecytology

The distinction between tele-surgical pathology and
telecytology is based on the inherent differences between the cytology and
surgical pathology material. Surgical pathology material consists of cells and
tissue architecture. Hence, the telepathologist and referring pathologist can
make use of the tissue architecture as a reference point to discuss the case
and/or obtain additional images from any suspicious areas. Cytology smears
mainly consist of cells with a few stromal fragments and are spread over a large
area. The whole smear needs to be scanned. Hence, telecytology requires more
comprehensive and optimized initial sampling of the smears, which increases the
number of images produced. Telecytology largely depends on the images chosen by
the referring pathologist. Hence, it is desirable to have the problematic areas
adequately represented in the initial images in telecytology.9

Experience of telepathology in Mumbai

The Tata Memorial Hospital in Mumbai, India is a tertiary
cancer referral centre, delivering comprehensive care to cancer patients in the
Indian subcontinent. The hospital has a static telepathology link with two rural
cancer centres located 500 km from Mumbai (Figure 14.1). The
process to establish a static telepathology link with one of

Figure 14.1 Static telepathology workstation
at the referring pathologist’s end in Barshi, Solapur, India

the rural cancer centres, the Nargis Dutt Memorial Cancer
Hospital, began in October 2000 and came to fruition in January 2002. The delays
were mainly due to hurdles related to the communication link. However, once it
became fully operational, tele-pathology was able to sustain itself.3,5,8,9 The
communication medium employed is the ordinary telephone system, with the 56
kbit/s dial-up modem providing access to the Internet. A set of compressed
images in conjunction with clinical data are sent as email attachments.

The performance of static telepathology was assessed by
comparing the diagnoses rendered on telepathology and glass slides,
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
consultations

In a study of 299 static telepathology consultations accrued
over a period of 3 years to December 2004, there were 251 surgical pathology, 2
international consultations and 46 cytology cases.3,4,8,12 Concordance
(absolute concordance, qualified diagnosis or minor, clinically unimportant
discrepancies) for tele-surgical pathology was 96% (199 of 207 cases). The
diagnosis was deferred in 30 cases.

Our experience of deferred diagnoses on telepathology indicates
that the ‘probable’ diagnosis rendered in complex cases such as lymphoid
neoplasia, sarcoma and round cell tumours matched the final glass slide
diagnosis in 47% of cases. The ‘probable’ telepathology diagnosis rendered on
potentially difficult cases does give the referring pathologist a direction or
impart a different thought process during decision making.12

We believe that static telepathology consultation helps the
referring pathologist to unravel the diagnosis while dealing with potentially
complex cases, even in the event of deferral. Static telepathology has the
potential to provide specialist support in the clinical management of such
cases.

Analysis of telecytology
consultations

A total of 46 cases accrued over period of 3 years were
analyzed.9 The cases
included 44 FNAC and 2 exfoliative cytology smears. The concordance (absolute
concordance, qualified diagnosis or minor, clinically unimportant discrepancies)
for telecytology was 91% (39 of 43 cases). The diagnosis was deferred in 5
cases.

The reasons for major discrepancies for both telesurgical
pathology and telecytology were interpretative errors, inadequate sampling,
poor-quality sections and images, and inadequate clinical data. We believe that
effective use of static telepathology can be achieved by thorough sampling by
the referring pathologist, expertise in surgical pathology at the
telepathologist’s 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,
the raw material, i.e. the stained glass slide, must be of optimum quality. We
have found that telepathology is valuable in bridging the gap between
under-served areas and specialty centres, and can build confidence and capacity
in the professionals working in under-served areas. This also reduces
professional isolation, as expressed by referring pathologists. Patients from
under-served areas receive better professional advice, while saving their travel
costs to tertiary centres. Another major advantage of teleconsultation is
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
developing world. A decision to implement a diagnostic telepathology system in
developing countries will be based on numerous factors, but the pivotal factor
will be the need for telepathology. A strong impetus to establish communication
between distantly located centres can help to establish successful, inexpensive
and effective teleconsultation and to transfer knowledge and expertise to
medically underprivileged areas and bridge the gap of knowledge and expertise at
low cost. I believe that once the advantages of tele-pathology are visible to
pathologists generally, the technique will rapidly gain in popularity.

Acknowledgements

I am grateful to Dr KA Dinshaw, Dr Ashok Mohan, Dr BM Nene, Mr
MK Chauhan, Mr TK Ghosh, Mr Manoj Chavan, Mr Amit Satvekar and Mr Bipin Gadhave.
I thank Dr Roshni Chinoy, Dr Shubhada Kane, Dr Tanuja Shet and Dr Mukta Ramadwar
for reporting telepathology cases and Dr Rajasa Patil and Dr Sanica Bhele for
providing logistical support.

Further reading

Arizona Telemedicine Program. Available at: www.telemedicine.arizona.edu/index.cfm.

Armed Forces Institute of Pathology. Department of
Telemedicine. Available at: www.afip.org/consultation/telemedicine.

International Union against Cancer (UICC) Telepathology
Consultation Center. Available at: pathoweb.charite.de/UICC-TPCC/default.asp.

Kayser K, Szymas J, Weinstein RS. Telepathology.
Berlin: Springer-Verlag, 1999.

Li X, Gong E, McNutt MA et al. Assessment of diagnostic
accuracy and feasibility of dynamic telepathology in China. Hum Pathol
2008; 39: 236–42.

Wells CA, Sowter C. Telepathology: a diagnostic tool for
the millennium. J Pathol 2000; 191: 1–7.

References

1.
Wootton R. Recent advances: telemedicine. BMJ 2001;
323: 557–60.

2.
Weinstein RS, Descour MR, Liang C et al. Telepathology overview: from concept to
implementation. Hum Pathol 2001; 32: 1283–99.

3.
Desai S, Ghosh TK, Chinoy R et al. Telepathology at Tata Memorial Hospital,
Mumbai and Barshi, a rural centre in Maharashtra. Natl Med J India
2002; 15: 363–4.

4.
Desai S, Patil R, Chinoy R et al. Experience with telepathology at a tertiary
cancer centre and a rural cancer hospital. Natl Med J India 2004;
17: 17–19.

5.
Cross SS, Dennis T, Start RD. Telepathology: current status and future prospects
in diagnostic histopathology. Histopathology 2002; 41:
91–109.

6.
Weinstein R, Descour MR, Liang C et al. An array microscope for ultrarapid
virtual slide processing and telepathology. Design, fabrication, and validation
study. Hum Pathol 2004; 35: 1303–14.

7.
Doolittle MH, Doolittle KW, Winkelman Z, Weinberg DS. Color images in
telepathology: How many colors do we need? Hum Pathol 1997;
28: 36–41.

8.
Desai S, Patil R, Kothari A et al. Static telepathology consultation service
between Tata Memorial Centre, Mumbai and Nargis Dutt Memorial Charitable
Hospital, Barshi, Solapur, Maharashtra: an analysis of the first 100 cases.
Indian J Pathol Microbiol 2004; 47: 480–5.

9.
Jialdasani R, Desai S, Gupta M et al. An analysis of 46 static telecytology
cases over a period of two years. J Telemed Telecare 2006;
12: 311–14.

10. Frierson HF Jr,
Galgano MT. Frozen-section diagnosis by wireless telepathology and ultra
portable computer: use in pathology resident/faculty consultation. Hum
Pathol 2007; 38: 1330–4.

11. Kalyanpur A,
Neklesa VP, Pham DT et al. Implementation of an international teleradiology
staffing model. Radiology 2004; 232: 415–19.

12. Bhele S,
Jialdasani R, Kothari A et al. Analysis of deferrals on static telepathology
consultation service. Ind J Pathol Microbiol 2007; 50:
749–53.

15 Internet-based store-and-forward telemedicine for
subspecialty consultations in the Pacific region

C Becket Mahnke, Charles W Callahan and Donald A
Person

Introduction

An early form of telemedicine communication in the developing
world was the radiotelephone. A series of ham radio operators would establish a
schedule of time available for the long-distance communication between remote
locations and more centralized locations. During the early 1960s, one of us
(DAP) managed distant medical consultations between US military staff in Panama
and distant military groups, missions and embassies from Mexico to South America
using the Military Affiliate Radio System. At a prearranged weekly time, a radio
operator would connect the various organizations together. Medical questions
were discussed, which facilitated decisions regarding local medical care versus
evacuation. However, radiotelephony was susceptible to problems caused by the
weather and sunspot activity, resulting in loss of bandwidth and sometimes loss
of signal. During the same period of the 1950s and 1960s, communications within
the far-flung US-associated Pacific Trust Territories were handled in a similar
manner.1

Early telemedicine work at Tripler Army Medical
Center

Tripler Army Medical Center (TAMC) was the test site for the
Composite Health Care System, a database of the US Department of Defense. It was
deployed in the late 1980s, and included modules for order entry, retrieval of
radiology and laboratory results, pharmacy, patient administration and coding
information. An email function was added in 1995, and this provided the basis
for teleconsultations and referrals within the military health care system in
Hawaii and ultimately military medical facilities in the Pacific. File
attachments, however, were not allowed in the secure Composite Health Care System, which limited telemedicine to the
written word only.

In 1993, telemedicine consultations with TAMC were begun from
the US Army Kwajalein Atoll Missile Range in the Marshall Islands. There was an
existing AT&T videoconference system at Kwajalein Atoll. About 150
consultations were conducted over 5 years, and a few unnecessary referrals to
Honolulu were avoided.2 The process,
however, was difficult to schedule. Expensive computer and video hardware and
costly maintenance with special technical support were required. By virtue of
the proximity of the Ebeye Island to Kwajalein, a few Marshallese patients
benefited from this demonstration project, but it was obvious that such a
technology-dependent system was not practicable in the rest of the
Pacific.

In 1995, at the inaugural meeting of the Pacific Basin Medical
Association held in Pohnpei, the utility of the Picasso still-image telephone
was demonstrated by a consultation on a patient in Palau, some 2400 km away.
That consultation avoided the evacuation of the patient from Palau to Hawaii
(saving at least US$20 000).1 Four Picasso
telephones were donated by AT&T to jurisdictions in the Western Pacific, and
over 30 telemedicine demonstration projects were successfully carried out on the
island of Pohnpei, between islands in Pohnpei State, and internationally between
Alaska, Hawaii, Pohnpei, New Caledonia, Kosrae State and Palau. Several patients
were transferred using this process. However, the cost of long-distance calls
became prohibitive, and local health budgets could not continue paying such
costs (US$5–10 per minute).3

Pacific Island Healthcare Project

At about the same time (1989–1990), a programme to benefit the
graduate medical education needs of TAMC’s residents in training was developed.
The Pacific Island Healthcare Project (PIHCP) was developed to facilitate the
referral and treatment of indigenous peoples of the former Pacific Trust
Territories, now referred to as the US-associated Pacific Islands (USAPIs). The
USAPIs include three US territories (American Samoa, Guam and the Commonwealth
of the Northern Mariana Islands) and three independent, freely associated states
(the Republic of the Marshall Islands, the Federated state of Micronesia and the
Republic of Palau) (Figure 15.1 and Table 15.1). The
peoples of the USAPIs suffer from diseases such as tuberculosis, rheumatic heart
disease, leptospirosis, dengue fever, pyomyositis and leprosy, as well as
chronic diseases such as diabetes mellitus, obesity, hypertension,
hyperuricaemia and cancer. In addition, there are surgically correctable
congenital lesions, such as cleft lip/palate, congenital diaphragmatic hernia,
Hirschprung disease and hypospadius.

The challenges of managing consultations with the time
differences (five time zones and an International Date Line) and great distances
(8000 km between Honolulu in Hawaii and the Republic of Palau) are formidable.
The region is extremely remote (Figure 15.1). Some
distant islands and atolls are 600–1300 km from the jurisdiction’s capital,
reachable only by sailing canoe. Prior to the development of the web-based
referral system, consultations from the jurisdictions came in the form of

Figure 15.1 US-associated Pacific Islands,
with an overlay of the continental USA (to scale) to demonstrate the distances
invlolved

Table 15.1 Pacific Island Healthcare
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
estimates

letters, long-distance telephone calls, faxes and even the
diplomatic pouch. From 1988 to 1997, the PIHCP provided definitive care at TAMC
for about 2500 patients from the USAPIs. The web-based system was established in
1997, and in 1998 we were able to demonstrate asynchronous consultations with
TAMC.4

Since that time, email with attached images has been shown to be
an acceptable medium for consultation for almost all patients. Several steps
were needed to implement four test sites in Micronesia. First, a consultation
web page was created with a request form to ensure that there was sufficient
information to allow TAMC specialists to comment. Second, a web page was created
to display all current or recent consultations received from the USAPIs. Third,
a group of TAMC specialists was trained in the use of a web
browser to access the consultations and comment on cases where appropriate. The
use of a web-based system provided a flexible approach to patient management
discussions. Four sites within Micronesia were selected as test sites: Chuuk,
Pohnpei, Palau and Majuro in the Marshall Islands. Each location had relatively
inexpensive Internet service providers (ISPs) and 24-hour access to the
Internet. Each site was provided with:

a desktop
computer

a digital camera
(D-600L, Olympus)

a flatbed scanner
with transparency adapter (Scanmaker E6 Professional, Microtek)

a digital video
camera (DCR VX-1000, Sony)

a printer.

In addition, two sites were provided with a digital otoscope
and ophthalmoscope (American Medical Devices).

Training was conducted in two phases. First, a group of all
interested clinicians at the annual Pacific Basin Medical Association meeting in
Chuuk were allowed to test the equipment. Once the equipment had been installed
at each site, small groups were trained. For many of the medical officers, this
was the first opportunity that they had had to see or use a computer. It should
be noted that five senior physicians in Yap, Pohnpei and Palau had access to the
web page using their personal computers. Their involvement was important to the
success of the programme.4

Clinical procedure

The first step in creating an electronic consultation is to
gather digital images where appropriate. Even in cases where images do not
support the consultation, an image of the patient helps to humanize the
electronic process. Images are acquired using a digital still camera, digital
video camera or digital medical device camera. Additional images can be acquired
using the flatbed scanner (e.g. laboratory results, ECG recordings, photographs
and X-ray films). Initially, it proved difficult to produce images of acceptable
quality from X-ray films. However, in most cases, careful use of the digital
camera to acquire an image on a light box proved satisfactory.5 Images are
annotated using simple image editing software, with date, comments on area of
concern and an identifying code as applicable.

Next, the history of the patient must be typed into the
computer. This step is often completed before the connection to the Internet is
made. The clinicians use a common word-processing program to type the medical
history, and then copy and paste it into the website form; we do not use a rigid
format for the history. Once complete, the clinician connects to the Internet
and submits the case. Depending on the number and size of attached images, this
process can take several minutes. The resulting electronic patient record is
archived and can be retrieved via the website.

Once a new case is received, an automatic email notification is
sent to the PIHCP Director. The Director queries the database to find the case.
The information is protected by secure socket layer (SSL) encryption, which
meets the current Health Care Financing Administration
guidelines for secure clinical use of the Internet. The consultation is
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
specialists as required. All comments are stored in the database, complete with
time/date stamp and user information.

Specialists are notified of a new case via email. The email
message contains a working diagnosis, a case number and a link to the PIHCP
website. After reviewing the clinical data and images, the specialist can
comment on the case or ask for further information or testing to be done. The
remote provider is notified by email of the new comments, and reviews these on
the website. If further information is required, he or

Figure 15.2 Numbers of PIHCP cases (n
= 3039): (a) origin; (b) type. CNMI, Commonwealth of the Northern Mariana
Islands

she can enter the response on the web page. In this manner, a
difficult case can be discussed using the website as a discussion group for a
specific patient.

Results

By the end of 1999, we had installed 10 workstations in all of
the jurisdictions of the USAPIs. More than 3000 consultations and referrals have
been submitted in the nearly 10-year history of the telemedicine programme (Figure 15.2). The
majority of the cases have come from the Marshall Islands, the Republic of Palau
and Chuuk State. The US Congress provides US$2.5–5 million per year to the PIHCP
for patient travel and medical care. After an initial investment of
approximately US$300 000 to install the workstations and train the local
providers, the PIHCP programme has been self-sustaining. The leadership of TAMC
has supported the programme and integrated its administration into the
hospital’s business plan. Administrative support is provided by TAMC’s Patient
Administration Division and technical support is provided by TAMC’s Information
Management Division. The Medical Director has provided the direction, leadership
and oversight of the PIHCP as a labour of love.

We do not provide a list of indications for telemedicine. The
decision to initiate a teleconsultation is left to the referring doctor. The
numbers of patients accepted to TAMC for further evaluation and treatment are
shown in Table 15.2.
With the implementation of the web-based system in the late 1990s, there has
been a drop in the

Table 15.2 Pacific Island Healthcare
Project: number of patient referrals accepted at TAMC for further
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
treatment. This has not been due to a decrease in the number of cases submitted
to the PIHCP. It has been due to more accurate triage of those who would benefit
from transfer to TAMC using the web system. In addition, the web-based system
allows many patients to be treated locally with telemedical support from TAMC
specialists. Both factors lead to improved health care for a greater number of
patients. The costs associated with the care of those patients brought to TAMC
are shown in Figures
15.3 and 15.4.

The PIHCP telemedicine system has had a significant effect on
medical practice as reflected by the length of stay (Figure 15.5). Prior to
the development of the web-based PIHCP system, the average length of stay for
Pacific Island patients approached 30 days. Since implementation of the
teleconsultation process, the length of stay has fallen, and is currently just
over 5 days. This is a consequence of more appropriate triage of patients prior
to transfer to TAMC, as well as improved coordination of care once the patient
arrives.

Implementation of the web-based consultation system has had
other advantages. It has allowed isolated practitioners to stay connected with
their colleagues throughout the Pacific and be kept up to date with modern
medicine. There has also been educational value for the residents in training at
TAMC. Numerous publications have resulted from patient referrals.5–10 Pacific
Islanders have been restored to health, and have returned home to lead normal
and productive lives.

Figure 15.3 Number of PIHCP cases and total
costs

Figure 15.4 PIHCP: total expenditure for all
islands. FY, financial year

Figure 15.5 PIHCP: number of cases accepted
and length of stay

Pacific Asynchronous TeleHealth system

TAMC is the tertiary military medical treatment facility for
the US military (active duty staff, retirees and dependants) in the Pacific
region. TAMC’s area of responsibility includes US military bases in Korea,
mainland Japan, Okinawa and Guam (Figure 15.6). These
remote military health care facilities are often staffed by relatively junior
physicians and have limited access to subspecialty care. Even if subspecialty
care is available in the host nation, language and cultural limitations
represent significant impediments to providing safe and effective care. A
teleconsultation system capable of providing subspecialty services had the
potential to improve both access to and quality of health care delivered.

TAMC’s asynchronous telemedicine for US military beneficiaries
started in 2000, with the Electronic Children’s Hospital of the Pacific
(ECHO-Pac) asthma intervention. Children with asthma were enrolled from military
facilities in Guam, Okinawa, mainland Japan and Korea. Each child was cared for
utilizing an asthma clinical pathway with advice from a paediatric pulmonary
specialist via the website. All patients experienced an improvement in their
asthma. There were fewer emergency room visits and fewer unscheduled acute
clinic visits. At the same time, the primary care provider’s practice in caring
for children also improved as a result of increased use of asthma education and
planning.11

In addition to the asthma intervention, ECHO-Pac included a
general consultation capability modelled on the PIHCP. This feature was far more
popular with remote

Figure 15.6 US military health care facilities
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
it is to Seoul (7320 km) or Okinawa (7480 km)

health care providers than the asthma intervention. From
October 2000 until April 2004, a total of 875 teleconsultations were submitted
to the ECHO-Pac system from 14 different US military hospitals and clinics
throughout the Western Pacific. These consultations included over 1700 images
and more than 7000 clinical comments from numerous specialists.

One of the difficulties with technology research is the lack of
‘measures of effectiveness’ for new initiatives. Technology is often pursued
because it can be done, without asking whether it should be done and with no
plan to measure whether the technology makes a difference. In 2004, the PacRim
Teleconsultation Effectiveness Trial evaluated ECHO-Pac’s impact on access to
specialty care, the quality of the care provided and the cost savings. A panel
of 5 physicians evaluated 267 consultations over a 1-year period. The average
time for the consultation to be reviewed and forwarded by the consult manager
was 5 hours (SD 3), with a reply from a consultant in an average of 32 hours (SD
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
TAMC for further evaluation was reduced by 30%. Given the significant cost of
moving patients (approximately US$5800 per case), use of the ECHO-Pac
teleconsultation system demonstrated significant cost avoidance.12

As a result of the success of the ECHO-Pac teleconsultation
system, TAMC launched the Pacific Asynchronous TeleHealth (PATH) system in 2004.
PATH was created with a modular design to expand the capabilities to the care of
both paediatric and adult patients. Subsequent modules have included Lightning
Med (used by military health care providers in Afghanistan and Iraq) and a
module for tele-auscultation development and testing.13 The secure
website allows health care providers at medical treatment facilities throughout
the Pacific region to submit cases for subspecialist input. Referring physicians
provide clinical information, along with images, video and sound as necessary.
At the TAMC, physician managers forward the case to the appropriate subspecialty
for comment, and email messages notify all involved in a case when new
information or comments have been added.

Differences from the Pacific Island Healthcare
Project

Although PATH was modelled on the PIHCP website, it became
apparent that the different patient and referring provider populations served
would require some modifications to the teleconsultation process. For example,
US military beneficiaries have both increased health care options and
expectations compared with patients served by the PIHCP. Since use of PATH is
not mandatory, referring providers can simply refer the patient for local
specialty care (if available) or for air evacuation to TAMC or another tertiary
military treatment facility. Our philosophy has been to simplify the
teleconsultation process where possible, knowing that many health care providers
will opt for the least time-consuming option when sending a patient for
subspecialty care. As a result, the processes of teleconsultation submission,
administration and multimedia handling have continued to change with technology
innovations and provider needs.

Documentation and privacy requirements are demanding in PATH,
which must comply with all US regulations. The results of teleconsultation must
ultimately reside in the patient record, so we developed a
system that allows the consultation notes to be printed onto standard US
military health care forms for inclusion in the patient’s record. The security
is sufficient to comply with the Health Information Portability and
Accountability Act of 1996. The password encryption protocols are rigorous so as
to ensure security. Although email is used to inform providers of new
information regarding a specific case, no individually identifiable health
information is included in the messages.

Documentation of services provided in PATH is important.
Although few US insurance companies offer reimbursement for asynchronous
telehealth, the Surgeon General of the Army grants appropriate workload credits
for telemedicine. For this purpose, a billing module was created in PATH
allowing for workload capture on the part of the subspecialist. Once a
teleconsultation is entered into the PATH system, the patient administrators
receive an email message informing them of a new patient requiring registration
into the local hospital system. Once a subspecialty provider completes
teleconsultation services in PATH, the billing module allows for easy coding of
diagnosis. On completion, departmental coders are alerted of the billing form
via email and can enter the data into the system. This streamlined approach
reduces the extra work required of the consultant (approximately 10–15 seconds
to complete and email the workload credit form) while documenting the workload
provided by PATH. Accurate documentation is essential to continued funding of
the PATH system.

Experience with PATH

Since its launch in October 2004, the number of consultations
submitted to the PATH system has increased (Table 15.3). There has
also been a 20% increase in the number of images submitted per teleconsultation
in just over two years. Since the opening of the adult telemedicine module,
nearly one-third of all consultations submitted have been for adult patients.
This rapid growth verifies the demand for adult subspecialty teleconsultation
services in the region.

The system is designed to accept all types of referrals. When a
physician is registered in PATH, and during the consultation process itself,
referring providers are reminded that it is not intended to be used for medical
emergencies. Currently, there are over 600 registered users from 30 military
hospitals and clinics throughout the Pacific. All of this activity has occurred
despite the fact that PATH’s use is optional,

Table 15.3 PATH teleconsultation
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
physicians serve for only one to two years in the Western Pacific, there is high
turnover among PATH users.

As described above, the PATH system improves subspecialist
access and quality of care while reducing health care expenditures from air
evacuation or referral to host-nation specialists. Even for patients who are
transferred to TAMC for further evaluation, PATH minimizes health care
expenditures by reducing test duplication and coordination of efficient
diagnostic and therapeutic options, resulting in a more rapid return to
duty.

Challenges

Like many telemedicine systems, PATH was initially funded by
research and development funds without a clear plan for financial
sustainability. Once initial funding had been obtained, we sought funds from
referring institutions based on the cost savings from avoided air evacuations.
We chose this avenue because of the high cost of air evacuation (US$3000–6000
per patient), believing that the 30% reduction demonstrated in the PacRim
Teleconsultation Effectiveness Trial12 would make
the system sustainable. Owing to the financial structure of the US military
health care system, however, no single institution was responsible for these
expenditures and, although each potential organization felt that PATH was a
useful service, none was willing to contribute to its costs. Fortunately, the
Army Surgeon General recognized PATH’s value and provided funds (approximately
US$100 000 per year). Since the initiation of the workload capture function in
late 2006, we anticipate that the revenue generated from PATH’s teleconsultation
services will provide the necessary financial resources for future
sustainability.

The US military’s transition to an electronic medical record
(EMR) has resulted in further challenges for the PATH system. Since the clinical
information needed for teleconsultation is already stored in a digital format in
one of several computer systems, remote US health care providers have requested
system interoperability to streamline the consultation process. In addition, the
results of a PATH teleconsultation must find their way back to the patient’s EMR
so that future caregivers have access to the information. At present, this is a
manual process, albeit one under review.

The introduction of telemedicine has provided opportunities to
expand PATH’s capabilities. We are currently experimenting with a variety of
tele-auscultation devices for telecardiology. Although there was initial
enthusiasm about using these devices, once the novelty wore off most were
abandoned because of the time required and the lack of technical support
available. We have learned that, although transmission of useful telehealth
information may be possible with these devices, they must first be tested and
integrated into PATH for seamless use prior to deployment. This is a challenging
task, owing to the range of proprietary software and hardware, and the few
interoperability standards.

Improved communications in the Western Pacific, by non-secure
email, telephone or fax, has resulted in frequent consultations by health care
providers outside the PATH system. Since these routes allow
for easy, rapid consultation, some health care providers prefer this to
utilizing the PATH system. However, such consultation routes do not meet privacy
requirements, result in little, if any, clinical documentation, and fail to
generate workload credit for the physicians involved.

Future work

We continue to develop the PATH system. For example, the
tele-auscultation module allows remote digital stethoscopy. This includes a
digital heart sounds recording system, which can be operated via a graphical
user interface. Using this system, paediatric cardiologists can differentiate
normal from abnormal heart sounds with a high degree of accuracy.13 We are also
beginning to use the PATH system for tele-education. This will provide
continuing medical education to staff distributed throughout the Pacific
region.

Acknowledgements

The views expressed here are those of the authors and do not
reflect the official policy of the Department of the Army, Department of Defense
or the US Government.

Further reading

Mahnke CB, Mulreany, MP. PacRim Pediatric Heartsounds
Trial: store-and-forward pediatric telecardiology evaluation with
echocardiographic validation. In: Klapan I, Poropatich R, eds. Remote
Cardiology Consultations Using Advanced Medical Technology – Applications for
NATO Operations. NATO Science Series, I: Life and Behavioural Sciences,
Volume 372. Amsterdam: IOS Press, 2006: 65–72.

Swinfen R, Swinfen P. Low-cost telemedicine in the
developing world. J Telemed Telecare 2002; 8(Suppl 3):
63–5.

Tripler Army Medical Center. Pacific Island
Healthcare Project (PIHCP). Available at: tamc-tmed.tamc.amedd.army.mil/pihcp.

Wootton R, Youngberry K, Swinfen R, Swinfen P. Referral
patterns in a global store-and-forward telemedicine system. J Telemed
Telecare 2005; 11(Suppl 2): 100–3.

References

1.
Yano V, Finau SA, Dever G et al. The PBMA and telemedicine in the Pacific: the
first steps. Pac Health Dialog 1997; 4: 81–4.

2.
Delaplain CB, Lindborg CE, Norton SA, Hastings JE. Tripler pioneers telemedicine
across the Pacific. Hawaii Med J 1993; 52:
338–9.

3.
Person DA, Whitton RK. An Internet based consultation and referral network
between Tripler Army Medical Center and hospitals in the Western Pacific. In:
Proceedings of Pacific Medical Technology Symposium, 1998: 132–8.

4.
Person DA. Pacific Island Health Care Project: early experiences with a
web-based consultation and referral network. Pac Health Dialog 2000;
7: 29–35.

5.
Ruess L, Uyehara CF, Shields KC et al. Digitizing pediatric chest radiographs:
comparison of low-cost, commercial off-the-shelf technologies. Pediatr
Radiol 2001; 31: 841–7.

6.
Person DA. The Pacific Island Health Care Project: easing the cancer burden in
the United States associated Pacific Islands. Pac Health Dialog 2004;
11: 243–7.

7.
Person DA. The Republic of Palau and the Pacific Island Health Care Project
(PIHCP). Pac Health Dialog 2005; 12: 132–40.

8.
Hensel KS, Person DA, Schaefer RA, Burkhalter WE. An internet-based
referral/consultation system for the US-associated Pacific Islands: its
contribution to orthopedic graduate medical education at Tripler Army Medical
Center. Mil Med 2005; 170: 214–18.

9.
Belnap CP, Freeman JH, Hudson DA, Person DA. A versatile and economical method
of image capture for telepathology. J Telemed Telecare 2002;
8: 117–20.

10. Meza-Valencia BE,
de Lorimier AJ, Person DA. Hirschsprung disease in the US associated Pacific
Islands: more common than expected. Hawaii Med J 2005;
64: 96–101.

11. Malone F, Callahan
CW, Chan DA et al. Caring for children with asthma through teleconsultation:
‘ECHO-Pac: The Electronic Children’s Hospital of the Pacific’. Telemed J E
Health 2004; 10: 138–46.

12. Callahan CW,
Malone F, Estroff D, Person DA. Effectiveness of an Internet-based
store-and-forward telemedicine system for pediatric subspecialty consultation.
Arch Pediatr Adolesc Med 2005; 159: 389–93.

13. Mahnke CB, Abbas
M, Mulreany MP. PacRim Pediatric Heartsounds Trial: asynchronous pediatric
cardiology evaluation via tele-auscultation. Presented at the 2nd Annual
Pediatric Telehealth Colloquium, San Francisco, CA, 6–8 September 2007.

16 Telemedicine support for a global network of Italian
hospitals

Gianfranco Costanzo and Paola Monari

Introduction

In 2002, the Italian Ministry of Health began a project to
support Italian hospitals around the world. This was driven by an ad hoc
governing body, the Alliance of Italian Hospitals Worldwide. The IPOCM
(Integration and Promotion of Italian Hospitals and Health Care Centres
Worldwide) project originated from a census of Italian hospitals abroad
conducted by the Ministry of Foreign Affairs. By using an elastic definition of
the term ‘Italian’, hospitals were identified in most developing countries. The
hospitals included those with Italian ownership, Italian management or Italian
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
health care centres. Almost immediately, another hospital was added to the list
(Table 16.1), and
after the First Conference on Italian Hospitals Worldwide, which was held in
Rome, other Italian health care centres applied to be included. At present,
there are 79, and the number is expected to increase in the future.

The project’s vision was of a new kind of international health
cooperation that was able to keep results locally, for use by health providers
who are committed to improving the health status of the population. In other
words, the intention was not to adopt a spot approach to health cooperation,
which might alleviate the specific health needs of certain population groups,
but rather to share with local staff the most appropriate methodologies for
attaining ambitious and sustainable targets.

Within this framework, telemedicine was considered as one
strategic factor in the structure and organization of the health care network.
Since telemedicine facilitates diagnosis, medical consultation and assistance
using the resources of centres of excellence, it could therefore improve both
medical and administrative support for Italian hospitals abroad. A model based
on the use of the Internet1–9 which is
autonomous and cooperative at the same time would conform with the principle of
subsidiarity, i.e. decisions would be taken at the nearest level of
responsibility.

At the 2003 conference in Rome, Italian hospitals abroad made
the request to be part of a democratic organization. The Alliance of Italian
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
Cordoba

Associacion Hospital Italiano Regional Del Sur

Ospedale Italiano De La Plata

Armenia

Ospedale Redemptoris Mater, Ashotsk

Brazil

Poliambulatorio Nossa Senhora Aparecida, Foz do
iguaçu

Hospital Italiano di Rio de Janeiro

Burkina Faso

Centro di Accoglienza Notre Dame de Fatima – CANDAF,
Ouagadougou

Centre Médical avec Antenne Chirurgicale St Camille,
Nanoro

Centro di Salute e Promozione Sociale Suore Figlie di San
Camillo, Ouagadougou

Centro Medico St Camillo, Koupela

Centro Medico St Camillo, Ouagadougou

Canada

Ospedale Italiano Santa Cabrini Montréal

Côte d’Ivoire

Centro Don Orione, Bonoua

Democratic Republic of the Congo

Hôpital Général Conventionné Catholique, Kimbau

Hôpital de Mokala, Kinshasa

Hôpital Txingudi, MC Lumbi

Egypt

Ospedale Italiano Umberto I, Cairo

Ethiopia

HEWO Hospital – Quihà, Mekele

Italian Dermatological Centre IISMAS, Mekele

Jordan

Ospedale Italiano – ANSMI, Amman

Ospedale Italiano – ANSMI, Kerak

India

Indian Spinal Injuries Centre, New Delhi

Israel Ospedale Italiano – 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 – ANSMI, Tangier

Paraguay

Sociedad Italiana de Socorro Mutuo, Asuncion

Syria

Ospedale Italiano – ANSMI, Damascus

Sudan

Mary Immaculate Hospital. Mapourdit

Tanzania

Mbweni Hospital ‘Santa Maria Nascente’

Uganda

St Mary’s 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’s Mission Hospital, Ngezi

Luisa Guidotti Hospital, Mutoko

then formally established. The founding partners were a
number of government ministries. Immediately afterwards, certain centres of
excellence in Italy were invited to join the Alliance. It was agreed that all
partner hospitals in Italy and abroad would cooperate on health by supporting
the network. The strategic objective was to contribute expertise from Italy to
increase the quality of health care in Italian hospitals abroad.

Policy-making process

Under normal circumstances, a distinction can be made between
the different phases in the policy-making process.10 Accordingly,
the Italian Ministry of Health began a public policy cycle. The phases were
agenda setting, policy formulation, policy implementation and policy evaluation,
i.e. those of classical public policy research.

The agenda setting was established on the basis of the wishes of
the Italian hospitals abroad, which expressed a need for diagnostic support and
organizational assistance. Within the Ministry of Health, a group of experts who
later on would be working for the IPOCM project started studying the problem,
using systematic methodologies and tools. Five objectives resulted:

1. To connect the Italian hospitals abroad with centres of
excellence in Italy and the Secretariat for Technical Assistance (STA) in
Rome

2. To reduce diagnostic and organizational shortcomings among
doctors working in Italian hospitals abroad, through a teleconsultation
service

3. To increase the individual and collective skills of the
health personnel through an e-learning service

4. To facilitate twinning arrangements between hospitals and
facilitate government agreements with the countries hosting Italian hospitals
abroad

5. To find out more about the health needs of Italian hospitals
abroad in order to provide better cooperation and sustain the acquisition of
medical equipment.

Task environment

Since the IPOCM participants and activities were functionally
interconnected, actions of any one could potentially affect the others.11 Given this
complex framework for

Figure 16.1 The Alliance’s power-interest
grid

action, an assessment of stakeholders and their relevance was
undertaken. The relevant internal stakeholders were the founding ministries and
the associated hospitals in Italy and abroad. The relevant external stakeholders
were the hospitals in the developing countries, the scientific community,
citizens’ associations and the press.

Observation of the policy arena requires accurate management of
all stakeholders. They can be prioritized using the power versus interest
grid.12 Figure 16.1 shows the
power–interest grid of the project stakeholders.

The task environment of the Alliance describes the ideal area
occupied by its stake-holders, such as clients, providers, competitors, unions,
employees, financiers, institutions and scientific organizations. It is also a
place in which the Alliance operates intense and continuous relationships.13

In order to pursue the project’s objectives, telemedicine
instruments and political levers were identified, all of them designed to
empower health professionals abroad. Medical teleconsultation and e-learning
services were designed. In addition, an inventory of health equipment was set up
in order to allow hospitals abroad to benefit from health equipment donated by
institutions in Italy. (A complete description of the Alliance’s services and
user manuals is available at the Ministry of Labour’s website.14)

Teleconsultation

Various telemedicine approaches have been used over the last
few years.15–17 In
particular, those of medium or low cost that use customized computer
applications have been found to be best for developing countries. This is
confirmed by the extensive use of the Internet18,19 and email in
low-resource settings,20 on the basis
of cost–benefit considerations, high availability of
connection services and common knowledge about their use.

The methodology adopted for the network was to assess first the
technological need expressed by each Italian hospital abroad. As a consequence
of this, all information from the different countries was collected and studied
by the Secretariat in order to identify those that were viable. The availability
of local Internet connectivity was examined, and standard contracts to be signed
by hospitals with Internet service providers (ISPs) were developed. All this
work was designed to allow all hospitals to have similar connectivity. The best
approach for about 30% of the hospitals, most of them in the sub-Saharan area,
was a satellite connection through individual contracts with a non-profit-making
provider. To improve interoperability, the hospitals were equipped with similar
workstations. Finally, software specifications were produced.

The Alliance’s network is based on access to the Internet via
ADSL, HDSL (high-bit-rate digital subscriber line) or full-duplex 256 kbit/s
Ku-band satellite communication. The satellite
connections are mainly used by hospitals in sub-Saharan Africa. Workstations are
PCs equipped with peripheral devices such as a digital cameras, printers and A4
scanners. The teleconsultation architecture is based on a Management Centre (MC)
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
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
made at the referring site. Instead, the teleconsultation allocation is
performed by the MC. This guarantees the same quality to all referring doctors.
The MC allocates the request to the most appropriate specialist based on a
routing matrix. The MC can monitor the process until the teleconsultation is
completed (the target is to complete consultations within 72 hours). The
Alliance’s database contains 86 disease code groups, according to the
International Classification of Diseases, 9th revision, Clinical
Modification (ICD9-CM),21 which expand
into 8500 single disease codes. Each specialist centre is responsible for
negotiated code groups, and organizes itself to satisfy the service workload
within the established targets for reply time and performance quality. Most
specialist centres decided to concentrate the incoming referral traffic on a
single workstation.

The referring doctor uses the client software to generate an
email message containing clinical case data, or to access a videoconsultation if
necessary. When compiling the fields on the electronic form, structured XML
messages are created. Since both enquiry and reply are managed by the same
client software, any health centre is able to act as a referral or a specialist
site. The referring doctor, in addition, can invite a close examination of a
clinical case by sending a videoconsultation invitation to the specialist.

International standard medical terminology is supported by the
system, as well as five different languages (Italian, English, French,
Portuguese and Spanish). Diseases are codified according to ICD9-CM and drug
names are taken from a standard reference work.22 The
interface collects all relevant data for the teleconsultation request or reply
into encoded fields, in order to allow later textual retrieval and statistical
analysis. ICD9-CM codes and the patient’s gender and age are the relevant pieces
of information for the routing function performed at the MC,
and they are put into the form by the referring doctor through multi-option
lists. Most attached files are captured by digital cameras, and are usually sent
after compression (i.e. with a .zip extension). Some attached files are taken
directly from diagnostic equipment where feasible.

The database does not store any patient identity information,
and therefore the system complies with Italian privacy law. The message reaching
the MC contains a teleconsultation identification number, which is automatically
generated by the software, as well as the hospital and workstation identifiers.
Request and reply data are stored in a teleconsultation record in the database
(Microsoft Access), which also holds diagnostic attachments and other
information, such as the time of the request delivery at the MC and the time of
the reply being forwarded to the referring doctor. Attachments are classified by
content (e.g. patient pictures, reports, images or chart recordings). The
attachment extension is automatically captured by the system, allowing the MC to
detect possible mismatches between the number of attachments that are sent and
those actually received. Transfer protocols between the PC and mail server are
SMTP and POP.

In addition, a videoconsultation can be requested by a referring
doctor in relation to a clinical case where a reply has already been delivered.
It can also be requested by a specialist when sending the reply. The MC manages
the videoconsultation requests until the referring doctor and the specialist
reach an agreement about the date and time. The MC’s main functions allow
clinicians to contact hospitals in different time zones while they are not
online and allow clinicians to handle requests for videoconsultation. Once the
meeting has been agreed, the MC notifies the caller, and those involved are sent
an invitation message that contains a link to the web portal. Finally the system
sends an alert message some minutes before the scheduled time to ensure that
both doctors are available in front of their PCs. Doctors can therefore launch
the session from any workstation with a browser that accepts ActiveX controls
and discuss the case with the help of the relevant documentation.

E-learning

Global support to health personnel includes the provision of
an e-learning service oriented to the needs of doctors and health staff abroad.
This facility is provided in addition to training events on specific topics of
common interest.

Assessment of training needs

One main problem was to understand as accurately as possible
the scale and quality of the training required. The Secretariat reviewed various
information sources. The first was the declaration given by the hospital at the
time of application to the Alliance. They are required to complete a health
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
with the Alliance e-learning platform. Potential users are asked to give
information about their professional and training profile,
curriculum and career expectations. They are also requested to state their
training need in terms of medical disciplines. This information is also stored
in the database and used for subsequent analysis.

A third source, although an indirect one, is the medical
teleconsultation service itself, with a database that provides statistics about
the most commonly used ICD9-CM codes. The teleconsultation data therefore
identifies disease areas that deserve particular attention and thus training
support.

Other aspects that are taken into consideration are the hospital
resources and the sociopolitical framework. Developing countries, especially the
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
result of an assessment of the training needs expressed by the hospitals. Each
centre of excellence selected its own production materials and made them
available to the Secretariat. These materials were optimized for uploading and
organized by training area and by an assigned ICD9-CM code.

Other important data accessible via the platform come from the
medical teleconsultation reports. In fact all teleconsultations result in
reports that are classified by ICD9-CM code, and therefore a referring doctor
can consult this archive before making a new teleconsultation request. The
teleconsultation service therefore has substantial training benefits.

In addition to all this, the Secretariat has produced 18 new
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
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
monitored by the Secretariat for Technical Assistance. The MC
looks after the whole production process with an expert who manages relations
with the external producer company. The role of the MC’s expert is essential in
monitoring the timing, given the complexity of the multiple production
processes.

Health equipment inventory

In response to requests for new equipment coming from doctors
working abroad, the Secretariat produced a web-based inventory for health
equipment that was being donated. In 2005, Italian law provided the legal
framework for public health centres to give notice to the inventory of the
planned disposal of functioning health equipment. Thus, the inventory allows a
centre to make the equipment available for an interested hospital abroad.
Hospitals can see all equipment on the inventory and reserve items according to
their need. This system, which matches offer and demand, improves the efficiency
of the donation process and provides a picture of the entire donation cycle,
which is useful for a better cooperation policy.

An ontology for the Alliance

Classification of diagnoses and other statistical data is
fundamental to the work of the Alliance. This led to an ontological definition
of the Alliance’s services.23,24 ICD9-CM
codes are ontology agents of the teleconsultation routing matrix. Doctors can
scroll through the list of training materials and cross-link the interservice
ontology agent, taking advantage of different databases. The same thing is
possible when using the web-based inventory of donated medical equipment (which
is the third service of the Alliance), where the agent is hospital structure, as
well as when talking of teleconsultation, where both ICD9-CM and hospital
structure are considered (Figure 16.2).

Quality control

Customer satisfaction

In 2005, a survey of service satisfaction was carried out
among teleconsultation users. The areas investigated were technology,
communication and organization. The results of the survey showed that 89% of
specialists expressed positive judgements, and 86% of referring doctors. There
were only a small number of negative judgements (about 9%). Criticisms were
discussed subsequently with specialist and referring centres in order to improve
service quality.

The Secretariat urged the MC to intervene on a few points
related to technological and organizational matters. In about 10% of the
hospitals, the MC detected trans-coding actions on teleconsultation messages
operated by some Microsoft Exchange mail servers, as well as difficulties
related to internal security policies. These

Figure 16.2 The first implementation of the
Alliance’s reference ontology. (Adapted from Top Level Concepts of the
Reference Ontology of Medicine. Laboratory of Applied Ontology of Rome,
National Research Council.)

problems were overcome by helping the hospital IT departments
to properly configure their internal mail servers and security systems. The
automatic alarm facilities at the MC helped to identify the problem of lost
attachments and to solve it.

As far as the service organization at the health centres is
concerned, after experiencing some mismanagement of time and allocation of
requests, hospitals were advised by the Secretariat to install the
teleconsultation workstation in the health directorate in order to manage the
incoming flow of enquiries centrally. Some teleconsultation forms were not
properly filled in by the referring centres in terms of completeness of medical
data for diagnosis, so the Secretariat intervened in order to improve the
request quality and speed up the processing. This represents a global process of
optimization.

In 2006, a second survey on satisfaction was carried out. The
results were positive in relation to the national health centres and to the
Italian hospitals worldwide. For the latter, a slight decrease of service
satisfaction was recorded in comparison with the previous survey. The reasons
are essentially due to the ‘distance’ of some physicians who in Italy are far
from the day-to-day problems of hospitals in other countries. As far as the
specialists are concerned, communication can sometimes be difficult (mostly
because of the use of the English and Spanish languages on the form, rather than
Italian, and the lack of clinical data).

Manual of procedures

The total quality management approach adopted by the Alliance
includes a manual of procedures. Procedures are planned for each of the
Alliance’s services with the help of the relevant people in the operational
management. This is an attempt to standardize actions in a conceptualized
framework. It helps operators to manage routine and unexpected events.
Procedures are revised either periodically or when needed.

Insights

Common difficulties experienced during the first years of the
project included a shortage of local infrastructure and a lack of financial
resources. War conditions in some of the countries hosting the Alliance’s
hospitals provided additional problems. Planning and implementation activities
were therefore very important, and the Secretariat accomplished these tasks
successfully. We concentrated on finding technical solutions tailored to the
micro dimension of each problem, since it was impossible to act with a
country-level approach. The motivation and cohesion of the hospitals were
continuously supported by the Secretariat, and there was public–private
sponsorship for some technical solutions. After four years of experience, it is
clear that success is mainly due to the strong organizational framework provided
by the Secretariat, in terms of methodologies and procedures. This has made it
possible to produce better results than are common with telemedicine projects in
developing countries, where simple email is the usual medium of communication.
Key factors in our success were a telecommunication network, specialized
software for teleconsultation, an organized database and ad
hoc ontologies.

There were other components that were also essential for the
success of the initiative. The hospitals in Italy provided valuable expertise,
both in teleconsultation and in distance learning. In addition, it should be
mentioned that free-of-charge participation of hundreds of specialists would be
simply inconceivable if done outside the public health system.

Finally, all doctors of Italian hospitals worldwide have left
their own mark in strengthening the mission of the Alliance, which is both
ethical and cooperative. The mixture of all these things has made the programme
effective, and now partnership appears to be a main asset.

Conclusion

The IPOCM programme is rather different from other
telemedicine work recorded in the literature. Although it shares some elements
with other telemedicine initiatives in developing countries, it has relied on a
solid organizational element as well as standardized procedures. Institutional
support, in terms of resources and know-how, was crucial in ensuring
sustainability and high service quality. Furthermore, good governance was
required to keep all these elements together. Appropriate resources and good
governance are therefore important components for a public policy focused on
health partnership in developing countries.

Further reading

Aas IH. The future of telemedicine – take the
organizational challenge! J Telemed Telecare 2007; 13:
379–81.

Geissbuhler A, Bagayoko CO, Ly O. The RAFT network: 5
years of distance continuing medical education and tele-consultations over the
Internet in French-speaking Africa. Int J Med Inform 2007;
76: 351–6.

References

1.
Vassallo DJ, Buxton PJ, Kilbey JH, Trasler M. The first telemedicine link for
the British Forces. J R Army Med Corps 1998; 144:
125–30.

2.
Vassallo DJ. Twelve months’ experience with telemedicine for the British armed
forces. J Telemed Telecare 1999; 5(Suppl 1):
117–18

3.
Edejer TT. Disseminating health information in developing countries: the role of
the Internet. BMJ 2000; 321: 797–800.

4.
Fraser HS, McGrath SJ. Information technology and telemedicine in sub-Saharan
Africa. BMJ 2000; 321: 465–6.

5.
Vassallo DJ, Swinfen P, Swinfen R, Wootton R. Experience with a low-cost
telemedicine system in three developing countries. J Telemed Telecare
2001; 7(Suppl 1): 56–8.

6.
Vassallo DJ, Hoque F, Roberts MF et al. An evaluation of the first year’s
experience with a low-cost tele-medicine link in Bangladesh. J Telemed
Telecare 2001; 7: 125–38.

7.
Graham LE, Zimmerman M, Vassallo DJ et al. Telemedicine – the way ahead for
medicine in the developing world. Trop Doct 2003; 33:
36–8.

8.
Wootton R. Design and implementation of an automatic message-routing system for
low-cost telemedicine. J Telemed Telecare 2003;
9(Suppl 1): 44–7.

9.
Cone SW, Carucci LR, Yu J et al. Acquisition and evaluation of radiography
images by digital camera. Telemed J E Health 2005; 11:
130–6.

10. Anderson JE.
Public Policy-Making. New York: Praeger, 1972.

11. Kirsh D. Adapting
the environment instead of oneself. Adaptive Behavior 1996;
4: 415–52.

12. Eden C, Ackermann
F. Making Strategy: the Journey of Strategic Management. London: Sage,
1998.

13. Johnson G, Scholes
K. Exploring Corporate Strategy. Englewood Cliffs, NJ: Prentice-Hall,
1993: 75–114.

14. Ministero del
Lavoro, della Salute e della Politiche Sociale: Settore Salute. Available (in
Italian) at: www.ministerosalute.it.

15. Mitka M.
Developing countries find telemedicine forges links to more care and research.
JAMA 1998; 280: 1295–6.

16. Strode SW, Gustke
S, Allen A. Technical and clinical progress in telemedicine. JAMA 1999;
281: 1066–8.

17. Rodas EB, Latifi
R, Cone S et al. Telesurgical presence and consultation for open surgery.
Arch Surg 2002; 137: 1360–3.

18. Fisk NM, Vaughan
JI, Wootton R, Harrison MR. Intercontinental fetal surgical consultation with
image transmission via Internet. Lancet 1993; 341:
1601–2.

19. Kuntalp M, Akar O.
A simple and low-cost Internet-based teleconsultation system that could
effectively solve the health care access problems in underserved areas of
developing countries. Comput Methods Programs Biomed 2004;
75: 117–26.

20. Zolfo M, Lynen L,
Dierckx J, Colebunders R. Remote consultations and HIV/AIDS continuing education
in low-resource settings. Int J Med Inform 2006; 75:
633–7.

21. National Center
for Health Statistics, US Centers for Disease Control and Prevention.
International Classification of Diseases, 9th revision, Clinical
Modification (ICD9-CM). Available at: www.cdc.gov/nchs/icd9.htm.

22. Martindale:
The Complete Drug Reference, 35th edn, London: Pharmaceutical Press,
2007.

23. Gruber TR. Toward
principles for the design of ontologies used for knowledge sharing. Int J
Hum Comput Stud 1995; 43: 907–8.

24. Eccher C, Purin B,
Pisanelli DM et al. Ontologies supporting continuity of care: the case of heart
failure. Comput Biol Med 2006; 36: 789–801.

17 Telemedicine in Nepal

Mohan R Pradhan

Introduction

Telemedicine is the process of providing medical expertise
remotely with the help of telecommunication. It is particularly valuable in
remote areas, and is therefore useful in Nepal, where the few specialists are
separated from most of the population. Nepal has one of the lowest gross
national products (GNPs) (US$300) per capita1 and one of the
lowest literacy rates (50%)2 of the South
Asia Region. These factors have contributed to the prevalence of communicable,
respiratory and nutrition deficiency diseases, which are among the most common
disorders seen in hospital outpatient departments. Telemedicine is therefore an
attractive potential means of improving health services. In industrialized
countries, real-time telemedicine is commonly used. However, this modality is
not applicable in a developing country, like Nepal, because of the high cost of
bandwidth and the poor telecommunication infrastructure.

The alternative modality, more suitable for a developing
country, is store-and-forward telemedicine. In a store-and-forward interaction,
the referring doctor usually enters the clinical information and digital images
in a computer. The information can then be transmitted via a dial-up Internet
connection as an email attachment to a central computer. The expert doctor can
access the data independently at a convenient time. The size of the images
attached to email messages is a potential problem with this technique, which may
necessitate some degree of image compression.

HealthNet Nepal

HealthNet Nepal is a non-governmental organization (NGO) that
provides affordable Internet services to the Nepalese health community, access
to health information and technical support for various regional
information-sharing initiatives. It has developed its own software, called Hnet
telemedicine.

Development of the software

When we examined the available telemedicine software, we found
that open source software was not suitable for our purpose3 and that
commercial software could not be easily modified. It was therefore decided to
develop software suitable for telemedicine in the context of Nepal.

The local system collects a clinical history and images, which
are then transmitted to a specialist for diagnosis. For the clinical history,
both general information and discipline-specific information are collected. The
general information includes the following:

patient
information

basic
information

personal history

past medical
history

family history.

There is also discipline-specific information for the
following specialties:

pathology

radiology

dermatology

cardiology.

In acquiring digital images, the following components were
considered.

Pathology

Images were obtained using a digital camera (Nikon CoolPix
4500). This type of camera is suitable for pathology. It has a resolution of 4
megapixels (Mp), which is sufficient for telemedicine according to the
recommendations of the American College of Radiology.4 An additional
advantage of this camera is that it can be easily mounted on a microscope with a
30 mm eyepiece adapter.

Radiology and dermatology

It was found that using the same camera for pathology was not
practical. The camera used for radiology and dermatology was a Nikon CoolPix P4,
which has a higher resolution (8 Mp). An additional feature of this camera is
its vibration-reduction ability, which makes it suitable for taking pictures in
shaky conditions.

Cardiology

For cardiology, an ECG machine was used (ECG 9620L, Cardiofax)
that directly transfers an ECG image to a computer. Thus, there is no need to
use a digital camera to photograph ECG recordings.

Software for data transfer and
security

The software ensured data security during transfer in the
following ways.

Image processing

Once images have been stored in the computer, they need to be
cropped to reduce the file size and annotation has to be provided for better
description of the clinical problem. A simple graphics package was developed for
this purpose and incorporated into the client software of the Hnet telemedicine
system. This graphics package allows cropping, annotation,
rotation, colour balance and conversion to black and white. In addition, the
free image-viewing software IrfanView was used.5

Compression

Image compression was used to reduce the quantity of memory
required to store an image. For example, an image that has a resolution of 640 ×
480 pixels with 24-bit colour requires 900 kbyte of storage. If this image can
be compressed at a compression ratio of 20 : 1, the quantity of storage required
is reduced to about 45 kbyte. Hnet has used the camera’s built-in JPEG image
compression at a ratio of 16 : 1. It has been found that image compression of
60–80% can be achieved without significant loss of diagnostic quality.

Security and confidentiality

Data stored in a computer must not be read or compromised by
unauthorized users. The Hnet software uses password-level encryption. The
passwords are stored in MD5-encrypted format for security. Without an authorized
login, no one can run the application.

Receiving and reviewing cases

After logging on to the Hnet system, the two physicians
concerned, typically a remote physician or health worker and a medical
specialist in a hospital, communicate by email. After uploading a case, the
server selects a doctor on a simple round-robin basis from the names listed in
the roster. The server regularly watches for a reply from the doctor. If a
doctor does not reply to a case within 12 hours, then the case is automatically
assigned to another doctor listed in the roster. Doctors are categorized into
groups, such as dermatology, radiology, cardiology and pathology. These
specialists can view only their own cases.

Digital photography guides

A technical manual was developed as a basic guide for
non-medical professionals and general practitioners on how to take clinical
photographs in radiology, pathology and dermatology using a digital camera.

Pilot project

The pilot telemedicine network was implemented from July 2004
to December 2006. The project was financed by the PAN Asia programme of the
IDRC, Canada (see Chapter
7). The following hospitals referred cases for telemedicine:

AMDA Hospital, Damak
(eastern region)

Siddhartha
Children’s and Women Hospital, Butwal (western region)

Siddhi Memorial
Hospital, Bhaktapur (central region).

Specialist expertise was provided from the following
central-level hospitals:

Teaching Hospital,
Tribhuvan University (Department of Radiology and Dermatology)

Kathmandu Medical
College (Department of Pathology and Department of Dermatology)

Sahid Ganga Lal
National Heart Centre.

The medical experts located at the medical colleges and
special hospitals of the central level (capital city) were chosen because the
doctors there had better knowledge of IT and were willing to participate in the
project. The local hospitals were chosen based on the size and location of the
local population.

It was found that the availability of telemedicine increased the
volume of teleconsultation and provided exposure to a rural community for the
medical interns of medical colleges. It also provided continuing education and
reduced the professional isolation of health professionals working in rural
areas. All these factors improved the quality and efficiency of the health
service. With the use of telemedicine, access to the literature through the
HINARI system of the World Health Organization increased. The observations below
are based on informal communication with the referring physicians.

Study

A study was conducted in Nepal to assess whether telemedicine
based on store-and-forward technology would be satisfactory for the diagnosis of
cases sent from remote rural areas in the specialties of dermatology, radiology,
pathology and cardiology. There were two components to the work: a basic
component and a clinical component.6 The basic
component was to define the minimum technical specifications to ensure that
diagnostically important information could be captured through a clinical
history and digital image. This component also included an investigation of the
medical expert’s ability to make an accurate diagnosis based on digital images
and clinical history. The second component was to evaluate whether the
technology would improve the process of health care delivery by increasing
information flow and reducing professional isolation.

For inclusion of cases, data were collected from the field
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
perception of the image exposure and diagnostic quality using a binary scale (0
= poor or 1 = adequate). At the second stage, the specialist doctors recorded
their confidence in the presence of each diagnostic indicator on a five-point
scale (1 = definitely absent to 5 = definitely present). The ratings from these
scales were used for receiver operating characteristic (ROC) analysis. The ROC
analysis was used to determine whether the image quality was sufficient for
diagnosis.

A two-step rating method was used to plot the ROC data. First, a
dichotomous variable indicating quality of image (0 = negative or 1 = positive)
was used. Second, the dichotomous variable based on the quality of the image was
further rated based on a five-point scale (1 = definitely
negative to 5 = definitely positive. The use of five categories is a reasonable
compromise between the needs of ROC analysis and the precision with which the
observers can be expected to reproduce their ratings. The five-point rating
scale was used to calculate predicted probability. This predicted probability
along with the dichotomous variable can be used to plot an ROC curve in order to
provide a visual impression of the reliability of the points. The statistical
package SPSS 11.5 was used for calculating predicted probability using a
logistic regression model. Based on the dichotomous variable, a predicted
probability ROC curve was plotted.

Similarly, provisional diagnosis by primary care physicians and
diagnosis by clinical experts was used for comparing baseline medical knowledge
of primary care physicians with clinical experts. These data were used only in
dermatology.

Study findings

A total of 218 cases were observed:

dermatology : 75
cases

radiology : 90
cases

histology : 34
cases

cytologu : 19
cases.

The gold standard for any specialist referred remains the
traditional method of consultation, i.e. in the case of radiology, it is the
viewing of an X-ray film; in the case of pathology, it is viewing through a
microscope; and in the case of dermatology, it is face-to-face
consultation.

We adopted an affordable system that was appropriate to our
needs.7 Compared with
real-time systems, store-and-forward systems are more practical and less
expensive. Store-and-forward methods allow the use of low-cost equipment,
low-bandwidth connections and asynchronous consultation. This approach has been
used successfully in industrialized countries where high-quality images are
transmitted via tele-medicine networks for consultation.8

Digital cameras are an efficient method of obtaining digital
images. Krupinski et al9,10 evaluated
the effectiveness of digital photography for dermatology and bone trauma
diagnoses, and found that digital camera images were of satisfactory quality.
Piccolo et al11 found high
diagnostic concordance between telepathology and histopathology diagnosis. Lim
et al12 and High et
al13 evaluated a
digital camera for teledermatology, and also found high concordance with
face-to-face diagnoses.

For determining the quality of images sufficient for diagnosis,
a ROC analysis was performed. It has been suggested that qualitative conclusions
can be drawn from ROC experiments performed with at least 100 observations.14 In our
example, all four tests (dermatology, radiology, histology and cytology) had low
p values (p < 0.5).15 Figure 17.1 shows the
ROC curve for dermatology. It can be concluded that the images had the ability
to detect disease.

Figure 17.1 ROC curve for dermatology (the
broken line represents no discrimination, i.e. a random guess)

Willingness to participate in the telemedicine
project

In Nepal, there are few doctors. There is only one doctor for
6000 people (the doctor-to-population ratio is 1 : 6000). Our study showed that
practising doctors usually did not use IT for knowledge updating. The reasons
given for not using IT were that most of the doctors were busy practitioners and
they perceived that they could manage communicable, respiratory, tropical and
nutritional deficiency diseases without recent information. Another reason was
the heavy patient workload.

However, the circumstances are different in medical colleges,
since doctors are required to update their knowledge in order to teach students.
IT has become a useful medium for updating their knowledge. So, doctors working
in medical colleges and special research institutes are chosen as experts for
the diagnosis of certain cases. Another reason is that doctors working in
medical colleges and research institutes feel comfortable in using IT.

Age of users

All the users were aged 31–50 years. This included
participants from both central and local hospitals. The reason may be that the
younger generation grew up with computers, witnessing developments in computers
and the Internet first hand.

Gender

Only one (10%) female was involved in a telemedicine project,
and she was a health professional from a central hospital. In Nepal, medicine
has been and still is a male-dominated profession. Nurses
were not involved in telemedicine in the local hospital. The reason is that
consultations are like a second opinion, which exclude nurses’ participation
because they do not have the doctors’ level of competence.

Organizational position

With reference to the organizational position of participants,
it was found that staff involved in the telemedicine project were doctors or
technicians responsible for the technical part of the project.

Users’ attitudes to telemedicine

The technical components of telemedicine were related to the
computerization process of central and remote sites. The problems related to the
computerization process were related to low computer literacy and the absence of
reliable communication infrastructure. In this context, the users’ attitudes
depended on their general knowledge and familiarization with computer
technology. All participants in the project from local hospitals and central
hospitals felt comfortable with IT as a whole and telemedicine in particular.
Telemedicine gave them an opportunity to enhance their efficiency and distance
learning and to minimize professional isolation. With the help of telemedicine,
they were able to create databases for various diseases, their forms and methods
of treatment. Doctors perceived that the databases helped to improve their
efficiency.

Consultation areas

Telemedicine was used for the purpose of general guidance,
assessment of diagnosis, treatment and examinations. It was also found that
confidence between local and remote hospitals was crucial to achieve and
maintain a fruitful dialogue. Often it is difficult to state the diagnosis from
the first information transferred. For this, two-way communications in the form
of chat is provided to make a precise diagnosis.

Collaboration between doctors at local and central
level

The users in the telemedicine project noted that their
collaboration with professionals changed with the help of telemedicine. Doctors
become more open to advice from their colleagues and specialists. Doctors came
to believe that the process of patient care could be enhanced through
telemedicine, and their trust in information technology increased.

Exposure to rural areas

In Nepal, most doctors are reluctant to work in rural areas
owing to professional isolation, lack of facilities to update their knowledge
and lack of continuing education. In medical colleges, as a part of an
internship programme, a doctor has to work in rural areas. The telemedicine
process minimized the gap of professional isolation and gave the opportunity for
continuing education in rural areas. This first-hand experience in rural areas
with telemedicine may motivate doctors to work in rural areas when their medical
courses are completed.

Drawbacks

Although telemedicine clearly has a number of potential
benefits, it also has some disadvantages. The main drawbacks are a potential
breakdown in professional relationships and a number of organizational
problems.

Breakdown in the relationship between health
professionals

Skilled staff at the remote site sometimes perceive that their
autonomy is threatened by the use of telemedicine, or, worse still, think that
they will become no more than technicians, acting solely at the guidance of the
remote specialist.16

Organizational problems

The following organizational problems were identified in
Nepal:

Fear of the unknown.
Nepal remained poorly networked because of inertia, fear and technical
inexperience of higher management personnel in government and NGOs.

Lack of trained
manpower. In spite of widespread enthusiasm about IT, there are very few local
facilities for higher-level technical training.

Possessiveness. In a
country with the lowest GNP in the region and having few opportunities, people,
including higher-level management, tend to hoard everything. They do not
hesitate to break contracts, even for minor financial benefits. This attitude
runs counter to networking and information sharing.

Economic evaluation

An analysis was carried out to compare the cost of
telemedicine with the cost of traditional methods of providing health care
services (Table
17.1). Only variable costs were considered. The cost charged by the remote
site was approximately 50% less than the charge to be paid in city areas.
However, the patient need not bear the cost of transportation and lodging. The
telemedicine service charge would be sufficient to

Table 17.1 Comparison of variable costs
(1 US$ = Rs0.65)

Type of service

Charge through traditional method (Nepalese
Rs)

Charge through telemedicine (Nepalese
Rs)

Radiology (plain X-ray)

15

15

ECG

400

200

Pathology (cytology)

500

250

Dermatology

200

50

Transportation (nearest city)

200

—

Lodging

200

—

cover the fixed costs and to pay the fees of the expert. Thus,
only the cost of the expert’s Internet connection would have to be borne by the
remote centre. It is too early to calculate all the costs (fixed and variable)
in order to estimate whether tele-medicine could become financially
sustainable.

Research findings

We also compared the baseline medical knowledge of primary
care physicians with clinical experts. Here, we also found that there was no
difference in the diagnosis among primary care physicians and expert doctors.
This supports the view that textual information supplemented by images is
sufficient for diagnosis.

The telemedicine system helped primary care physicians to
interact with medical experts. This, in turn, helped to reduce the professional
isolation of health care staff working in rural areas.

At the start of the project, we found technophobia among health
professionals working in rural areas. To reduce this, we provided IT training
courses to all the health professionals working in rural areas. These training
courses helped rural health workers to become familiar with IT. These health
workers also found that IT could enhance their efficiency. The technical
knowledge encouraged staff to use IT in other areas such as hospital information
systems, to improve the efficiency of the hospital and to provide access to the
health literature to update their knowledge.

Future developments

In our research project, we found that there was potential for
telemedicine in Nepal, especially in rural areas, but also in urban areas. It
was also found that textual information with images was sufficient for diagnosis
in many cases. Telemedicine helped medical education, medical care and collegial
support. However, continuation of the work after the project has finished will
depend on how the local health professionals and medical experts support the
services. To support and continue the telemedicine work, there should be other
computerized health services, such as distance education, digital libraries and
computerized hospital information systems. That is, telemedicine cannot develop
in isolation. These types of activities will encourage rural health workers and
medical specialists to continue the telemedicine work. As users become more
comfortable with the technology, they are inclined to experiment with new
applications. These activities help to enhance their efficiency, update their
knowledge and reduce professional isolation.

Low-cost telemedicine based on store-and-forward systems has
also been carried out in other developing countries. For example, the Swinfen
Charitable Trust established a telemedicine link to support the Centre for the
Rehabilitation of the Paralysed (CRP) in Savar, near Dhaka in Bangladesh, in
July 199917 (see Chapter 19). Based on the
success of the Bangladesh project, the Swinfen Charitable Trust supplied digital
cameras and tripods to more hospitals in other developing countries. These
included the Patan Hospital in Nepal (March 2000), Gizo
Hospital in the Solomon Islands (March 2000), Helena Goldie Hospital in the
Solomon Islands (September 2000) and LAMB Hospital in Bangladesh (September
2000). In South Africa, the technique has been used for referrals from remote
clinics. The US Armed Forces have made use of store-and-forward telemedicine for
telepathology (see Chapter
15), and a link has been established between Italian hospitals worldwide
(see Chapter 16).18
Store-and-forward teledermatology has been used in linking remote parts of
Africa to teaching hospitals in the USA and Europe.

Suggestions were invited from the users in Nepal for improving
the telemedicine service. The following were the main suggestions:

Include separate
funding for telemedicine in hospitals with telemedicine units and in central
hospitals providing expert advice.

Improve the
technology for telemedicine from still images to videoconferencing.

Increase the
frequency of consultations and organize videoconferences.

Define a list of
cases for mandatory advice apart from emergency cases.

Computerize the
hospital information systems, which will help to follow up patients treated
earlier.

It is not easy to answer the question whether telemedicine in
a developing country is cost-effective, since this requires evaluation in a
properly controlled, scientific trial. Unless this can be done, the answer to
the question whether telemedicine represents an appropriate use of resources
will remain unknown.19

Further reading

Blanchet KD. Innovative programs in telemedicine.
Telemed J E Health 2008; 14: 318–22.

Clarke M, Thiyagarajan CA. A systematic review of
technical evaluation in telemedicine systems. Telemed J E Health 2008;
14: 170–83.

iPath Association. Telemedicine in Developing
Countries. Available at: ipath.ch/site/node/19.

Latifi R, ed. Establishing Telemedicine in Developing
Countries: From Inception to Implementation. Amsterdam: IOS Press,
2004.

Wurm EM, Campbell TM, Soyer HP. Teledermatology: how to
start a new teaching and diagnostic era in medicine. Dermatol Clin
2008; 26: 295–300.

References

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2. World Health
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3. Carnall D. Medical
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4. American College of
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8. Szot A, Jacobson FL,
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9. Krupinski E,
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10. Krupinski EA,
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11. Piccolo D, Soyer
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42: 776–83.

14. Metz CE. Basic
principles of ROC analysis. Semin Nucl Med 1978; 8:
283–98.

15. Zweig MH, Campbell
G. Receiver-operating characteristic (ROC) plots: a fundamental evaluation tool
in medicine. Clin Chem 1993; 39: 561–77.

16. Hjelm NM. Benefits
and drawbacks of telemedicine. J Telemed Telecare 2005;
11: 60–70.

17. Vassallo DJ,
Swinfen P, Swinfen R, Wootton R. Experience with a low-cost telemedicine system
in three developing countries. J Telemed Telecare 2001;
7(Suppl 1): 56–8.

18. Della Mea V,
Beltrami CA. Telepathology applications of the Internet multimedia electronic
mail. Med Inform (Lond) 1998; 23: 237–44.

19. Wootton R. The
possible use of telemedicine in developing countries. J Telemed
Telecare 1997; 3: 23–6.

18 Telemedical support for surgeons in
Ecuador

Stephen Cone, Edgar J Rodas and Ronald C
Merrell

Introduction

A surgery project for the isolated and under-served in
Ecuador, which began more than 25 years ago, has matured into a fixed element of
service delivery. Telemedicine was first applied to support the surgery
programme in 1995.1 Ecuador has
characteristics that make it highly suitable for telemedicine.

Ecuador (more properly called the Republic of Ecuador) has a
population of 13 million.2 They are a
mixture of European heritage and indigenous peoples, and occupy three distinct
geographical zones.3 The
westernmost zone is the coastal region. The central zone is the highlands (the
Sierra). The easternmost region (the Oriente) marks the beginning of the
Amazonian rainforest.

The majority of the population work in the service industry,
many being employed in eco-tourism.3 However, the
unemployment rate is 10.6%, with poverty affecting 39% of the population.3 The gross
national product (GNP) for Ecuador is US$4070 per capita.2 The average
per capita expenditure for health care is US$127.2 Total health
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
of the rest of the world, some that are common to tropical regions and some that
are common to developing countries. These three categories are important in
considering illness in Ecuador. Like the world in general, Ecuador is facing
changing illness patterns that reflect the emergence of chronic conditions,
rather than the acute, infectious diseases more common in earlier times. There
is also increasing interpersonal violence and trauma (mainly due to increased
motor vehicle activity) and tropical disease. As a developing country, Ecuador
has the common problems of sanitation, nutrition and access to health care.

Despite these challenges, life expectancy in Ecuador is similar
to that in industrialized countries, with recent data predicting 70 years for
males and 75 years for females.2 Infant and
child mortality are high, at 22 and 25 per 1000 live births, respectively.2 Compared with
10 years ago, non-communicable diseases have increased in importance (up to 42% of deaths), as have injuries (21% of deaths), while
communicable diseases have declined as a measure of the burden for mortality
(down to 37% of deaths).4

Medical system in Ecuador

Ecuador has developed a health care system based on a
combination of public, private and volunteer support. In 2000, the total health
workforce (physicians, nurses, midwives and dentists) numbered 41 000.2 There were 18
000 physicians (or 1.5 per 1000 people).2 These numbers
do not include the traditional tribal healers, once an important part of the
culture of the indigenous peoples. With 39% of the people living in rural areas,
and up to 30% of the population classified as Amerindian,3 the role of
the ‘curanderos’ in health care is still significant.

The more common, Western-style practitioners study in a
traditional style of medical education, modelled on the European system. The
national government supports the education of doctors (six years of medical
school followed by a one-year internship), in return for which the doctors are
expected to provide a year of service, typically in rural/under-served
areas.

The national government is also responsible for 41% of total
health spending, of which about 15% is from social security funds, the rest
coming from the Ministerio de Salud Publica (MSP), the public health
ministry.2 In many cases,
the patient’s family is responsible for providing meals, medicines and some
materials during the course of care. Despite the efforts of private payers, and
government support for health care, about 25% of the population do not have
access to health care.2

For people in rural areas and the poorest sections of urban
areas, care may be nonexistent or may come from volunteer providers. Many
providers in the country are philanthropic organizations, such as the Fundación
Cinterandes (Cuenca, Ecuador). Many health care workers are volunteers from the
USA and elsewhere. Interplast and Operation Smile are two examples of plastic
surgery missions well established in many developing countries, including
Ecuador.

Intermittent surgical services

Volunteer organizations, such as those mentioned, provide
intermittent surgical services to meet the surgical needs of under-served
populations. This has previously been decried as poor-quality care, since the
surgeon does not follow the care of the patient directly throughout the process
of healing. However, intermittent surgical services are becoming recognized as
part of a comprehensive system of health care delivery.5 With the use
of telemedicine, the distance between patient and surgeon becomes less of a
problem and, with a system of integrated providers (primary care and
specialist), the patient need never be without expert opinion.

The original intention of the mobile surgery programme of the
Cinterandes Foundation was to use Ecuadorian and international volunteers to
provide intermittent surgical services to under-served populations. The system
has subsequently expanded to become a more inclusive,
integrated part of a continuum of care.1 Since 1994,
the Cinterandes Foundation has been providing surgical care to remote
populations, decreasing the need for patient/family travel (and travel-related
expenses), reducing delays in treatment, and the associated mortality and
morbidity.1

The mobile surgery programme is based on a truck with an
operating room built on it (Figures 18.1 and 18.2). There is a small
permanent staff, which is supplemented with volunteers and students. However,
even from the beginning, it was apparent that the role of local providers would
be essential. The local primary providers supply initial contact with the
population in need, and act as the continuing contact for follow-up care. In
many ways, the mobile surgery programme operates like the typical specialist
practice, depending on primary care for patient referrals, and then proceeding
through preoperative care, the operation and the immediate postoperative care.
Local surgeons lend support and participate when the mobile programme is in
their community. Thus, the programme is properly integrated into a model of
continuous care.

Prescreening evaluation is extremely important in the mobile
surgery programme. It is during this period that the primary care providers in
the region, working under strict protocols, recruit patients with surgical
problems for further evaluation. Cinterandes personnel then travel to the area
to evaluate the patients, decide which patients are appropriate for the mobile
surgery programme, which of them have priority needs, which patients have
disqualifying comorbidities and which patients need medical treatment before
surgical consideration.1,6–8 This careful
prescreening has

Figure 18.1 Operating room on the truck with
tents for patient preparation and recovery

Figure 18.2 Interior view of the operating
room, showing the induction of a patient. Note the laparoscopic equipment in the
background

been important to the success of the programme. Patients with
additional illnesses or infections may be referred to definitive facilities or
may be excluded, to avoid unnecessary complications. Those who are accepted into
the programme must be followed using existing local resources after surgery.

Prior to the day for surgery, the truck arrives on location, and
parks outside the local health care facility. On the day of surgery, patients
are re-examined in the local facility or in a Cinterandes tent (when local
facilities are lacking).1,7,8 After surgery,
while the patient is recovering from anaesthesia, he or she is transferred to
the recovery area, either in the local facility or in a recovery tent. During
this time, postoperative care is arranged and ambulatory patients are discharged
to home.

Cinterandes personnel provide the initial postoperative
care.1,7,8 Generally,
doctors and students/residents see any patients still in the facility on the
morning of the first postoperative day, returning to base in the afternoon. For
those ambulatory patients sent home on the day of surgery, the postoperative
plan has already been discussed with the patient and local
provider. For those patients spending the night in the facility, postoperative
plans are decided upon and communicated prior to discharge.

Although the initial postoperative evaluation is performed by
the Cinterandes personnel, continuing care requires the support of the local
caregivers. Continued postoperative care generally consists of visits at one
week, one month and six months after surgery – or more frequently in the case of
complications or suture removal. While these visits are performed by the local
providers, the Cinterandes personnel remain available for consultation by
telephone, advising about wound care and providing guidance about transferring
patients in need of more advanced care.7

Understandably, this interdependence has made the interaction
with local providers an important part of the success of the intermittent
surgical service in Ecuador. Local providers and patients need the additional
services provided by the intermittent surgical service to avoid costly
alternatives or increased morbidity/mortality. The mobile surgery programme
depends on the local providers to find suitable patients, arrange preoperative
evaluations, assist with surgical scheduling and provide postoperative care to
the patients.

In addition, the mobile surgery programme has come to develop an
interaction with local and international medical education. The local schools in
the Cuenca region provide students and residents to help with the surgery
programme, in turn gaining a unique educational experience.1 With this
success, the Cinterandes Foundation has expanded the educational role to include
students from foreign medical schools, who also gain valuable experience in
learning about a new culture and medical system.

Programme activity

The Cinterandes Foundation has been operating the mobile
surgery programme in various areas of Ecuador since 1994.1 In that time,
the programme has visited 15 of the 22 provinces in the country, performing
approximately 40–50 surgical trips per year, i.e. each location generally
receives more than one visit per year.5 Thus, the
surgical truck is in operation almost every week.

The programme has performed over 4500 operations in general
surgery and specialties such as gynaecological and paediatric surgery.1,5 Even with this
patient volume in a small, mobile operating room, there has been no recorded
mortality, and only four major complications (bleeding, cardiac arrest,
pulmonary embolism and gastrointestinal injury).5 A complication
rate of less than 1% is similar to that of sophisticated US surgical centres. At
this workload, the average cost of an operation performed by the mobile surgery
programme is less than US$100.5 These costs
are met by the programme, so the service is free to patients.

Telemedicine to support surgery

Telemedicine has made a strong contribution to the
intermittent surgical service. The first step was to apply digital records and
review the management of the programme. Next, the primary
care, Foundation and international consulting sites were connected by dial-up
Internet connections for email (Figure 18.3). Then the
needs of the programme were assessed. The telemedicine stations were installed,
personnel were trained in their use, and all participants were encouraged to
practice protocols and use the Spanish-language electronic health record (EHR)
before programme implementation. Both store-and-forward and real-time
telemedicine were used.

Telemedicine support is, of course, limited by the
telecommunications available. The rate that data (bits) can be transferred
between sites is known as bandwidth. Table 18.1 shows the
bandwidths of some of the different means of connectivity. All around the world,
telecommunications continue to improve. However, in remote areas of the
developing world, slower-speed connections remain the most robust medium for
telemedicine.

Figure 18.3 Cinterandes Foundation
headquarters in Cuenca, during review of patient postoperative records. The
images shown on the computer screen were collected during the postoperative care
of a patient following a laparoscopic cholecystectomy

Table 18.1 Common connectivity
modalities and associated bandwidths

Modality

Bandwidth

Ordinary telephone network (PSTN)

Up to 56 kbit/s

Integrated services digital network (ISDN)

64–128 kbit/s

Digital subscriber line (DSL)

256 kbit/s–2 Mbit/s

Cable modem

512 kbit/s–8 Mbit/s

Ethernet

10 or 100 Mbit/s

In developing a telemedicine system in such areas, it is often
necessary to use connections of limited bandwidth.6,9 Satellite
transmission could certainly be employed, but the high cost usually makes this
impractical. The ordinary telephone network (PSTN) is available in most of
Ecuador, so that dial-up modems permit connection to an Internet service
provider (ISP).6,8,10 A technician
may operate the equipment for the clinician, while attempting to familiarize the
local providers with the use of such technology.6

The procedure for telemedicine to support mobile surgery begins
with patient registration and the creation of an EHR. The data can be text,
pictures (e.g. JPEG images), video or voice recordings. Registration includes
the medical history and demographics, and can be longitudinal for primary care
management. When surgical consultation is needed, there are, by protocol, strict
criteria for acceptable patient risk for comorbidity and scope of surgery. The
record is forwarded to the Foundation in an email attachment with a question.
Staff at the Foundation assess the problem, recommend further diagnostic tests
if necessary, order preoperative measures and, if appropriate, schedule the
surgical procedure. Videoconferencing between the Foundation and patient is an
option. This has been done using Microsoft NetMeeting. By this screening
mechanism, the requests for surgical care are managed promptly and efficiently.
Prior to telemedicine, large surgery consulting clinics took up enormous amounts
of time, with little patient care offered. After operation, the same EHR keeps
the surgeons apprised of the patient’s progress and any complications, for care
continuity. This postoperative phase can also use videoconferencing.

The telephone network can also be used during the operation to
allow distant surgeons to advise (telementoring) or to educate (distance
education).10
Better-quality video and audio during surgery has been achieved with
higher-bandwidth connections, for example using a satellite link from time to
time. While an intraoperative videoconference is certainly improved with
increased bandwidth, the pre- and postoperative visits are also better with the
use of improved video. Low-bandwidth video transmission results in
lower-resolution images or slower frame rates, or both, which may be
unacceptable.11 However, in
increasing the bandwidth, the biggest problem is the cost. None the less,
clinically acceptable transmission has been consistently achieved at 56 kbit/s
using the ordinary telephone network.6–10

Videoconference consultations can run as smoothly as in-person
examinations. Telemedicine establishes a sense of continuity in the care of the
patient, and a link between the patient, primary provider and surgeon, despite
the distances and intermittent services. The cost of telemedicine in Ecuador has
been low once computers (US$1500) and digital camera (US$250) have been
supplied. Training is provided by volunteers, and the only ongoing cost is for
telecommunication. The cost of a local ISP is quite affordable in Ecuador.

The cost of telemedicine should be compared with that of on-site
screening and consultation. In general, telemedicine allows time savings in a
three-day surgical mission. For the cost of the ISP, there is a 25% increase in
efficiency. The impact on patient safety is difficult to quantify, but the
rarity of transfers suggests that telemedicine is at least as good as
conventional management.

Experience in Ecuador

The role of the primary caregiver in the use of intermittent
surgical care cannot be overemphasized. Likewise, the role of the primary
caregiver in supporting the use of telemedicine should not be underplayed. The
equipment used in primary care centres must be familiar to the providers, with
utility beyond the support of intermittent surgical services. The equipment
should be used daily and computer skills should be encouraged on a regular
basis. This daily practice, along with curiosity and an interest in providing
better care for their patients, prompts primary caregivers to seek additional
skills with computers. Databases can provide a good means of storing patient
data, allowing both archiving and retrieval. Spreadsheets simplify the process
of calculating statistics. The addition of a digital camera to the equipment
available in the clinic allows for digital image documentation of lesions,
radiographs and the general appearance of patients. Digital cameras are now
reasonably easy to use. One primary care doctor in the eastern rainforest region
of Ecuador computerized his entire clinic, networking five computers (Figure 18.4) in
different treatment areas, sharing the same database, and integrating images
from a handheld digital camera, a video camera, a microscope eyepiece camera and
an ultrasound scanner.12 He has even
employed the equipment in remote areas.

Figure 18.4 Primary care site in Macas.
Computers are connected via a local area network (LAN). The unit shown is
stationed in the clinic’s laboratory, and can import microscopic images into the
EHR, via an eyepiece camera

Early on, the surgeons in the Cinterandes Foundation recognized
the importance of the role of primary care providers in supporting the continued
intermittent mobile surgery programme. Using existing communications systems in
rural areas of Ecuador, the surgeons have been able to integrate the primary
providers into the prescreening process of surgical care. Store-and-forward
telemedicine, i.e. asynchronous transmission of information, provides the basis
for this support. As in work done in Kenya,9 primary care
providers can send information via email to the surgeons for review prior to a
surgical trip.6–8,10 With this
advance information, surgeons are able to make better decisions about
appropriateness for surgery. Equally important, the surgeons may use this
opportunity to address the problems that made the patient inappropriate for
surgery, and may direct further care for the patient. In Ecuador, the programme
has sent students and junior surgeons to the field areas to set up and perform
the remote clinics. Local providers have been enlisted to conduct the
prescreening clinics, and have networked with permanent telemedicine stations in
primary care clinics in three areas of Ecuador.7 These
connections employ computers with telephone dial-up modems that deliver, at
best, 26 kbit/s bandwidth. Yet the system has prospered and continues to
function (see Figure
18.3). The ISP may not have a fixed Internet Protocol (IP) address for the
subscriber, and this can be very frustrating. Furthermore, the ISP’s servers
have limited capacity, and there is a consistent decline in quality and
reliability during business (high-traffic) hours.

Prescreening of patients only needs store-and-forward
telemedicine. However, video interaction by NetMeeting is possible. For the
prescreening work, the videoconferencing may elicit further information and
support informed consent. Low bandwidth may be used intraoperatively, sometimes
with the additional transmission of high-quality still images.13 As
considerable image compression is required at these low bandwidths,
higher-bandwidth transmission is certainly easier and faster for video-intensive
applications.11 A
hand-carried, portable satellite communications system provides 64 kbit/s
connectivity, while larger models and vehicle-mounted models provide even
greater bandwidths. Using two 64 kbit/s satellite channels in parallel (i.e. a
total of 128 kbit/s), transmission of live surgical images from the mobile
surgery equipment can be performed at 30 frames per second with little image
degradation.14 Using a
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
with patient and procedure information.14

Anaesthesia may also make use of telemedicine. In addition to
using store-and-forward technology to share a patient’s data and develop an
anaesthetic plan, higher bandwidth allows transmission of live anaesthetic
images and data. A single 64 kbit/s satellite connection provides enough
bandwidth to transmit images, including endotracheal intubation via a
fibre-optic intubation system, along with physiological data during the surgical
procedure.16

Following surgery, the patient recovers in a familiar locality
with familiar care-givers. It is important in this setting to provide a means
for the concerns of the patient and the health providers to reach the
intermittent surgery team. The telemedicine systems in place can provide support
for postoperative care. Wound images and data may be sent in
a store-and-forward manner, unless the surgeon decides that real-time
videoconferencing is required. Again, the relationship with the local providers
is important to the success of the intermittent surgical service.

The mobile surgery programme in Ecuador has enjoyed clinical
success. This has been accompanied by great success in maintaining social
support for patients in their communities and solidarity with primary care
providers. Telemedicine has made this programme more efficient, and therefore
available to more patients. The interactions with consultants outside Ecuador
have matured into sound professional friendships.

Further reading

American College of Surgeons. Operation Giving
Back. Available at: http://www.opera-tiongivingback.facs.org/.

Istepanian R, Laxminarayan S, Pattichis CS. M-Health.
Emerging Mobile Health Systems. New York: Springer, 2006.

Latifi R, ed. Establishing Telemedicine in Developing
Countries: From Inception to Implementation. Amsterdam: IOS Press,
2004.

References

1.
The Cinterandes Foundation. Available at: www.cinterandes.org.

2.
World Health Organization. Ecuador. Available at:
www.who.int/countries/ecu/en.

3.
Central Intelligence Agency. The World Factbook: Ecuador. Available at:
www.cia.gov/library/publications/the-world-factbook/geos/ec.html.

4.
Pan American Health Organization. Country Health Profile: Ecuador.
Available at: www.paho.org/English/SHA/prflECU.htm.

5.
Rodas E, Vicuna A, Merrell RC. Intermittent and mobile surgical services:
logistics and outcomes. World J Surg 2005; 29:
1335–9.

6.
Doarn CR, Fitzgerald S, Rodas E et al. Telemedicine to integrate intermittent
surgical services into primary care. Telemed J E Health 2002;
8: 131–7.

7.
Mora F, Cone S, Rodas E, Merrell RC. Telemedicine and electronic health
information for clinical continuity in a mobile surgery program. World J
Surg 2006; 30: 1128–34.

8.
Rodas E, Mora F, Tamariz F et al. Low-bandwidth telemedicine for pre- and
postoperative evaluation in mobile surgical services. J Telemed
Telecare 2005; 11: 191–3.

9.
Lee S, Broderick TJ, Haynes J et al. The role of low-bandwidth telemedicine in
surgical prescreening. J Pediatr Surg 2003; 38:
1281–3.

10. Rosser JC, Bell
RL, Harnett B et al. Use of mobile low-bandwith telemedical techniques for
extreme telemedicine applications. J Am Coll Surg 1999;
189: 397–404.

11. Broderick TJ,
Harnett BM, Merriam NR et al. Impact of varying transmission bandwidth on image
quality. Telemed J E Health 2001; 7: 47–53.

12. Cone SW, Hummel R,
Leon J, Merrell RC. Implementation and evaluation of a low-cost telemedicine
station in the remote Ecuadorian rainforest. J Telemed Telecare 2007;
13: 31–4.

13. Broderick TJ,
Harnett BM, Doarn CR et al. Real-time Internet connections: implications for
surgical decision making in laparoscopy. Ann Surg 2001;
234: 165–71.

14. Rodas EB, Latifi
R, Cone S et al. Telesurgical presence and consultation for open surgery.
Arch Surg 2002; 137: 1360–3.

15. Cone SW, Leung A, Mora F et al. Multimedia data capture
and management for surgical events: evaluation of a system. Telemed J E
Health 2006; 12: 351–8.

16. Cone SW, Gehr L,
Hummel R, Merrell RC. Remote anesthetic monitoring using satellite
telecommunications and the Internet. Anesth Analg 2006;
102: 1463–7.

19 A low-cost international e-referral
network

Richard Wootton, Pat Swinfen, Roger Swinfen and Peter
Brooks

Introduction

Telemedicine provides the opportunity of delivering health
care at a distance, and reduces the need for a face-to-face interaction. It is
often conducted by videoconferencing, which permits a high-quality interaction
between the parties concerned, but demands relatively expensive equipment and
high bandwidth communications. In the context of developing countries, there has
been little use of videoconferencing, for the obvious reason of cost. Most of
the videoconferencing work that has been conducted has been for the purposes of
education.1–3

Although there has been little use of real-time telemedicine,
much useful clinical work has been performed in developing countries using
store-and-forward techniques, which are less expensive of infrastructure and
easier to organize because the interaction between the parties concerned is
asynchronous. The two main methods of store-and-forward telemedicine are based
on use of web messaging or on email.

Web telemedicine

In web-based telemedicine (for clinical purposes), the
referring doctor connects to the Internet and completes a web-based proforma
that stores the patient details and any associated images on a remote server.
This information is reviewed by a specialist at some later time, and appropriate
diagnostic and management advice is provided. The specialist’s reply is stored
on the web server, from where the referring doctor can access it. To ensure
patient confidentiality, the information comprising the telemedicine interaction
is normally stored on a secure server and protected by passwords.

The US military had considerable experience with web-based
teledermatology in the late 1990s in Europe.4 They have also
operated a web-based teleconsulting system from the main US Army hospital in
Hawaii that supports referrers in hospitals (mainly military hospitals) on
US-associated Pacific islands.5,6 Further
details are provided in Chapter 15.

Finally, a software package called iPath was developed for
telepathology case conferences, and several tens of thousands of case
conferences have now been conducted – technically by a number of different
organizations who all use the same software. The use of this software for
general clinical work (i.e. non-pathology) is more recent.7

Email telemedicine

One drawback of web-based telemedicine is that in developing
countries there are still places where Internet connections are expensive, and
therefore web access in particular is restricted. Almost all health care
facilities have, or could have, telephone access to the Internet, so this
represents the lowest-cost communications medium for telemedicine.

In email-based telemedicine, the telephone network is used to
transmit email messages via a dial-up connection to an Internet service provider
(ISP). The referring doctor records the relevant patient information in the body
of the email message, and images of patients, or X-ray films, can be attached if
required. The specialist can reply by email at a convenient time.

Email telemedicine is cheap, but it has some drawbacks:

On any significant
scale, i.e. with multiple referring doctors and multiple specialists, managing
the traffic is a demanding and labour-intensive task. Messages may then fail to
be replied to.

Information sent in
an ordinary email message is not secure. Although the case details can be
anonymized to protect patient confidentiality, this depends on the message
sender, and is often difficult to enforce in practice.

Because the
referring doctor enters free text, it is much harder to ensure that all relevant
patient history details are collected.

Any system of
communication that employs email will sooner or later be bombarded with spam or
nuisance messages.

Two long-running examples of the use of email for low-cost
telemedicine are the work of the Swinfen Charitable Trust and of Partners
Telemedicine.

Swinfen Charitable Trust

The British military first used email telemedicine
successfully in Bosnia.8,9 In the 1990s,
Lieutenant Colonel David Vassallo, together with Surgeon Commander Peter Buxton
and Wing Commander John Kilbey, established a technique in which a digital
camera was used to capture images, which were then downloaded to a laptop
computer. The images were attached to an email message and then sent to the
Royal Hospital Haslar in the UK for evaluation and advice. A commercial INMARSAT
satellite telephone link was employed for communication in the field. The system
proved useful when a Czech Forces Helicopter crashed in Bosnia in January 1998,
severely injuring five crew members.10 David
Vassallo and Peter Buxton generously shared information about the system with
Lord and Lady Swinfen, enabling them to start a pilot project at the Centre for
Rehabilitation of the Paralysed in Bangladesh. This began in 1999 (see
below).

Partners Telemedicine

Since 2001, email consultations have been used to support
health workers at a rural clinic in northern Cambodia. The email advice comes
from specialists at a tertiary hospital in Phnom Penh and from the Massachusetts
General Hospital in Boston. In 2003, a second site at a small
hospital in northern Cambodia began referring cases.11 Further
details are provided in Chapter 13.

Start of the network, 1999

The Swinfen Charitable Trust was established in 1998 to assist
poor, sick and disabled people in the developing world. It is an apolitical,
non-religious organization, registered as a charity in the UK. The Trustees
decided to provide medical specialist advice, free of charge, to assist doctors
caring for poor patients, as they were unaware of any such service at the time.
In July 1999, an email telemedicine link was established for a hospital in
Bangladesh, the Centre for the Rehabilitation of the Paralysed (CRP). The CRP,
which is located near Dhaka, is a specialist spinal injury unit that services a
large region of South-East Asia. Email referrals thus concentrated mainly on
orthopaedics and neurology problems.

The email referrals were received by the administrators of the
charity and sent on for reply to members of a small panel of medical specialists
who had kindly offered to provide advice free of charge. This was a pilot study
and, after a year of email referrals, a paper was published demonstrating that
the system worked satisfactorily, and provided patient benefit and medical
education to the referring doctors.12

The CRP has continued to refer cases to the Swinfen Charitable
Trust network. At the time of writing, 182 cases have been referred in 10 years
(Figure 19.1).

Figure 19.1 CRP referrals, July 1999–June 2008
inclusive

Growth of the network, 1999–2004

Although the initial telemedicine link to the CRP was a pilot
study, word of its value quickly spread and, by the end of its first year of
operation, two other telemedicine links had been requested. These were
established at hospitals in Kathmandu, Nepal and the Solomon Islands. From then
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
resulting reply to the referrer and dealing with any subsequent dialogue) was
satisfactory for a single hospital, but rapidly became unmanageable as the
number of hospitals and the email workload increased. It was also difficult to
extract statistics about the operation of the network, since plain email
provides a poor archive, because it is ‘unthreaded’. An automatic email
message-handling system was therefore developed by the Centre for Online Health
at the University of Queensland.14 This came
into operation in 2002, and solved several of the problems associated with
manual message management.

From July 1999 to March 2003, the network grew to 17 hospitals.
As well as more referring hospitals, more volunteer specialists were
recruited.13 Many were
from the UK and Australia. The Swinfen Charitable Trust continues to be indebted
to the consultant specialists and others who contribute voluntarily to the
operation of the network.

Iraq and the Middle East

The Iraq war began in March 2003 with the invasion of Iraq by
a multinational coalition of troops from the USA and the UK, supported by
smaller contingents from Australia, Poland and other nations. In 2004, the
administrators of the Swinfen Charitable Trust visited Basra as part of a
British medical mission. During that visit, contact was made with doctors from
several Iraqi hospitals, who subsequently joined the email referral network (Figure 19.2). This led
to a jump in the number of cases referred from Iraq in particular, and from
other parts of the Middle East generally (Table 19.1).

A review conducted in 2007 showed that there was evidence of
improved management of cases as a result of email telemedicine.15 The review
also showed that the case mix from countries of the Middle East was different
from that from the rest of the world (although, technically, the difference was
not significant at p < 0.05). There was more obstetrics and
gynaecology, and less medicine and radiology (Table 19.2). Despite
the majority of Middle Eastern cases being referred from Iraq, relatively few
were the direct result of conflict, and there were fewer trauma and fracture
cases than from the rest of the world. There were also comparatively fewer
referrals in infectious and tropical diseases. The relative absence of trauma
cases can perhaps be explained by well-developed local expertise in trauma care.
This local expertise was honed during the Iraq conflict, during the eight years
of the Iraq–Iran war and during the internal troubles of the Saddam Hussein
regime.

Table 19.1 Origin and numbers of cases
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
leading research-intensive universities in 13 countries from around the world.
The purpose of the consortium is to facilitate collaboration between the member
universities and to create opportunities for them on a scale that none of them
could achieve by operating independently or through traditional bilateral
alliances. The U21 consortium has a strong health sciences group, led by the
deans of medicine, nursing, dentistry and rehabilitation sciences of the various
member universities.

Figure 19.2 First-referral dates for Iraqi
hospitals (n = 49)

Table 19.2 Types of queries for the
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
Understanding was signed between the U21 consortium and the Swinfen Charitable
Trust in 2006. The main objective of the Memorandum was to advance the aims of
the Swinfen Charitable Trust by drawing on U21 resources, such as consultants,
medical students, nursing/allied health students and other support.

The first pilot project involved U21 universities providing
support to an under-served health facility in a developing country.16 The initial
aim was to assist local doctors via information and communications technology –
telemedicine – and to involve U21 medical students on elective placements. As
well as establishing low-cost telemedicine networks in developing countries, a
long-term aim was to gather data about their effectiveness.

The project began in mid-2005. In the first two years, a total
of eight medical students from four U21 universities spent their electives at
hospitals in Pakistan, Papua New Guinea and Sri Lanka. Most electives lasted
about four weeks. Most of the students were in their final year.

A total of 49 cases were referred either directly by the
students or indirectly by the medical staff with whom they worked (i.e. after
the students had left).17 The students
were responsible for a total of 49 e-referrals, which resulted in 67 queries in
a wide range of specialties. The median response time was 20 hours
(interquartile range 5–85). Follow-up data were obtained in 14 of the 30 cases
from one hospital (47%). The major categories of the 67 queries were internal
medicine, paediatrics and surgery, and in very similar proportions to the 785
queries managed by the Swinfen Charitable Trust over the same period.

Before the project began, some initial concerns were expressed
by certain consortium members about possible medicolegal risks, and whether
students would feel superfluous in a local health care environment. Happily,
none of these matters turned out to be real problems. Indeed, the students
reported that the U21 project gave a purpose to their placement. One student
expressed it as follows: ‘often students don’t always have a “role” other than
to sometimes feel as though you are hanging around as the silent observer. This
way you could feel as though you were contributing.’ 17

The presence of a medical student facilitated e-referrals by
relieving the pressure on the local doctor to undertake the necessary clerical
and technical work. The students reported a rewarding elective experience, which
appears to have the potential to increase the ease with which heavily burdened
medical staff in developing countries can make use of e-referrals.

The future

Over the first 10 years of its operation, the Trust has
established telemedicine links for 135 hospitals/clinics in 34 countries and
dealt with over 1700 referrals (Figure 19.3). How do we
rate the success of this international e-referral network after 10 years of
operation? There are many indicators that could be employed to measure success
in telemedicine.18 These
include longevity and clinical outcomes.

If longevity is the criterion, then the Swinfen Charitable Trust
is doing pretty well

Figure 19.3 Swinfen Charitable Trust Network
(July 2008)

for a telehealth operation, many of which – as has been
observed elsewhere – blossom on a wave of initial enthusiasm and then wither
when the seed funding runs out. However, if clinical outcome is the criterion,
then the operation represents a failure at present, because there are no formal
follow-up data. This is due to the fact that the majority of patients, once
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
loss of income. However, one of the aims of the U21 involvement is to obtain
follow-up information, and the medical students in Papua New Guinea have begun
providing it (and it is showing useful outcomes).17

It is also worth pointing out that the Swinfen Charitable Trust
must be providing a clinically useful service to the referrer doctors, or they
would not continue to use it. This was confirmed in a survey of referrers
conducted in 2004.19

Ultimately, sustainability probably depends on scaling up the
size of the present operation, which in turn requires the real costs to be met,
i.e. when operating on a large scale, depending only on volunteers would be
difficult. This would mean paying for the medical time involved in answering the
referrals, for example, which in turn would require an income stream. Charities
may have difficulty in operating in this environment, i.e. where there are
pressures to increase in size to make things financially sustainable, with
simultaneous counter-pressures to reduce in size because things depend on
volunteers.

The work of the Swinfen Charitable Trust (and others)
demonstrates that low-cost telemedicine in the developing world is feasible,
clinically useful, scalable and apparently sustainable. However, telemedicine is
not yet being used on a significant scale. What then is the
right strategy? The sensible approach appears to be to build intra-country
telemedicine networks as soon as practicable. That is, we need telemedicine
networks that rely largely on within-country resources. Such telemedicine
networks might need to begin with support from outside the country, but they
should become independent of outside resources as quickly as possible.20

Further reading

Swinfen Charitable Trust. Available at: http://www.swinfencharitabletrust.org/.

Universitas 21 Health Sciences Group. Available at: www.u21health.org/index.html.

References

1.
Geissbuhler A, Bagayoko CO, Ly O. The RAFT network: 5 years of distance
continuing medical education and tele-consultations over the Internet in
French-speaking Africa. Int J Med Inform 2007; 76:
351–6.

2.
Vincent DS, Berg BW, Hudson DA, Chitpatima ST. International medical education
between Hawaii and Thailand over Internet2. J Telemed Telecare 2003;
9(Suppl 2): 71–2.

3.
Ozuah PO, Reznik M. The role of telemedicine in the care of children in
under-served communities. J Telemed Telecare 2004;
10(Suppl 1): 78–80.

4.
Pak HS, Welch M, Poropatich R. Web-based teledermatology consult system:
preliminary results from the first 100 cases. Stud Health Technol
Inform 1999; 64: 179–84.

5.
Callahan CW, Malone F, Estroff D, Person DA. Effectiveness of an Internet-based
store-and-forward telemedicine system for pediatric subspecialty consultation.
Arch Pediatr Adolesc Med 2005; 159: 389–93.

6.
Person DA. Pacific Island Health Care Project: early experiences with a
Web-based consultation and referral network. Pac Health Dialog 2000;
7: 29–35.

7.
Brauchli K, Oberli H, Hurwitz N et al. Diagnostic telepathology: long-term
experience of a single institution. Virchows Arch 2004;
444: 403–9.

8.
Vassallo DJ, Buxton PJ, Kilbey JH, Trasler M. The first telemedicine link for
the British Forces. J R Army Med Corps 1998; 144:
125–30.

9.
Vassallo DJ, Buxton PJ, Kilbey JH. Telemedicine made easy – the British way.
Mil Med 1998; 163: iii.

10. Vassallo DJ, Klezl
Z, Sargeant ID, Cyprich J, Fousek J. British–Czech co-operation in a mass
casualty incident, Sipovo. From aeromedical evacuation from Bosnia to discharge
from Central Military Hospital, Prague. J R Army Med Corps 1999;
145: 7–12.

11. Heinzelmann PJ,
Jacques G, Kvedar JC. Telemedicine by email in remote Cambodia. J Telemed
Tele-care 2005; 11(Suppl 2): 44–7.

12. Vassallo DJ, Hoque
F, Roberts MF et al. An evaluation of the first year’s experience with a
low-cost tele-medicine link in Bangladesh. J Telemed Telecare 2001;
7: 125–38.

13. Wootton R,
Youngberry K, Swinfen R, Swinfen P. Referral patterns in a global
store-and-forward tele-medicine system. J Telemed Telecare 2005;
11(Suppl 2): 100–3.

14. Wootton R. Design
and implementation of an automatic message-routing system for low-cost
telemedicine. J Telemed Telecare 2003; 9(Suppl 1):
44–7.

15. Patterson V,
Swinfen P, Swinfen R et al. Supporting hospital doctors in the Middle East by
email telemedicine: something the industrialized world can do to help. J Med
Internet Res 2007; 9: e30.

16. Wootton R,
Jebamani LS, Dow SA. E-health and the Universitas 21 organization: 2.
Telemedicine and underserved populations. J Telemed Telecare 2005;
11: 221–4.

17. Wootton R, Swinfen
PA, Swinfen R et al. Medical students represent a valuable resource in
facilitating telehealth for the underserved. J Telemed Telecare 2007;
13(Suppl 3): 92–7.

18. Wootton R, Hebert
MA. What constitutes success in telehealth? J Telemed Telecare 2001;
7(Suppl 2): 3–7.

19. Wootton R,
Youngberry K, Swinfen P, Swinfen R. Prospective case review of a global e-health
system for doctors in developing countries. J Telemed Telecare 2004;
10(Suppl 1): 94–6.

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

20 Telemedicine in China: Opportunities and
challenges

Jie Chen and Zhiyuan Xia

Introduction

China is a large country, with a huge population and poor
telecommunications infrastructure (although communications are being improved
rapidly). The level of social and economic development differs greatly between
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
areas, while there are shortages of medical care and drugs in the poor and rural
areas. Patients in rural areas often experience difficulties in accessing
medical care. If they travel long distances to access higher-quality medical
care, they incur a heavy financial burden.

Telemedicine past and present in China

In industrialized countries, the concept of using
communications technology to distribute medical expertise is not particularly
new. However, the development of tele-health is relatively new in China. The
earliest telehealth activities began in the late 1980s. An emergency
consultation in 1986 that was provided for a ship’s crew via radiotelegrams is
recognized as the earliest telehealth activity in China. In 1988, the General
Army Hospital in Beijing carried out a neurosurgery case discussion with a
German hospital. Shanghai Medical University developed one of the earliest
tele-medicine systems in China. In September 1994, they succeeded in performing
a tele-consultation between the Huashan hospital and staff at the Shanghai
Jiaotong University.1

The first generation of telemedicine systems in China was based
on videoconferencing via the telephone network (PSTN). In 1995, with the support
of the Shanghai Education and Research Network, Shanghai Medical University
launched a pilot tele-medicine project and established a telemedicine
centre.2 At about that
time, people began to employ the Internet to search for medical help. One of two
well-known cases occurred in March 1995: a girl named Yang Xiaoxia in Shandong
Province had an unidentified disease and asked for help through the Internet.
The disease was finally diagnosed as a phagocytic bacterial infection in her
muscles. The other case was in the same year. A student named
Zhuling at Beijing University was sick for unknown reasons. After searching for
help via the Internet, more than 1000 reply emails helped her to prove that she
had heavy-metal poisoning.1

At this stage, a few health-related institutions began to
develop experimental tele-health systems. The authorities noticed this trend,
and began to support these tele-health activities.

In 1997, the telemedicine system of Shanghai Medical University
obtained the re cognition of the country leaders at the national IT exhibition.
This boosted interest in telehealth. Various organizations and institutions
began their telehealth programmes. The late 1990s was a period of rapid progress
for telehealth in China. The Jin-Wei (Golden Health) Telemedicine Network began
operation in July 1997, and many national-level hospitals in Beijing and
Shanghai were included in this network. The network provided remote consultation
and remote education services for hospitals in 21 provinces, including Yunnan,
Sichuan, Tibet and Xinjiang, via satellite communication. In the same year, the
International Medical Network Committee of the China Medical Foundation
established their telemedicine network. Following these two large telemedicine
programmes, many others emerged. The Shuang-wei (Satellite Health Education
Network of the Ministry of Health) network was sponsored by the Ministry of
Health, and the MediChina BYL telemedicine network was sponsored by the Shanghai
municipal government. There were also many telehealth programmes initiated in
other areas, including Guangdong, Sichuan, Fujian and Yunnan provinces.3 When
telehealth activities began to grow in China in the late 1990s, the national
health authority recognized the importance of supervising them, and the Ministry
of Health established a set of rules for telehealth in 1999.4

The rapid development of telecommunications infrastructure in
the late 1990s helped to make telehealth a routine activity in China. The
ordinary telephone network, the ISDN network, satellite communications and the
Internet were all employed for telehealth purposes. Many different
organizations, including the government, medical universities, hospitals and
even some private companies, built telehealth networks and made telehealth a
routine application. Generally, they provided remote consultations and remote
education services for users of their networks.

Telehealth programmes in China

Since 1997, many different telehealth programmes have been
conducted in China. These programmes have been sponsored by different entities,
have employed different telecommunication means and have operated at different
scales. Some programmes have built large telehealth networks and connected many
different health organizations.

One of the most well-known telehealth programmes was the Jin-Wei
Telemedicine Network (the Golden Health Medical Network). This network was
established with the support of the Ministry of Health. The network operation
centre was located in Beijing and was a satellite network covering the whole
country. Many national-level and lower-level hospitals from more than 20
provinces were included in this network. The satellite
communication allowed an 8 Mbit/s upload speed and 2 Mbit/s download. Between
1997 and 2003, the Jin-Wei Telemedicine Network provided remote consultation
services for more than 1000 patients, and provided remote education services for
more than 50 000 doctors and nurses. The Jin-Wei organization also developed a
website to provide health-related information services for users. However, the
high cost of satellite devices and communications prevented many low-level
hospitals from connecting to this network. Subsequently, the Jin-Wei network
began to employ ISDN as a second telecommunication method to cover more
hospitals.3,5

The CMF (China Medical Foundation) Telemedicine Network was also
a large-scale telemedicine programme. It was supported by a non-profit-making
organization, the International Medical Network Association. It began in 1997.
From the start, several different methods of telecommunication were employed.
First, telephone lines were used to establish a network covering basic level
hospitals, then ISDN and the Internet were used to connect higher-level
hospitals, and eventually satellite communication was used to connect
national-level hospitals. The aim of the CMF Telemedicine Network was different
from that of the Jin-Wei network, in that it mainly provided telehealth services
for basic-level hospitals. It used telephone line communication and desktop
videoconferencing.3,5

The aim of the Shuang-wei (Satellite Health Education Network of
the Ministry of Health) network was to provide remote medical education services
for doctors and nurses all over the country. It was supported by the Ministry of
Health and began routine operation in 2001. Satellite and optical fibre were
employed as the major telecommunication means. The network supported different
kinds of remote education, such as live broadcasting, video on demand, the
interchange of online education materials, and point-to-point or multipoint
videoconferencing.3,6

The BYL Telemedicine Network was a branch of the China Social
Development Network. It was supported by the Shanghai municipal government and
connected Shanghai and western areas of China. Various telecommunication media,
including satellite, fibre-optic cables, the Internet and telephone lines, were
employed in this network. Specialists in Shanghai provided an image consultation
service for patients in other areas. When Shanghai provided telehealth services
for western areas via this network, they also provided business information
services.3

A Chinese Traditional Medicine Telemedicine Network was
established by the Chinese Academy of Traditional Chinese Medicine in 1997. It
employed ISDN for telecommunication to provide a traditional Chinese medicine
consultation service for international and domestic patients.3

Several other telehealth programmes were set up in China in the
late 1990s. These included the Sino-Japanese Telemedicine Collaboration for
high-resolution medical image consultation, the Sino-Russian Satellite
Telemedicine Collaboration, and the telemedicine programmes of the Sun Yet San
University, the Shanghai Second Medical University and the Western China Medical
University. The Shuang-wei and BYL networks are still in operation. The
programmes had different purposes, employed different technologies and
telecommunication media, and were supported by different organizations.3 Since 2003,
some provinces have established their own regional telemedicine networks: the
Fujian Province Telemedicine Network was set up in late 2003
and the Gansu Province Telemedicine Network in late 2007. All these regional
telemedicine networks are supported by local government and are still in
operation.

Telehealth programme of Shanghai Medical
University

Shanghai Medical University (SMU) provided medical services,
teaching and research, and had about 5000 students. It had an excellent
technical reputation in China. Many departments in SMU-affiliated hospitals were
well equipped, and some departments were ranked the best in the country. In
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
telehealth pilot project. It developed the first general telehealth system in
China, which was based on low-bandwidth videoconferencing over the telephone
network. Through this system, a surgeon in Huashan Hospital (an affiliated
hospital of SMU) succeeded in providing a remote consultation service for a
patient in Shanghai Jiaotong University. In 1995, with the support of the
Shanghai Education and Research Network, SMU launched a pilot telehealth
programme and established a telemedicine centre. It began to develop telehealth
systems conforming to international standards. In 1996, SMU began cooperation
with the telecommunications authority in Shanghai. Various telecommunication
companies began to establish different telecommunication connections for the
telemedicine centre.2,7

In 1997, SMU established a telehealth network based on the
telemedicine centre. The telehealth service providers were 7 affiliated
hospitals of SMU, and the telehealth service users were more than 20 hospitals
from remote and rural areas. The task of the telehealth centre was to act as the
administrative and telecommunication centre. All the service providers were
connected to the telemedicine centre by optical fibre. The service users were
connected by the ordinary telephone network, the ISDN network or satellite,
according to cost. The network connected hospitals from 21 provinces, including
Xinjiang, Tibet, Yunnan, Sichuan, Heilongjiang, Jiangsu and Zhejiang. In the
telemedicine centre, there were nurses for remote consultation administration
and technical staff for support. Each hospital of the service providers and
service users had its own operation staff. Figure 20.1 illustrates
the structure of the network.8

The SMU Telemedicine Centre developed many administrative rules
for remote consultation in China. Only professors or associate professors were
eligible to provide telehealth services. The operation staff had to have
completed special training in the network. When the service users requested a
remote consultation, they had to submit full information about the patients.
Because most of the hospitals in the network from remote and rural areas lacked
digital devices, they often needed to digitize images using a digital scanner.
The Telemedicine Centre provided a set of operational guidelines for the service
users after their research in this field. The Telemedicine Centre also designed
a procedure for remote consultation administration. In 1999, it developed a
web-based remote consultation administration database. By using this

Figure 20.1 The structure of the SMU
Telehealth Network

database, the service users could apply for remote medical
consultation services via the network, and the Telemedicine Centre could
despatch remote consultation requests to the appropriate service providers.
Also, the consultation providers in Shanghai could schedule the remote
consultations via the network. As a multimedia database, it could accept data in
the form of images, video and audio information relating to the remote cases
that needed consultation.8

In 1996, the SMU Telehealth Network began to experiment in
distance medical education. It provided distance education services for the
doctors and nurses in the hospital on Chongming Island. Subsequently, the SMU
Telemedicine Centre developed a remote education system. This comprised two
parts. One was a videoconference system, by which teachers and students could
have real-time discussions. The other part was a media system, which could be
used for media broadcasting, video on demand, recording and editing. By using
this system, teachers could finish their own tasks via the Internet.

The SMU Telehealth Network (now part of Fudan University) is
still in operation. It has provided remote consultation services for more than
2000 patients in remote and rural hospitals. These patients have been from
various specialties, including cardiology, oncology, surgery, neurology and
paediatrics. In their remote consultations, the specialists only provide a
second opinion or suggestion for the doctors in the user hospitals, because of
the absence of legislation that would permit them to make a diagnosis. The
network has also provided more than 1000 hours of distance medical education for
the Dali Medical College in Yunnan province and other hospitals in the
network.

After they began providing telehealth services for remote and
rural users, the specialists received much feedback about the services. A letter
from the hospital of Xindu, Sichuan province described how
patients benefited from telehealth. For example, one patient with colon cancer
made a full recovery after the operation, following the advice provided in the
teleconsultation. She was the oldest patient to have recovered following such an
operation at that hospital. Another patient with colon cancer recovered fully
without requiring chemotherapy following the advice provided in the
tele-consultation. One patient with heart disease avoided an operation to
implant a pacemaker.

Video and audio quality varies, depending upon how the rural
sites are connected with the telemedicine centre. The best quality is achieved
with a digital connection (DDN), followed by ISDN and satellite; unsurprisingly,
the quality is quite low via an ordinary telephone line. In China, when
providing a telehealth service via telephone line, it can be expected to be
interrupted every 5–10 minutes because of connection problems. The quality of
the consultation service is therefore poor, and remote education cannot easily
be delivered via telephone line.

The costs of the different communication methods also differ
greatly. Satellite communication is the most expensive, followed by DDN and
ISDN. Telephone line and Internet communication are the cheapest.

Satellite communication is not suitable for a remote
consultation service, because of the time delay. However, it is suitable for a
unidirectional broadcast service, such as that required for remote
education.

When considering all the factors relating to the quality of the
system, cost and breakdown rate of the service, it appears that ISDN
communication is the most appropriate means of communication for telehealth
services in China at present. Internet communication can be used in
non-real-time applications, for example to access databases and to apply for
remote consultations. Because the bandwidth of Internet communication has been
much improved, it can also be used for videoconferencing and remote education,
for example video on demand and broadcasting for distance education. Thus,
Internet communication has great potential as a communications method for
telehealth in China.

Opportunities for telehealth in China

China has the largest population in the world: at the end of
2005, it was 1.3 billion. Health expenditure in China is rising: in 2004, it was
75.9 billion RMB, and accounted for 5.6% of the gross domestic product. In 2004,
the per capita expenditure in urban areas was about 4.2 times that in rural
areas.9

The health sector in China faces two opposing demands: first, it
must provide expanded and equitable access to high-quality health care services;
second, it must reduce, or at least control, the rising costs of health care.
Telehealth offers the promise of giving people equal access to high-quality
medical care at affordable cost.

As in most other countries, the highest concentration of medical
resources (personnel, information and facilities) in China is in the major
cities, so telehealth could be a useful mechanism to balance the differences in
the level of access to medical resources.

Information technology in China has grown very rapidly in the
last few years. There has been rapid expansion of the telecommunication market
and very fast diffusion of the Internet. By December 2007, there were 210
million Internet users in China.10 Health IT is
also developing very rapidly in China: many hospitals have developed a hospital
information system, and now health information-sharing networks are developing
in many cities. This will facilitate the development of telehealth in China.

The large population and relatively insufficient health
resources have produced demands for China to develop telehealth, and the rapid
development of IT has provided the opportunities to do so. In 2003, China
formulated its national strategy in e-health. The plan outlined the strategy and
activities for China to develop e-health in 2003–2010. The plan described the
background information, the principles, the goals and the main tasks for China
to develop e-health.11 Telehealth
development is part of this plan.

Challenges for telehealth in China

Although there are undoubted opportunities, telehealth also
faces many challenges in China.12 Despite the
successes of early telehealth systems in China, not many of them were
self-sustaining, and few are still in operation today. A number of
implementation barriers remain to be overcome. These include the following.

A lack of understanding of telehealth by
society

Often, telehealth is perceived by health authorities as a low
spending priority. Because telehealth is not clearly defined, there are
different definitions of telehealth, which makes it difficult for patients to
understand its potential. Telehealth might adversely affect the relationship
between health professionals and patients compared with normal face-to-face
consultations. The reasons include physical and mental factors,
depersonalization, different process of consultation, reduced confidence of
patients and health professionals, different knowledge and skills required of
health professionals, and ergonomic issues. There are also various factors that
prevent health professionals from accepting telehealth, including too much
change, lack of a user-friendly interface, failure to collect the most important
information, inadequate training of physicians to use the system, and lack of
control by the organization over physician practices. Factors such as doubt
about the quality of the telehealth and conflicts between the telehealth
procedure and traditional clinical schedules will prevent patients and health
professionals from accepting the new system.

Incomplete telehealth organizational structure and lack
of human resources

In many health institutes that conduct telehealth programmes,
there are no special telehealth departments or staff. Lack of organizational and
personnel resources is a major constraint on telehealth development.

Lack of standards

In China, the telehealth systems and services are developing
very rapidly, but the standardization of telehealth lags behind. Standardization
of telehealth system components and services is an important element for
integration of heterogeneous systems. There are no standards for telehealth in
China, and this has restricted developments. For example, in the rural
hospitals, there is no digital X-ray equipment, so, when they need to transmit
X-ray images to specialists in the cities, the X-ray films are often digitized
using a scanner. In practice, poor-quality images result, which would be much
improved if there were standards to control the digitization process.

Absence of legislation and
regulation

Lack of legislation and regulation is also a major barrier to
telehealth development and deployment. There are some national regulations for
telehealth, such as regulations governing remote consultation administration.
But the work on regulation lags far behind the development of telehealth. There
are also some legislative barriers. There is no related law focusing on
telemedicine, electronic signatures and patient privacy protection. There are
problems with medical malpractice liability, because of legal uncertainties.

High cost and insufficiency of funds for telehealth
development

Telehealth depends on new technologies. The devices are often
relatively expensive. Also, telecommunication costs can be high. However, funds
for telehealth are insufficient, because the benefits of telehealth are mainly
realized by the patients. Thus, investors do not have a great interest in this
field. Another problem is that hospitals in remote and rural areas have a higher
demand for access to telehealth services, but also have smaller budgets.

Unbalanced development in different areas in
China

Because of unbalanced development, many hospitals in remote
and rural areas cannot apply telehealth, owing to limitations of equipment,
human resources and telecommunications.

Lack of reimbursement for telehealth
services

In China, health insurance does not cover expenditure on
telehealth services. Thus, patients need to pay for telecommunications and
specialists’ fees themselves. This represents a major economic burden for
patients.

Lack of evaluation of telehealth
programmes

Policy makers lack evidence from evaluation research to help
them to decide how to support the development of telehealth.

Policy recommendations

China can learn from experiences in industrialized
countries.12 This
suggests that, for the development of telehealth in China, it is necessary to do
the following:

Strengthen
the leadership of government in telehealth development. The government
should establish a special organization to lead telehealth development and
promote a government focus on telehealth.

Strengthen
the supervision of telehealth development. In China, many different
organizations are involved in telehealth activities. Many of these organizations
are not health related. It is important to strengthen the supervision of
telehealth and prevent unqualified organizations from taking part in
telehealth.

Promote the
development of telehealth standards. Health authorities should promote
the development of telehealth standards with users, researchers, technical and
scientific bodies, and industry. Establishing national standards and adopting
international standards will be important tasks for China.

Develop a
legal and regulatory infrastructure that will facilitate telehealth.
Legislation related to telemedicine, electronic signatures and patient health
information protection should be constituted.

Increase the
investment in telehealth. The government should strengthen its
financial support for telehealth development. Also, other sources must be
attracted to invest in telehealth. In China, there is a high demand for
telehealth services, especially for remote medical education services. Many
early distance medical education programmes are still in operation today.

Train health
professionals and technical staff in telehealth. Training will help
health professionals to understand telehealth, and will also promote the
efficiency of telehealth systems.

Promote
international collaboration, sharing and learning experiences from
industrialized countries. This will help China to develop telehealth.
Telehealth is relatively new to China. It can overcome geographical barriers and
make high-quality services available without regard to location. This can help
to reduce the unbalanced distribution of health resources. Because
telecommunications are developing rapidly in China, there are many opportunities
to develop telehealth. There are also many challenges for telehealth to
overcome. If the importance of telehealth for China is widely recognized, it
will have a better future in China.

Telehealth is relatively new to China. It can overcome
geographical barriers and make high-quality services available without regard to
location. This can help to reduce the unbalanced distribution of health
resources. Because telecommunications are developing rapidly in China, there are
many opportunities to develop telehealth. There are also many challenges for
telehealth to overcome. If the importance of telehealth for China is widely
recognized, it will have a better future in China.

Further reading

Fujian Province. [Telemedicine Network of Fujian
Province]. Available at: http://www.thydmed.com/.

Hsieh RK, Hjelm NM, Lee JC, Aldis JW. Telemedicine in
China. Int J Med Inform 2001; 61: 139–46.

References

1.
Zhu SJ, Cai JH, Yang QS. The establishment and development of telemedicine.
Hosp Adm J Chin PLA. 1998; 5: 277–98.

2.
Zhao JA, Xu YX, Chen J. The implementation of telemedicine network group.
Chin Hosp Manage 1998; 18: 27–8.

3.
Fu Z, Lian P. Telemedicine. Beijing: People’s Military Medical Press,
2005.

4.
Ministry of Health, People’s Republic of China. [Rules for the Development
of Telemedicine]. Available at: www.moh.gov.cn.

5.
Li BZ. The progress and prospect of Jinwei program. Chin Hosp Manage
1998; 18: 41–3.

6.
Ministry of Health, People’s Republic of China. [Satellite Health Education
Network of Ministry of Health. Shuang-wei Network]. Available at:
www.sww.com.cn.

7.
Xu YX, Mo MQ, Zhao JA. New Progress on the Internet and Using It in
Medicine. Shanghai: Fudan University Press, 2001.

8.
Xia ZY. The administration of telemedicine. Medl Inf 2005;
18: 907–9.

9.
Ministry of Health, People’s Republic of China. [Official website]. Available
at: www.moh.gov.cn.

10. China Internet
Network Information Center. Statistical Survey Report on the Internet
Development in China. January 2008. Available at:
www.cnnic.org.cn/uploadfiles/pdf/2008/2/29/104126.pdf.

11. China Centre for
Information Industry Development. [e-Health Development Plan for China in
2003–2010]. Available at:
industry.ccidnet.com/art/793/20051024/356253_1.html.

12. Xia ZY. Challenges
faced for telemedicine development in China and corresponding recommendations.
Med Inf 2005; 18: 206–9.

21 Telemedicine in South Africa

Maurice Mars

Introduction

South Africa is similar to most other sub-Saharan African
countries in facing a substantial burden of disease with limited human and
financial resources. South Africa is a relatively large country of over one
million square kilometres, with a total population of 45 million. Its people are
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
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
rate of 26% and an unofficial unemployment rate of 41%. About 50% of its people
live below the poverty datum.

Burden of disease

The burden of disease in South Africa is great. Until
recently, it had more HIV-positive people than any other nation. HIV prevalence
in adults aged 15 years or older is 17% and the incidence of tuberculosis is
1.3%.1 Data from 2000
show HIV/AIDS as the greatest cause of death (30%), with cardiovascular disease
(17%), intentional and unintentional injuries (12%), non-HIV-related infectious
and parasitic disease (10%), and malignant neoplasms (8%) as the next major
causes.2

Health provision

Public health services and budgets are devolved from the
national Department of Health (DOH) to provincial Departments of Health, with
some primary health care services being provided by municipalities. The annual
health care expenditure by the government is US$158 per capita.1 There is a
major inequality in health care funding, with private expenditure per person
about six times higher than public sector expenditure per person.3 By African
standards, South Africa is relatively well supplied with doctors, with 77
doctors per 100 000 people,1 but again the
distribution of doctors is skewed, with the provincial hospital sector being
served by 24 doctors per 100 000 people and 10 specialists per 100 000 people.
On average, 34% of the medical posts in the public health sector are
vacant.3

Telecommunications

Africa did not benefit from the substantial telecommunication
infrastructure roll-out and deregulation that occurred during the dot.com boom. As in most
African countries, telecommunication in South Africa is still tightly regulated,
with the government following a policy of ‘managed liberalization’. There has
until very recently been a telecommunication monopoly. A licence for a second
service provider has now been awarded, but services have yet to commence. The
government has 37% and 30% shareholdings in these two service providers,
respectively.4 International
bandwidth is provided by undersea cable (SAT 3) and satellite. Although plans
for an additional undersea cable running up the east coast of Africa (EASSY) are
well developed, the project appears to be stalled at present. Satellite services
are licensed to one company, which is totally owned by the Department of
Communications.

Internet access charges in South Africa are relatively high when
compared with those in industrialized countries, with 20 hours of Internet
access costing US$33 per month, compared with US$15 per month for the USA.
Similarly, ISDN costs are high, with a 30-minute ISDN link to the USA (at 128
kbit/s) costing US$15.80.5 ISDN and ADSL
access is available in most cities and towns. Wireless coverage is limited by
legislation, but it is hoped that Wimax will be made available by several large
municipalities. In an attempt to provide low-cost bandwidth facilities, the
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
services are available in most cities, and GSM coverage is estimated at 93%.
Data for the year 2004 indicate that 36% of South Africans have mobile phone
access. Local figures suggest that access to a mobile phone may be as high as
75%.4

Lack of bandwidth, especially in rural areas, is a major problem
facing telemedicine delivery in South Africa. All provincial hospitals are
linked to the government network (Govnet). Access to computers with Internet
access for doctors and nurses is limited in many rural hospitals and clinics,
with doctors having to send store-and-forward cases from home using local
Internet service providers. In KwaZulu-Natal, most hospitals have access to a
total bandwidth of 128 kbit/s, which must be shared across all sectors of the
hospital. Migrating videoconferencing from ISDN to IP is not feasible as yet,
because of the limited bandwidth. ISDN access is not always easy to obtain, and
delays of up to a year for installation are not uncommon. Likewise, support from
the telecommunication company is poor, and the time from registering an ISDN
line problem to a repair visit can be several months. ADSL, while available in
most cities and larger towns, is dependent on the state of the local telephone
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
Information Systems Committee of South Africa, tasked with designing a
comprehensive national health information system for South
Africa. Under the auspices of this Committee, a National Telemedicine Task Team
was formed in 1998, to implement a national telemedicine strategy for South
Africa. Four technical teams were established to work on telemedicine protocols,
network infrastructure, legal licensure and ethical issues, and teleeducation.
These teams were active until 2001, by which time Phase One of the national
telemedicine strategy had been implemented. While the national DOH has a
Telemedicine Director, management and implementation of telemedicine services
was devolved to provincial level during the Phase One project. In order to
coordinate this at a provincial level, the Health Act of 2004 requires Members
of the Executive Council at provincial level to form a committee that will ‘…
establish, maintain, facilitate and implement health information in the
province’. The provinces have taken different approaches to telemedicine. In
most provinces, telemedicine is seen as part of the duties of the provincial
representatives attending the National Health Information Systems Committee, who
may or may not be interested in telemedicine. As a result, telemedicine activity
has been limited or non-existent in some provinces. Other provinces have
appointed specific telemedicine committees, some of which have been extended to
include academic input from the medical schools. Only a few provinces actually
provide a budget and posts for telemedicine, but this is slowly changing.

The national telemedicine strategy planned for three phases of
development of tele-medicine. Only Phase One was implemented and, after
evaluation, it was decided not to continue with the project. However, after
several years of relative inactivity, there has been renewed interest in
telemedicine. The national DOH is developing a new strategic plan for 2008–2013.
The Presidential National Commission on Information Society and Development is
working on an e-health White Paper, the Departments of Communications and Trade
and Industry have included e-health in their most recent strategic plans, and
the Meraka Institute of the Council for Scientific and Industrial Research
(CSIR) is developing an e-health strategic plan.

The Medical Research Council (MRC) of South Africa has a
Telemedicine Lead Programme tasked with evaluating existing and planned
telemedicine systems, coordinating national telemedicine activities and
establishing tele-education for health care professionals. The eight medical
schools in the country have been slow to participate in telemedicine. The
University of KwaZulu-Natal is the only medical school with an academic
department of Telehealth, and the Walter Sisulu University has a Telemedicine
Unit.

Telemedicine background

Telemedicine in South Africa began in the early 1990s, with:
radiologists linking CT scanners in Provincial Hospitals in KwaZulu-Natal to the
Academic Radiology Department;6 neurosurgeons
in the province providing a teleradiology-assisted service;7 rural doctors
using email-based store-and-forward telemedicine for dermatology, orthopaedics
and radiology; and ophthalmologists linking with Moorfields Hospital in
London.8 At the Walter
Sisulu University Medical School, store-and-forward telepathology services have
been used since 1995, with links to the Armed Forces
Institute of Pathology in Washington and various pathology departments in
Europe.9

Phase One of the National Telemedicine Strategic Plan was
implemented between March 1999 and September 2000, establishing 28 telemedicine
sites in six of the nine provinces. Telemedicine services offered included
store-and-forward teleradiology using scanned X-ray films, tele-ultrasonography
(both real-time and store-and-forward), store-and-forward telepathology and
tele-ophthalmology. Of these projects, only the teleradiology service linking
three rural hospitals with the Pretoria Academic Hospital could really be deemed
a success. In the first 9 months of the Pretoria service, 264 radiographic
studies (10% of all the studies performed) were sent for specialist radiologist
reporting.10 Over the
years, this developed into a useful CT scan radiology service with the
neurosurgical department, but the service ended when the department moved into a
new building with no ISDN line access. Tele-ultrasonography, trialled in the
Northern Province and KwaZulu-Natal, was used occasionally and then stopped, and
the tele-ophthalmology project in KwaZulu-Natal was beset with software problems
and never started.

This lack of success meant that the second and third phases of
the project, to expand telemedicine capabilities to 71 and then to 200 sites,
was not undertaken. The second phase was then changed to an educational project
linking the eight medical schools, with the expectation that they would initiate
shared tele-education projects throughout the country. Although the medical
schools were supplied with videoconference units, this project lacked the
support of the deans of the medical schools, and never started.

Many lessons were learned in this process, and were similar to
those experienced by others. These can be summarized as follows:11

Failure to fully
appreciate the need for a well-structured change management plan

Lack of
participatory buy-in from doctors at the sending and receiving sites

Inadequate training
and support

Failure of
provincial Departments of Health to take ownership and commit human and
financial resources to the devolved project.

At the same time as the telemedicine project was being rolled
out, the Nkosi Albert Luthuli Central Hospital was built and commissioned in
Durban, KwaZulu-Natal in 2002. It is a paperless hospital, and has exposed its
staff to aspects of telemedicine through the use of radiology and pathology
PACS.

Telemedicine projects

With the relative inactivity of most of the provincial
Departments of Health, telemedicine activity was taken up by other agencies and
academia. The South African Defence Force together with the MRC developed a
mobile laboratory with satellite communication and telemedicine capability.12 However, no
information has been published about its subsequent deployment. The MRC
developed a test bed in Mpumalanga Province, linking two clinics and a hospital
to the Pretoria Academic Hospital by videoconference. Limited
data are available on its use: in 2002, 78 videoconference sessions took place –
68 teleconsultations and 10 tele-education sessions. This has been extended to a
wireless network, and a teleradiology project is planned.

In collaboration with the University of Stellenbosch, the MRC
has developed a ‘home-grown’ primary health care workstation for use in primary
health care facilities run by nurses and part-time doctors and dentists. It has
been trialled intermittently over the past two years at the Grabouw Community
Health Centre, with an ISDN-based link to the Tygerberg Academic Hospital. The
unit has been designed to be used by health professionals who have limited or no
previous computing experience. Features include:13

removal of the need
to interact with the operating system

a simplified
alphanumeric input device

integrated and
intelligent video control

a document interface
that is familiar to the local users

seamless integration
of peripheral devices

a back-up power
source

use of open-source,
loyalty-free software.

The experience has revealed some of the common challenges
associated with starting telemedicine services in environments where there is a
shortage of staff at both the sending and receiving sites:

Adequate buy-in has
to be obtained from users.

The service must be
integrated into the normal workflow of the hospital.

Incentives should be
offered for already overworked staff to use telemedicine, which is seen as an
additional and time-consuming burden.

There should be a
local telemedicine champion to drive the changes.

The unit has been used predominantly for teledermatology and
paediatric consultations.

Various other enthusiast-driven telemedicine projects have
commenced. At the Walter Sisulu Medical School in the Eastern Cape Province, the
telepathology services that started in the 1990s have migrated to the iPath
platform, with an iPath server located in Umtata. In the first 4 years, 36
pathology cases were referred for international opinion.9 This service
was then expanded to include a teledermatology project, with a general
practitioner in a small town in a rural area sending 110 cases in 6 years.14 An innovative
wireless solution, developed by the CSIR, was piloted in a rural Eastern Cape
clinic staffed by a nursing sister. The region does not have telephone coverage,
and images are sent via a webcam, with a simultaneous voice link, to a doctor in
another town.15 The activity
in the Eastern Cape has resulted in the formation of an active telemedicine
committee within their DOH. They have set up an education centre with Internet
and videoconference facilities in East London, and they are embarking on a
large-scale project linking 23 sites, focusing on teleradiology, teledermatology
and tele-spirometry. The project is not yet fully functional, and has yet to be
evaluated.

A different approach has been taken in KwaZulu-Natal. In 2002,
the University of KwaZulu-Natal established an academic
department of telehealth, with a mandate to assist the provincial DOH in
developing telemedicine, conduct research in telehealth, and develop academic
programmes in telemedicine and medical informatics. In addition to the
long-standing teleradiology and teleneurosurgery services in the province, a
store-and-forward tele-ophthalmology service has been running between a
peripheral hospital and the academic ophthalmology department for several years.
When last audited, this service had referred 282 cases in 18 months and had
saved 82% of the patients an unnecessary transfer to the academic unit, 118 km
away. Despite efforts, it has not yet been possible to replicate this service in
any of the other 64 provincial hospitals. A real-time teledermatology service
has been running between one hospital and the medical school for several years.
At audit in 2006, 132 patients had been seen over 27 months, with 80% being
saved a transfer. This service has been replicated in two other hospitals, and
further sites are planned. Store-and-forward teledermatology services have been
running in parallel, with cases sent from 23 hospitals.

Fledgling synchronous services have commenced in paediatric
surgery, plastic surgery and psychiatry. Store-and-forward burn management and
diabetic retinopathy screening programmes have also started. Through various
externally funded initiatives, there are now 35 hospitals in KwaZulu-Natal with
videoconference facilities, not all of which are currently active. The
provincial DOH, while being supportive of these initiatives, has not taken
ownership of telemedicine. As a result, it has only provided limited technical
support, and has not yet provided a specific telemedicine budget. This has
recently changed with the provision of posts for telemedicine, the development
of a strategic plan and a budget for telemedicine, and the formation of a joint
DOH and university Telemedicine Steering Committee for the province.

The national Department of Science and Technology has funded a
consortium of the MRC, the Meraka Institute of the CSIR and the University of
KwaZulu-Natal in a major three-year project in KwaZulu-Natal. The project will
investigate various bandwidth solutions in rural areas, aiming to achieve a
minimum of 512 kbit/s. It will also compare the locally produced primary health
care workstation with a Chinese tele-medicine workstation that has been acquired
through a bilateral government agreement, and will conduct research into the
development of appropriate administrative and financial models for the use of
telemedicine in the South African public health care sector. Other aims are to
investigate cultural and ethical matters relating to the use of telemedicine in
rural communities, to conduct telemedicine training, to develop a telemedicine
hub site and establish a virtual hospital to support the hospitals in the
province, and to develop capacity in telemedicine through masters and PhD
programmes. It is hoped that this project will result in a sustainable model for
telemedicine in South Africa.

The Free State, Northern Cape and North West Province were the
other three provinces that received telemedicine infrastructure in Phase One of
the national telemedicine project. Their services in teleradiology and
tele-ultrasonography have stopped. The Free State is actively investigating the
establishment of telemedicine in the province, and has been considering a
web-based PACS system for province-wide teleradiology.

The three provinces that were not part of Phase One were
Gauteng, the Western Cape and Limpopo. In Limpopo, a telemedicine steering
committee was established in June 2006. Videoconferencing was set up between
four hospitals. With the assistance of the MRC and the University of
KwaZulu-Natal, an ambitious telemedicine and tele-education programme began in
the third quarter of 2007. The project includes dermatology, emergency medicine,
psychiatry, dentistry, ENT, orthopaedics and surgery.

In Gauteng, work is under way to develop teleradiology in the
provincial hospitals. In the Western Cape, an email-based store-and-forward
telemedicine project has been running for several years between three district
hospitals and the Tygerberg Children’s Hospital.16 A pilot
store-and-forward teledermatology project has been started by the MRC and the
University of Cape Town, with nursing sisters at four rural sites sending images
and case histories back to a dermatologist in Cape Town.17

Telemedicine in the private health sector has not been well
documented. One large hospital group and some large radiology practices use
teleradiology and commercial PACS to transport and store X-ray images and
reports, and pathology practices are following suit. There are several informal
reports of images being captured during arthroscopic and endoscopic surgery and
being sent by email for another opinion. There is at least one ophthalmologist
who is sending photographs of retinal images to a colleague for second
opinion.

At present, there are no telepsychiatry services in South
Africa, but two services and a psychiatry tele-education programme are planned.
With recent changes to the Mental Health Act and the requirement to treat
psychiatric patients at district and regional hospital level for at least 72
hours, telepsychiatry may prove to be a major growth area. While
videoconferenced patient follow-up is relatively common in the industrialized
world, it is not yet being used in South Africa. This may be because of the
shortage of doctors and the lack of telemedicine site coordinators.

Some novel applications have been developed in South Africa.
Cell-Life is a mobile phone and Internet method of monitoring HIV patient
adherence to antiretroviral medication.18 SIMpill is a
device that utilizes mobile phone technology and SMS text messages to monitor
patients’ medication compliance. When a patient opens the pill bottle to take
their medication, an SMS text message is sent to a central server. If the
patient fails to open the pill bottle within a defined time, the server sends an
SMS message to the patient’s mobile phone and, if there is repeated
non-compliance, to the patient’s physician.19

Tele-education

Staffing of rural hospitals has been a long-term problem in
South Africa. The Government has had to employ doctors from other countries in
order to maintain services in some rural areas. In 2004, there were 240 Cuban
doctors working in South Africa. A recent press release reported that 1000
doctors are to be recruited from Tunisia, Cuba, Iran and elsewhere to work in
rural areas. Studies of the factors that influence local doctors’ decisions to
work in rural hospitals have identified salaries and professional isolation as key issues. The government has improved salaries
through the provision of a scarce skills allowance. Tele-education and
telemedicine have been cited as ways of overcoming professional isolation, and
the National Telemedicine Strategy included tele-education as an important
component of the strategic plan. The attempt to get the eight medical schools to
jointly develop a national teaching programme was not successful, and individual
medical schools have undertaken tele-education.

In 2001, as part of an e-health learning initiative, the Free
State Department of Health set up an interactive satellite broadcast system, and
now offers health care training at 40 venues. Their last evaluation included
over 2200 users. After the cessation of Phase One telemedicine services in
KwaZulu-Natal, the local university approached the provincial DOH, in 2001, and
was given approval to use the videoconferencing infrastructure for postgraduate
medical education. Equipment has been upgraded, and postgraduate teaching
sessions are multicast from the Nelson R Mandela School of Medicine to four
other academic sites. In 2006, 765 hours of tuition in 17 academic programmes
were shared by videoconferencing. A total of over 72 000 person-hours of tuition
were offered in 2006, with approximately 40% of participants situated at rural
hospitals. The medical school also shares its teaching sessions with other
provinces, including the Walter Sisulu Medical School and the East London
Medical Complex in the Eastern Cape, and the Polokwane Hospital in Limpopo.
International teaching has taken place in collaboration with several countries
in North Africa, Europe and North America.

The Walter Sisulu University has begun postgraduate teaching by
videoconferencing, and the Universities of Stellenbosch and Pretoria have
offered postgraduate courses by satellite TV. The University of the
Witwatersrand has been funded to start a videoconferenced academic programme in
public health. The College of Radiology of South Africa, aware of the extreme
shortage of radiologists in the academic sector, funded a pilot project to share
postgraduate teaching sessions between all eight medical schools by
videoconference. The first four sessions have been completed, and are being
evaluated before a decision is made to continue the project.

Mindset Health is a partnership between the Mindset Network, the
national DOH and Sentech (the Government-owned satellite information and
communication technology service provider), which aims to deliver large-scale
health education and health promotion. This is achieved through the development
of digital health education material delivered by video, by multimedia computer
lessons and print, and by daily satellite broadcast to 200 hospitals in South
Africa, with on-demand satellite datacasts for health care staff. The TV
receivers for the satellite broadcasts are usually placed in the outpatient
departments of rural hospitals. The initial focus has been on tuberculosis and
HIV/AIDS.20

Telemedicine training

Since the Phase One project, there has been very little formal
telemedicine training for health care workers. In Mpumalanga, several members of
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
workshop was arranged under the auspices of the Regional Impact of Information
Society Technologies in Africa project. Training has also
been provided by the MRC, the Walter Sisulu University and the University of
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
Health programmes. Formal training in telemedicine is offered at the University
of KwaZulu-Natal, where students can take a Masters in Public Health degree with
specialization in telemedicine or a Master of Medical Science in
telemedicine.

Legislation and guidelines

The DOH is drafting a Telemedicine Act that will address
matters such as licensure, consent, data security and patients’ rights. With the
shortage of doctors in South Africa, there is a need for a pragmatic approach to
the issue of licensure, so that the country can take advantage of international
telemedicine services. It is hoped that the Act will be enabling and not
restrictive. At the same time, the Health Professionals’ Council of South Africa
is drafting ethical guidelines for telemedicine. While these initiatives are
well intentioned, they may be premature, as there is as yet an insufficient base
of physicians and nurses with practical experience in telemedicine in South
Africa to fully appreciate and debate the implications of some the proposals in
the Act. Legislation that may be appropriate for an industrialized country may
not be appropriate in a developing country with a shortage of doctors and
nurses, and may indeed obstruct the use of telemedicine.

Conclusions

Telemedicine in South Africa appears to be at a crossroads.
While its potential is apparent, it is not yet clear whether the potential can
be realized in an environment in which there are human resource constraints at
both the sending and receiving sites. Despite several years of activity, the
volume of telemedicine use is still very low, and most services must be
considered as being still in the pilot phase. Efforts to date have been hampered
by several common factors. These include lack of buy-in from provincial
governments, lack of support from health professionals, lack of technical
support, insufficient training, failure to provide site coordinators, lack of
administrative and financial models for the public sector, and failure to
understand the complexity of change management.

Videoconferenced tele-education for health professionals has
been successful, and demand is growing. Tele-education may prove to be the
catalyst for rural practitioners to become involved in telemedicine activity.
There is renewed interest in telemedicine in South Africa, and this needs to be
well managed and coordinated for telemedicine to succeed. To do so probably
requires the formation of a national telemedicine association, bringing together
the government and the provincial DOHs, universities, nongovernmental
organizations, the private health sector and industry. The aim would be to
ensure that mistakes are not repeated, that pilot projects are scaled up through
cooperation and that local best practice is shared for the common good. If South
Africa cannot make telemedicine work, then other poorly
resourced African countries are unlikely to succeed.

Further reading

Mars M, Dlova N. Teledermatology by videoconference:
experience of a pilot project. S Afr Fam Pract 2008;
50: 70.

References

1.
World Health Organization. World Health Statistics 2007. Available at:
www.who.int/whosis/whostat2007/en/index.html.

2.
Bradshaw D, Groenewald P, Laubscher R et al. Initial burden of disease estimates
for South Africa. S Afr Med J 2003; 93: 682–8.

3.
Health Systems Trust. Health Statistics. Available at:
www.hst.org.za/healthstats/index.php?indtype_id=004002.

4.
Esselaar S, Gilwald A, Stork C. South African Telecommunications Sector
Performance Review 2006. Available at:
link.wits.ac.za/papers/SPR-SA.pdf.

5.
World Bank. ICT at a Glance Tables. Available at:
web.worldbank.org/WBSITE/EXTERNAL/DATASTATISTICS/0,,contentMDK:20459133~menuPK:1192714~pagePK:64133150~piPK:64133175~the
SitePK:239419,00.html.

6.
Corr P. Teleradiology in KwaZulu-Natal. A pilot project. S Afr Med J
1998; 88: 48–9.

7.
Jithoo R, Govender PV, Corr P, Nathoo N. Telemedicine and neurosurgery:
experience of a regional unit based in South Africa. J Telemed Telecare
2003; 9: 63–6.

8.
Kennedy C, Kirwan J, Cook C et al. Telemedicine techniques can be used to
facilitate the conduct of multicentre trials. J Telemed Telecare 2000;
6: 343–7.

9.
Brauchli K, Oberli H, Hurwitz N et al. Diagnostic telepathology: long-term
experience of a single institution. Virchows Arch 2004;
444: 403–9.

10. Gulube SM,
Wynchank S. Telemedicine in South Africa: success or failure? J Telemed
Telecare 2001; 7(Suppl 2): 47–9.

11. Gulube SM.
Evaluation Report of the First Phase of the SA National Telemedicine System
(NTS). Available at: www.kznhealth.gov.za/telemedreport.pdf.

12. Science in Africa.
Telemedicine Gets Mobile. Available at:
www.scienceinafrica.co.za/2004/september/telemedicine.htm.

13. Abrahams JF,
Molefi M. Implementing telemedicine in South Africa ‘A South African
Experience’. Available at: www.hrhresourcecenter.org/node/1265

14. Brauchli K,
O’Mahony D, Banach L, Oberholzer M. iPath – a telemedicine platform to support
health providers in low resource settings. Stud Health Technol Inform
2005; 114: 11–17.

15. Chetty M, Tucker
W, Blake E. Telemedicine in the Eastern Cape Using VOIP Combined with a
Store and Forward Approach. Available at:
pubs.cs.uct.ac.za/archive/00000202/01/Chetty.pdf.

16. Bridges.org.
The Tygerberg Children’s Hospital and Rotary Telemedicine Project.
Available at: www.bridges.org/case_studies/353.

17. Colven R, Todd G,
Wynchank S et al. A Teledermatology Network for Underserved Areas of South
Africa. Available at:
www.medetel.lu/download/2005/parallel_sessions/presentation/0407/A_Teledermatology_network.pdf.

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

19. SIMpill.
Simpill. Available at: www.simpill.com.

20. International
Marketing Council of South Africa. Beaming Education to the Nation.
Available at:
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
is no single repository of information on telemedicine in Africa, so it is
difficult to provide current and accurate information on every country. However,
it is apparent that many telemedicine projects in Africa are launched with a
fanfare of press releases, but there is little or no information about their
subsequent progress.

Demographics

Africa has a land mass of 30 million square kilometres, with
a total population of approximately 965 million people, who constitute 14% of
the world’s population.1 Health
provision in Africa is poor. The difference between Africa and the
industrialized world was highlighted in the WHO World Health Report of
2006:2

The WHO Region of the Americas with 10% of the global
burden of disease, has 37% of the world’s health workers spending more than 50%
of the world’s health financing, whereas the African Region has 24% of the
burden but only 3% of health workers commanding less than 1% of world health
expenditure. The exodus of skilled professionals in the midst of so much unmet
health need places Africa at the epicentre of the global health workforce
crisis.

Sub-Saharan Africa can be defined as that part of Africa
lying to the south of the Sahara Desert. This includes five countries whose
political boundaries are traversed by the geographical boundary. It is made up
of 42 countries and 6 island nations, extending as far east as Mauritius in the
Indian Ocean.

Burden of disease and population
predictions

The burden of disease is great. Africa has most of the
HIV-positive people in the world – approximately 24 million. A million people
die annually of malaria, and Africa accounts for over 90% of the half billion
new cases of malaria each year. There is a high prevalence of tuberculosis, and
poliomyelitis has re-emerged.3 The leading
causes of death in the WHO African Region in 2002, in order, were HIV/AIDS,
malaria, lower respiratory tract infections, diarrhoeal diseases, perinatal
conditions, cerebrovascular vascular disease, tuberculosis, ischaemic heart
disease and measles.4 While the focus
of the industrialized world is on the ageing population and how to keep people out of hospital, average life expectancy is still
falling in many African countries. Life expectancy is less than 45 years in 7
countries.3 For the
foreseeable future, there will be a large number of people dying in Africa and a
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
population are required to provide minimum basic health care services.
Thirty-eight sub-Saharan African countries fail to meet this standard, 31
countries have fewer than 10 doctors per 100 000 population and 13 countries
have fewer than 5 doctors per 100 000. It has been estimated that Africa would
require an additional one million doctors to meet this minimum requirement. The
shortage of health professionals in Africa is a result of underproduction, loss
through migration and, surprisingly, in some countries, unemployment. There are
121 medical schools in Africa, with a ratio of 1 per 7.6 million people,
compared with the industrialized world’s norm of 1 per 2 million people.5 The medical
schools are not equally distributed, with 87 medical schools in 47 sub-Saharan
African countries and 34 schools in 6 Mediterranean-rim countries. Four
sub-Saharan countries do not have a medical school. The brain drain of health
professionals from the developing world is the focus of the WHO World Health
Report 2006, with rates of migration of health workers from African countries
ranging from 8% to 60%.4

Health care funding

There is extreme poverty, with 41% of people in sub-Saharan
Africa living on less than US$1 per day.6 Funding of
health care remains difficult. A realistic estimate of the cost of providing
basic health care to people in Africa is about US$34 per person per annum. Based
on 2004 data, the governments of 34 sub-Saharan African countries allocate less
than US$34 per capita per annum to health; 23 countries spend less than US$10
per capita. The average per capita expenditure on health in sub-Saharan Africa
is US$22.

In 2001, Member Heads of States of the Organisation of African
Unity signed the Abuja Declaration on HIV/AIDS, Tuberculosis and Other Related
Infectious Diseases, in which they pledged to set a target of allocating at
least 15% of their annual budgets to the improvement of the health sector. This
was re-affirmed by the Ministers of Health in the Gaborone Declaration of 2005.
Only two countries have achieved this. By 2004, the average general government
expenditure on health was 8.8% in the WHO African Region3 and, by 2005, a
third of the countries had reached 10%. There was also a commitment by developed
countries to give 0.7% of their annual income in aid. By 2006, only Denmark,
Luxembourg, the Netherlands, Norway and Sweden had honoured this pledge.

Telemedicine as a solution?

Telemedicine has great potential to solve problems such as
the shortage of health-workers and the provision of care to underserved rural
populations (Box
22.1).7 The

Box 22.1 The plight of many rural patients in
Africaa

Patients are referred to the Black Lion Teaching Hospital
in Addis Ababa from all over Ethiopia. If they do not die on the way to
Addis Ababa, they often face long waiting times once they get there.
Under-investment in rural health care facilities, a shortage of doctors
and the lack of incentives to retain medical staff in rural areas all
serve to increase the problem.

Demissie Sahle is a 68-year-old farmer who lives in
Amhara, about 200 km north of Addis Ababa. He was ill for six months, and
tried to obtain treatment at the nearest health post, but without success.
Together with his son Laike, he raised nearly 4000 birr (US$500) to travel
to the capital: ‘whatever we could sell, we have sold to get here and to
pay for treatment, including our only oxen’, said Laike. Father and son
embarked on the journey, leaving their families and their land behind,
unsure whether anyone would look after them.

Telemedicine, if it were to be rolled out to rural areas,
could make Demisse Sahle’s journey a thing of the past. This case
exemplifies the plight of many rural patients in Africa and highlights the
potential for telemedicine in Africa.

aAdapted
from Abebe S. Ethiopia: Digital Doctors. London: Panos.7

World Health Assembly Resolution on e-health (WHA58.28) of
2005 called on member nations to develop long term e-health strategic plans,
provide the telecommunications infrastructure necessary for e-health and
establish national centres of excellence. Several African countries have started
to develop strategies.

It is disheartening to note that neither the WHO African
Regional Health Report of 2006 nor the 2007 WHO publication, African Health
Monitor, which was devoted to the crises in Human Resources For Health in
Africa, mentions telemedicine as a possible solution to the shortage of health
workers or the training of health workers in Africa. The World Health Report
2006 mentions telemedicine/telehealth/e-health once: ‘Greater access to
education at lower cost can be achieved by regional pooling of resources and
expanding the use of information technologies such as telemedicine and distance
education.’2 Similarly, the
Africa Health Strategy: 2007–2015, developed by the African Union Ministers of
Health in April of 2007, makes no mention of telemedicine, telehealth or
e-health.8 The use of
information communication technology (ICT) is mentioned twice, in the context of
its lack of use to provide evidence to guide action within a health system, and
as an ‘ingredient’ that makes up a functional health system. Africa’s commitment
to the use of telemedicine is not clear.

The UN Millennium Development Goals (MDGs) include four relating
to health: access to clean drinking water, reduced child mortality under the age
of 5 years (currently 16.6%), improved maternal health, and combating HIV/AIDS,
malaria and other diseases. It is unlikely that any African country will achieve
these goals. In 2007, the UN Secretary General found it necessary to form a
Millennium Development Goals Africa Steering Group to help African countries
improve their performance in meeting the goals.9 Forty-one
countries have begun developing their national strategies in line with the MDGs,
and several have included telemedicine in their plans.

Obstacles to telemedicine

There are many obstacles to the implementation of telemedicine
in Africa.

Telecommunication costs

Many barriers to the introduction of telemedicine in Africa
centre on telecommunications legislation, infrastructure and costs.
Telecommunications are not fully deregulated in Africa, and liberalization of
policies is required. In 2003, there were monopolies for local, long-distance
and international call services in over 60% of the countries, with 10% of the
countries allowing monopolies for mobile and very small-aperture terminal (VSAT)
services and Internet service providers (ISPs). This, and the fact that about
70% of Africa’s continental Internet traffic passes out of Africa, pushes up
Internet cost.10 In the USA,
the average cost for 20 hours of Internet access (10 hours peak and 10 hours
off-peak usage), based on the cheapest available tariff and including telephone
usage charges, is US$15.11 The average
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
(GNI) per capita, in 26 countries. To put these costs into perspective, the
annual GNI per capita is US$41 400 in the USA and the percentage of GNI for 20
hours of Internet access is 0.4%. It is not surprising that fewer than 4% of
Africans have Internet access and that broadband access is below 1%.10

Because of the cost of Internet access, even simple
store-and-forward telemedicine is not always an affordable option in Africa.
Videoconferencing via ISDN is also expensive. The average cost of a 30-minute
videoconference at 128 kbit/s, from Africa to the USA, is US$48.30.11 Satellite
connectivity is also expensive. While VSAT access is available to all African
countries, its use in telemedicine has been impeded by legislative problems,
which have tended to restrict private enterprise and have resulted in high
costs. The average annual VSAT licence fee in 83 African universities is US$13
553, compared with US$426 for European Union universities.12 VSAT
communication has been widely used in pilot projects, but the associated high
costs are a factor in the lack of sustainability of some projects.

There has been rapid growth in the use of mobile phones in
Africa. Mobile penetration has risen from 3% in 2003 to 21% in 2007, and is
forecast to reach 30–35% by 2011. Costs are also relatively high, averaging 27%
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
telemedicine policies at national and regional levels and, as a result, a lack
of budgets

poor connectivity to
the rural areas that are most in need of support

the shortage of
doctors and nurses in almost all countries

low levels of
computer literacy among health professionals

lack of training in
telemedicine

poor technology
support

continuing regional
conflicts in Africa

the absence of
administrative and financial models for telemedicine in the African
setting.

The shortage of doctors is a particular problem. Telemedicine
requires additional effort and, while its potential benefits are acknowledged by
most doctors, many will not participate in telemedicine because of the extra
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
remunerated at the rates to which they are accustomed, if at all. Also,
diagnostic and treatment algorithms used in the industrialized world may not be
appropriate in Africa, and pharmacopoeias are likely to differ from country to
country. The question of liability is yet to be formally resolved.

What has proved to be effective in South Africa is
videoconferenced education, and there is a growing demand from African medical
schools to participate in shared education. The provision of education may prove
to be the catalyst for developing tele-medicine services.

Telemedicine initiatives in sub-Saharan
Africa

Telemedicine in Africa is not new. In 1984, doctors in London
made a diagnosis of Crouzon’s syndrome in a patient in Swaziland, using
satellite communication.13 In 1987,
there was clinical case-conferencing between Canada, Kenya and Uganda. This
consisted of twice-weekly satellite audio-conferences, with EEGs transmitted
from Mulago in Kampala to the Health Science Centre at St John’s in Canada.14
Satellite-based store-and-forward telemedicine was used by the US Army in
Ethiopia in 1993.15

Pan-African telemedicine initiatives

The African Union is an international organization of 53
member states. The New Partnership for Africa’s Development (NEPAD) is a special
programme of the African Union. NEPAD has developed a health strategy for the
African Union, which does not refer to telemedicine or e-health but does refer
to ‘the appropriate use of technology’.16 The NEPAD
e-school project makes provision for the incorporation of an ‘e-health point’.
The first NEPAD e-school was launched in mid-2005 at the Bugulumbya Secondary
School in Busobya Village in Uganda, and a consortium of private companies has
agreed to sponsor the demonstration project of 6 schools in each of the 16
participating countries.

The former President of India announced the launch of the Pan
African Network, which aims to connect 53 African countries by satellite and
fibre-optic links, to provide tele-education, telemedicine, Internet access,
videoconferencing and voice-over-Internet protocol (VOIP) services. For
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
provided with email and videoconferencing facilities, and facilities for
transmission of ultrasound scans, echocardiographs and ECGs. The project has
financial backing for five years, and will be coordinated by the African Union. While this will not provide a solution to Africa’s
medical problems, it might serve as a starting point for further development and
cooperation.

A workshop sponsored by the European Commission and the European
Space Agency was held in Brussels in 2006. It established a Telemedicine Task
Team, which has subsequently reviewed telemedicine opportunities in Africa. It
will make recommendations for future telemedicine actions in Africa and in
particular sub-Saharan Africa, with an emphasis on the use of satellite
communications.17

International telemedicine
initiatives

Some international store-and-forward projects, in which
African doctors have participated, have been in operation for several years.
However, use of these services in Africa has been limited. Why is this? The
obvious reasons include the lack of infrastructure, the shortage of health
professionals and the cost of bandwidth. What is often overlooked is the lack of
training of African health professionals in simple store-and-forward
telemedicine. The assumption is made that everyone knows how to take a
photograph and send an email message. Many of the obstacles listed previously
are relevant.

The Moorfields Eye Hospital ophthalmology projects have linked
three regional hospitals in South Africa to England for second opinion services
by videoconference and email,18 and their
web-based second-opinion service is used by doctors in South Africa, Gambia,
Tanzania and Ghana. The Orbis Cybersight programme also offers store-and-forward
services to ophthalmologists in Ethiopia and Tanzania. The Swinfen Charitable
Trust’s store-and-forward telemedicine service has been used by doctors in
Sierra Leone, Ethiopia, Malawi, Uganda and Zambia,19 as has iPath,
which commenced as a telepathology service and evolved into dermatology and
radiology services. Private and multinational companies have also set up
telemedicine services, both for their employees and for private patients who are
able to afford international service.

In the Francophone African countries, the RAFT (Résau en Afrique
Francophone pour la Télémédicine) project, based at the Hôpitaux Universitaires
de Genève, has been running at eight sites in Mali since 2001, with additional
sites in Mauritania, Morocco, Burkina-Faso, Senegal, Tunisia, Cameroon, Côte
d’Ivoire, Madagascar, Djibouti and Niger coming on line in 2005. Over the first
5 years, this project ran 98 webcast teaching sessions (50 from Geneva and 48
from Bamako in Mali). The infrastructure was also used for teleconsultations
using the web-based iPath platform and IP-based videoconferencing for remote
consultations. Only 14 international teleconsultations, for neurosurgery,
radiology and dermatology, were reported by 2005. This project has noted that
the ‘high expectations of satellite technology are still unmet, as the cost of
connectivity remains unaffordable for rural communities’.20

The African Medical and Research Foundation (AMREF), based in
East Africa, was founded in 1957, and has a long history as a flying doctor and
radio doctor service. It is currently involved in developing four
store-and-forward telemedicine sites in Kenya and Tanzania.

Projects within countries

As well as the international store-and-forward services, there
are several examples of telemedicine projects in sub-Saharan Africa. As stated
previously, this summary of activity in sub-Saharan African countries is likely
to be incomplete, and may refer to some projects that are no longer active, as
failure is not often reported.

In Angola and the Democratic Republic of the Congo, a
non-governmental organization (NGO) called Promoting Social Development in
Africa ran a trial store-and-forward project in collaboration with Partners
Telemedicine. The project was not sustainable, and ended in 2005. Botswana has
identified the need to set up telemedicine services, and the Botswana–Baylor
Children’s Clinical Centre of Excellence has established the first telemedicine
site in the country. Benin has a histopathology store-and-forward service with
Paris, for the management of Buruli ulcers. Burkina-Faso is part of a
tele-epidemiology network with France, and also participates in the RAFT
project. Burundi participates in the iPath programme. Chad participates in the
RAFT programme.

Anesthesia Overseas is assisting in training nurse anaesthetists
in Eritrea, and is setting up a telemedicine distance education resource centre
in one of the hospitals. Ethiopia is relatively active, although the country’s
five-year health sector development plan does not include the use of digital
technology to improve rural health. In 2006, an ICT for Health workshop attended
by 300 people agreed to set up a working group to formulate an e-health strategy
for Ethiopia. Telemedicine activity has been supported by a recent grant of US$2
million from India to fund a telemedicine project between Ethiopia and India for
3 years. There is also a report of 10 local hospitals being linked for
telemedicine. Doctors have participated in both the Swinfen and iPath programmes
and Johns Hopkins runs biweekly HIV clinical case presentations at the distance
learning centre in Addis Ababa.

Gabon has participated in iPath. The Gambia has used the Swinfen
Charitable Trust service and has participated in the Moorfields project. Ghana
too has participated in the Moorfields and iPath programmes, and Satellife has
been very active in the evaluation of personal digital assistants (PDAs) for
clinical data capture. Ghana is in the process of expanding its fibre-optic
connections throughout the country, which will improve its capacity to offer
real-time telemedicine. At the same time, two projects are being piloted in a
collaborative programme between the University of California at Berkeley and
Intel Research. These are the REACH (Remote Asynchronous Communication for
Healthcare) and TIER (Technology and Infrastructure for Emerging Regions)
projects. In the latter, 5 WiFi networks covering distances of up to 58 km have
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
made further advances. Guinea-Bissau is participating in the Spacedream project
funded by the European Space Agency, which is investigating how Earth
observation, navigation and telecommunication systems can be used to improve
access to antiretroviral therapy and health care. Telecommunications will be
used to connect health workers in rural areas with a central hospital.

Kenya is working on an e-health initiative. The AMREF group has
set up telemedicine pilot projects, and the Agah Khan Hospital group has
telemedicine links with North America. They are also investigating the use of
videoconferenced education between their centres. The Regenstrief Institute at
the University of Indiana has a long association with Moi University in Eldoret
and helped to found the Open MRS project, which is developing a framework for
electronic patient records in resource-poor areas.

The Malawi Polytechnic is developing a wireless network to be
used for telemedicine, and the Baobab Health Partnership has developed a
touch-screen clinical workstation in open source software, which captures data
in real time at the point of patient contact. The patient management system
allows poorly qualified health care workers to provide high-quality HIV
treatment.

Mali was an early partner in the RAFT programme and, with the
ongoing assistance of the Hôpitaux Universitaires de Genève, has implemented the
e-well project, which supplies stable power supplies and Internet connections to
six sites to enable telemedicine, primary school education, adult literacy and
the development of small business enterprises. In 2005, a store-and-forward
teleradiology service was established between four hospitals using open source
software via switched telephone links. After a slow start due to technical
problems, 338 cases were sent in the first 4 months, a case load of
approximately 30 X-rays per hospital per month, or about 1 case per day per
hospital.

Mauritania has participated in the Raft and iPath programmes,
and a strategy for community access to ICT has been proposed. In 1997, Mauritius
– which is classified as part of sub-Saharan Africa – launched its first
telemedicine project. The project failed, and a new store-and-forward service
for radiology and ECGs between a private hospital and a hospital in India was
set up in 2005, with a supplementary videoconference link.

Mozambique had a teleradiology service operating in 1998 between
two hospitals, but this project was not sustainable. Namibia is a large country
with a small population and no medical school. A nuclear medicine telemedicine
link between Namibia, South Africa and the UK was established in 2003. Niger is
part of a tele-epidemiology network with France, which monitors infectious
disease. Doctors in the country have also made use of the RAFT and iPath
programmes. Nigeria has Africa’s first and only national telemedicine
association. In 2006, the first telemedicine centre was launched with a
videoconference-based service between a private hospital and a hospital in
India.

Rwanda formally launched its national telemedicine programme in
2007. Videoconference links have been established between three hospitals. An
active distance education programme in public health has been running between
the National School of Public Health and Tulane University. Sao Tome has sent
cases to iPath. Sites in Senegal have participated in the RAFT programme, with
reports of videoconferenced consultations with Toulouse and three hospitals with
store-and-forward facilities for teleradiology and teledermatology. Sierra Leone
and Sudan have sent cases to the Swinfen Charitable Trust.

South Africa has several new and established projects and
services, which are described in Chapter 21. Tanzania has a
store-and-forward project with the Rikshopitalet in Oslo and the Aga Khan Board
of Volunteers in North America. AMREF has linked two sites in Tanzania as part
of its four-site pilot project. Healthspan International, an NGO, has been
active in setting up telemedicine projects using telephone lines, video cameras
and television monitors for both store-and-forward and real-time
telemedicine.

Uganda has connected three hospitals, and has been very active
in a PDA project to gather health data, using Healthnet and Satellife. Through
the International Telecommunication Union, there are several projects providing
ICT access to rural communities. Cases have been sent to the Swinfen Charitable
Trust service from Uganda and Zambia. In Zambia, two hospitals were recently
linked to the University Teaching Hospital through a Swedish International
Development agency grant.

Conclusion

While there is an upsurge in telemedicine activity in
sub-Saharan Africa, it remains to be seen whether sustainable programmes will
emerge. There is a need for telemedicine training throughout Africa, as, without
it, telemedicine practice will remain the domain of a few enlightened
enthusiasts. The use of international projects such as the Swinfen Charitable
Trust, iPath, RAFT and the new Pan African Telemedicine Project will assist the
introduction of telemedicine, but, unless substantial use is made of these
services, they will not make a major contribution to improved health care in
Africa. Problems such as international cross-border practice of telemedicine
have not yet been adequately addressed, nor have questions of international and
ethical standards for the practice of telemedicine. Africa needs to solve these
problems so that they do not impede further progress.

For telemedicine to be of assistance in Africa, there needs to
be greater government will to embrace telemedicine, changes in telecommunication
policies, provision of affordable bandwidth, and the development of sustainable
and affordable rural tele-medicine solutions. This will require substantial
external assistance, goodwill and perseverance.

Further reading

Heinzelmann PJ, Lugn NE, Kvedar JC. Telemedicine in the
future. J Telemed Tele-care 2005; 11: 384–90.

Kaplan WA. Can the ubiquitous power of mobile phones be
used to improve health outcomes in developing countries? Global Health
2006; 2: 9.

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

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12. Hawkins R.
Enhancing Research and Education Connectivity in Africa. Available at:
www.aau.org/tunis/presentation/Panel1/NREN%20ATICS%20WSIS%20Nov%202005.pdf.

13. Ojo T.
Communication networking: ICTs and health information in Africa. Inf
Dev 2006; 22: 94–101.

14. House M, Keough E,
Hillman D et al. Into Africa: the telemedicine links between Canada, Kenya and
Uganda. CMAJ 1987; 136: 398–400.

15. Crowther JB,
Poropatich R. Telemedicine in the U.S. Army: case reports from Somalia and
Croatia. Telemed J 1995; 1: 73–80.

16. NEPAD. The New
Partnership For Africa’s Development (NEPAD) Health Strategy. Available at:
www.nepad.org/2005/files/documents/129.pdf.

17. Asamoah-Odei E, de
Backer H, Dologuele N et al. eHealth for Africa. Opportunities for enhancing the
contribution of ICT to improve health services. Eur J Med Res 2007;
12(Suppl 1): 1–38.

18. Kennedy C, Kirwan
J, Cook C et al. Telemedicine techniques can be used to facilitate the conduct
of multicentre trials. J Telemed Telecare 2000; 6:
343–7.

19. Swinfen Charitable
Trust. Available at: www.swinfencharitabletrust.org.

20. Geissbuhler A,
Bagayoko CO, Ly O. The RAFT network: 5 years of distance continuing medical
education and tele-consultations over the Internet in French-speaking Africa.
Int J Med Inform 2007; 76: 351–6.

23 Telehealth for mountainous and remote areas of northern
Pakistan

Hameed A Khan and Irfan Hayee

Introduction

Pakistan is ranked 124 out of 191 countries in terms of health
care.1 About a third
of the population lives below the poverty line, with unhygienic living
conditions, poor health, and food and water insecurity. As a consequence, there
is a high burden of infectious and chronic diseases among people in Pakistan,
especially women and children. Poor nutrition and repeated infections have
aggravated the situation. According to a health assessment conducted by the Aga
Khan University, Pakistan ranks 157th in the world in terms of infant mortality,
and 39th in child mortality.2 Moreover, with
agriculture being the main occupation in the country, the majority of the
population still live in rural and remote areas that are underprivileged in
terms of access to basic health care services.

The northern area of Pakistan, comprising five districts
(Gilgit, Skardu, Diamer, Ghizer and Ghanche), is one of the most remote and
disadvantaged regions of Pakistan. The area has a population of around one
million people, who live in more than 600 villages scattered over 72 000 km2 of rugged
terrain. Lack of communications is a major problem.

People in the northern area of Pakistan have long been poorly
served in terms of access to health and education services. The area is known
for its difficult terrain, extreme climate and geographical remoteness from
large cities (Figure
23.1). Baltistan and Hunza, particularly, being remote and underdeveloped
mountainous regions, do not have access to high-quality health care services.
The health facilities do not have specialists, particularly for women’s health
care. Major hospital and health facilities are a long way away. For instance,
Gilgit is about 800 km away from a tertiary health care facility. Owing to the
lack of satisfactory health services, people suffer as a result of late
diagnosis and treatment. Furthermore, the rural health centres (most of which do
not have doctors) are not linked to the hospitals in the main urban centres,
resulting in avoidable mortality and morbidity, especially among women, children
and the elderly. Lack of information and communication facilities and the
absence of development networking compound the problems.

The Commission on Science and Technology for Sustainable
Development in the South (COMSATS) was established in 1994 to promote science
and technology in all spheres of life. It has 21 developing countries as its
members and there are 16 centres

Figure 23.1 Northern area of Pakistan

of excellence. In view of conditions in the northern parts of
Pakistan, COMSATS launched a project on telehealth, which went into service in
2005. Its objective was to facilitate access to specialized health services and
education, and thereby contribute towards raising the standard of living in the
area. The Baltistan Health and Education Foundation, which was working to
improve health care services for women in the remote and backward regions of
Baltistan, collaborated with COMSATS on the project. The International
Development Research Centre (IDRC), a Canadian government development
organization, was the principal funding organization (see Chapter 7).

Telemedicine in northern Pakistan

Establishing a telehealth service in the mountainous and
remote areas of northern Pakistan required not only having reliable technology
but also matching the services to the socioeconomic and cultural environment of
the area. This required cultural change, although, after three years, the
telehealth service is now well established and accepted by the local
communities.

In the rural areas of Pakistan, the lives of people are strongly
governed by cultural and traditional norms, which makes introducing change
difficult. Women are particularly marked by certain limitations as far as their
mobility and interaction with the outside world are concerned. In such a
situation, building a rapport with the local people, convincing them to adopt
telehealth and interact with people who did not belong to their community, as
well as disclosing personal information, especially in the case of women, was a
formidable task. However, the COMSATS team was successful in bringing about
change in the attitudes of the local people. This meant involving members of the
local community in delivering the services, so that patients coming in for
consultation did not feel alienated.

The lack of telecommunication infrastructure in the region was a
major problem. The government had installed landlines (digital telephone
exchanges) to some villages, but these were of poor quality and also expensive
for the users. On an experimental basis, the government introduced wireless
local loop (WLL) in some villages, but this was not very successful. The only
Internet service provider (ISP) in Gilgit was established by COMSATS.

The technology required for the project was installed by
COMSATS Internet Services (CIS), the executive agency of COMSATS. The tasks
included:

establishing an ISP
at Skardu

capacity building at
the Gilgit node

training the project
staff

operating the ISP at
Skardu

assisting with
procurement of equipment

documenting the
technical aspects of the project.

The equipment for the project is listed in Table 23.1. A major
task was obtaining a licence to operate an ISP in Hunza.

Very-small-aperture terminal (VSAT) links between Skardu and
Islamabad and between Hunza and Islamabad were established at an initial
bandwidth of 128 kbit/s. Internet bandwidth was provided from Islamabad at
subsidized rates. Once an ISP had been established at Skardu, surplus money
being generated could be invested in the telehealth services.

Project experience

Medical services

During the first phase of the project, a needs assessment was
carried out at Skardu. This showed the need for teleconsultations in five
medical fields. In order to develop standard operating procedures and to
synchronize the efforts of the Telehealth Centre (Skardu) and the Resource
Centre (Islamabad), a study was made of various aspects:

level and type of
medical services

availability of
medical specialists

scheduling of
services

medical equipment
required

clinical
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:
general medicine, cardiology, gastroenterology, dermatology and nephrology.
After three years of operation, services are now being provided in all fields
except nephrology. Services in

Table 23.1 Project equipment

Quantity

Equipment for the resource centre at
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 – high-resolution

1

Air conditioners

1

Dish/VSAT equipment

1

Satellite receiver

1

Equipment for telehealth at
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
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
that asynchronous (store-and-forward) telehealth would be used most frequently,
but later on, as telehealth came into routine use, the synchronous (real-time)
method became common.

Medical equipment

After careful examination it was felt necessary to have
similar videoconferencing equipment at both the Telehealth Centre (Skardu) and
the Resource Centre (Islamabad). The equipment chosen (VSX 7000, Polycom)
transmitted video calls over an IP connection. The Telehealth Centre was
established in the premises of the Abdullah Hospital in Skardu and operated by
the collaborating institution, the Baltistan Health and Education Foundation.
The hospital is a secondary-level health care unit. The Telehealth Centre is
located close to the ultrasound room, reception and the conference room, which
makes patient care efficient and reduces teleconsultation times.

To reimburse medical specialists for teleconsultation, it was
decided to pay them for each visit to the Resource Centre, and not on the basis
of the number of patients seen. Reimbursement for delivering seminars was
handled separately. To coordinate a team of medical specialists, it was
necessary to have a coordinator between the specialists and the people at the
Resource Centre and the Telehealth Centre.

Telehealth Centre at Skardu

Five medical specialists and a telehealth consultant were
employed at Islamabad. Teleconsultancy services were operated for a test period,
and then later run operationally for patients in Skardu. Training and
orientation of staff at the Abdullah Hospital were carried out. Development of a
patient information system and linkages with experts and donor and medical
organizations were also made.

A total of 361 patients received specialist consultations in the
first 4 months of operation. Dermatology was the most common specialty. Women
benefited greatly from the service, and showed confidence and satisfaction. In
one period, 101 female patients received a specialist consultation, in
comparison with 51 male patients. Feedback received from the specialist doctors
at Islamabad, as well as project staff at Skardu, called for increased bandwidth
to improve the quality of the service.

Experience with the service

The level of trust and confidence of the community grew
steadily, as indicated by the steady number of follow-up cases, which ranged
between 15% and 20% of the patients each month. A substantial proportion of
females benefitted from the service (58% overall).

Despite some problems due to connectivity, infrequent
availability of a general practitioner at Skardu and difficulties in data
transfer, the telehealth service continued smoothly with minor glitches, and the
level of satisfaction of patients and doctors remained satisfactory (on the
basis of initial and post-project interviews).

The 1000th consultation was conducted during May 2006. More
importantly, women and children (between the ages of a few months and 13 years)
were the main beneficiaries of telehealth services. Women
account for 61% and children 21% of those receiving specialist consultations
from doctors in Islamabad. It was observed that women and children are the ones
who suffer the most in the absence of specialized medical services. First, they
find it difficult to travel on their own to tertiary care centres in remote
areas. Second, it costs them more to travel, since they are dependent on male
family members to accompany them because of societal and cultural norms.

Another important fact that indicated the acceptance of the
service was that people from rural areas came pouring in to receive specialist
consultation. No promotional campaign was run to inform people from outlying
areas, and word of mouth seemed to be enough. The consultation data show that in
the first few months more consultancies were provided for people from urban
areas, while in the later months more consultancies were provided for people
from rural areas (Figure
23.2).

Teleconsultations continued as scheduled after the launch of the
service in April 2005, i.e. one session a week for dermatology, cardiology,
gastroenterology and general medicine. However, the services were disrupted for
some time in the wake of the earthquake of October 2005, which caused havoc in
the northern parts of Pakistan and killed some 80 000 people.

Although the earthquake did not affect the Baltistan region
directly, it made the specialists at the Resource Centre (Islamabad) unavailable
for telehealth for most of the consultations in the following month and a half.
Most of the medical specialists were engaged in serving a large influx of
patients from the earthquake-hit areas at their principal medical facilities,
and therefore routine consultations had to be reduced or postponed owing to the
emergency situation.

Figure 23.2 Number of teleconsultations during
the first 14 months of the project

Problems and corrective measures

Connectivity

Low bandwidth and poor connectivity were the major impediments
to telehealth services. Although the telehealth clinic was connected to the ISP
through an HDSL modem, the increased clientèle of the ISP at Skardu affected the
bandwidth available for data transfer and videoconferencing. Weather conditions
and physical damage to copper wires also caused problems.

Various measures were taken to overcome these difficulties. The
videoconferencing system was adjusted to make the calls at 128 kbit/s so that
packet loss could be minimized. This greatly improved the audio quality during
consultations. Separate downlink services were arranged from another service at
the ISP in Skardu to make VSAT link bandwidth available for the telehealth
project (Figure
23.3). An average of only 32 kbit/s was then used by the COMSATS Internet
service from the total 128 kbit/s VSAT link. Fine tuning was done at the ISP to
decrease the choking and packet loss.

The graphs of bandwidth usage obtained from the ISP identified
the time when the Internet usage was least, and the timings for teleconsultation
were adjusted to take advantage of this. The connection between the Telehealth
Centre and the ISP was lost twice owing to physical damage to the copper wires
between the two sites, which subsequently halted the telehealth service for two
or three days each time. Therefore, a second cable link was made available so
that it could be used as an alternative connection in case of similar problems
in the future.

Figure 23.3 Telecommunications

Unavailability of human resources

Infrequent availability of general physicians or well-trained
paramedical staff has been one of the major problems in providing the telehealth
service at Skardu. Most doctors in Pakistan prefer to work in large cities
(either to gain experience or to earn more), and only those who are visiting
their families, or female doctors whose spouses are stationed in army units, are
available in rural areas. Often, these doctors are available only for a limited
period of time, and many leave within a few months. There are few paramedics in
the northern parts of Pakistan, and not many are sufficiently trained to provide
telehealth services. In view of these problems, the following steps were
taken.

A doctor dedicated to the telehealth service at the Abdullah
Hospital in Skardu was employed for telehealth. The doctor’s role was to present
accurate and detailed information about the patients (e.g. the history and basic
physical examination results) to the specialist doctors. Having detailed medical
data is important for successful tele-consultation. In view of the large number
of female patients seen by telemedicine, a female doctor was hired.

All the specialists opined that the quality of consultation was
satisfactory when there was a supporting doctor (general physician) present at
the remote site to provide the basic data. In the absence of a general
physician, it was observed that the consultations were manageable, but did not
meet the satisfaction of the specialists.

The computer operator, who was responsible for running the
remote Telehealth Centre, gained a lot of experience through hands-on training.
He was formally supervised by the doctors at the Telehealth Centre and the
Resource Centre, which helped him to gain expertise in delivering services.
After training, the computer operator could take a good patient history and
perform a general physical examination, e.g. checking blood pressure, pulse and
temperature. This was useful if the general physician at the remote centre was
not available. Given suitable training, a paramedic or non-medical person can be
a useful substitute when a doctor is not available for conducting
telemedicine.

Patient information software

The patient information software proved to be of great help in
maintaining the medical records of visitors and patients. Initially, the patient
information system was developed as a client–server application. The information
was thereafter transmitted using file transfer protocol (FTP) servers at both
ends. In addition, FTP servers were placed at the ISP to increase the rate of
transfer of files, as well as to avoid undue delays in the transfer during power
failure or problems in the computers. This option improved the situation to some
extent, leaving only the problem that complete data on a patient could not be
accessed from one program, making it rather time-consuming. In the light of
experience, it was realized that a web-based solution would be a better way in
the future of providing similar services from different sites.

It was also realized that there is a need to provide the patient
data to the specialists at their workplace and at their homes, so that they can
conduct telemedicine without coming to the Resource Centre. Visits of the
medical consultants to the Resource Centre could be reduced by using a web
portal.

Service methodology

Although the consultations in this project were mainly based
on real-time videoconferencing, in a few instances where live consultation was
not possible (for technical reasons), the diagnosis and expert opinion were
based on store-and-forward information. About 10% of all consultations were
performed in this way. It turned out that patient management decisions were
easily made in dermatology, while, in the single instance of a cardiology case,
it was most difficult. The reason may be that the images in dermatology cases
are self-explanatory and require little elaboration, whereas in cardiology there
are often many unanswered questions. However, the store-and-forward technique
was more time-consuming than live interaction, for both the physician and the
patient.

In discussion with the specialists, it appeared that both
patients and doctors felt that store-and-forward consultations were inferior to
real-time consultations, except in dermatology. In dermatology, a detailed
history of the patient along with high-resolution pictures could be sent easily,
thus facilitating the correct diagnosis.

Recommendations

Based on our experience, we recommend that careful attention
be paid to the design and implementation of telehealth services in
underdeveloped areas. It is feasible to utilize relatively inexpensive and
robust equipment that is easy to operate and repair. Activities must be chosen
that result in benefits for as many people as possible, while the technology
chosen should be compatible with immediate health care needs.

As well as support from the government, it is important to
persuade private sector and local organizations to participate in planning and
implementing telehealth services. The participation of local organizations will
not only assist in developing health care services attuned to the local
settings, but also facilitate the acceptance of these services in the area. The
collaboration between COMSATS and the Baltistan Health and Education Foundation
has been a success. It demonstrates how local organizations can catalyze the
implementation of telehealth and bring ownership to the community.

Appropriate guidelines need to be developed for establishing
high-quality and consistent standards for teleconsultations. Formulating a
tele-education strategy and conducting a resource inventory may be helpful in
this regard.

An important factor in a successful telehealth service is the
information management system. This should be devised in conjunction with the
specialists and other doctors who are involved in delivering the telehealth
services.

Conclusions

Despite the difficulties, telehealth can be a practical method
of providing specialist consultations and supporting other health care services
for people in developing countries, particularly those in
remote regions. Telehealth can also be used to improve access to the health care
providers of these regions and reduce their isolation.

Establishing a telehealth service in Skardu was a difficult
task. However, with an enthusiastic team, the project was successful, and it is
clear that many patients, especially women and children, have benefited from the
service. Those who are unable to travel to cities to obtain specialist advice
now have easy access to specialist health care.

Economies may be possible in future by using digital cameras or
newer versions of webcams, instead of specialized videoconferencing equipment.
In future, the resource centre might be established at a hospital to save time
for both the doctor and the patient. While promoting telehealth to doctors, it
is important to emphasize that existing health care delivery methods will not be
replaced – rather, telehealth will supplement them.

Finally, the general public, patients and health professionals
should be informed as much as possible about telemedicine, so that they feel
comfortable with the concept. This will mean that future generations will feel
at ease in using telehealth to improve traditional methods of health care
delivery.

Further reading

Adler AT. A cost-effective portable telemedicine kit for
use in developing countries. Thesis, Department of Mechanical Engineering,
Massachusetts Institute of Technology, 2000. Available at: www.media.mit.edu/resenv/pubs/theses/AriAdlerThesis.pdf#search=’telemedicine%20problems%20developing%20countries.

Edworthy SM. Telemedicine in developing countries.
BMJ 2001; 323: 524–5.

Graham LE, Zimmerman M, Vassallo DJ et al. Telemedicine –
the way ahead for medicine in the developing world. Trop Doct 2003;
33: 36–8.

Office of Technology Policy, US Department of Commerce.
Innovation, Demand and Investment in Telehealth. Available at: www.ncsbn.org/2004Report.pdf.

References

1.
World Health Organization. The World Health Report 2000 – Health Systems:
Improving Performance. Available at:
www.who.int/whr/2000/en/whr00_en.pdf.

2.
Aga Khan University. Assessment of Health Status and Trends in
Pakistan. Available at:
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
Medline search for telemedicine papers found 911 articles concerning its use in
radiology, 931 in surgery and 735 in pathology (Figure 24.1). There
were 69 articles concerning telemedicine in neurology and 19 concerning
epilepsy.

The term ‘imaging’ was found in 710 articles, ‘video’ in 969 and
‘electrocardiography’ in 250. ‘Electroencephalography’, the typical
investigation of epilepsy, was found in 27 articles only. The most commonly
mentioned aim of telemedicine was consultation (3022), followed by diagnosis
(3654) and education (1718). Other

Figure 24.1 The number of telemedicine articles
published in different specialities (PubMed search, April 2008)

indications were instrumentation (1729), treatment (2984),
cost (2015) and payment (45).

Clinical telemedicine applications can be considered on two
axes: a vertical axis representing the level of maturity and a horizontal axis
representing the extent of the application. The maturity is based on several
factors, including quantity and quality of research pertaining to the
application, the degree to which the application has been accepted by the
profession, and the development of standards or protocols for its use. The
evidence of the application refers to attributes such as technical feasibility,
diagnostic accuracy, sensitivity, specificity, clinical outcome and
cost-effectiveness. Tele-radiology, telesurgery and telepathology rank high on
the maturity scale. Psychiatry, dermatology and ophthalmology are regarded as
maturing areas of telemedicine, whereas paediatrics and emergency medicine, for
example, are emerging specialties with respect to the use of telemedicine (Figure 24.2).1

In neurology, real-time telemedicine has the greatest potential
in the management of neurological emergencies such as status epilepticus, stroke
and movement disorders and in neurophysiology. Status epilepticus and stroke
require urgent treatment within the window period for better outcome.
Transporting these patients to a specialist centre might take several hours,
resulting in high mortality and morbidity. Live demonstration or video
recordings of patients with movement disorders and neuro-physiological tracings
(electroencephalography, nerve conduction studies and evoked potentials) can be
transmitted to a specialist centre for expert opinion without physical referral
of the patient.

Figure 24.2 Categorization of medical
specialties according to their maturity in telemedicine

Epilepsy

Epileptic seizures can be infrequent and difficult to
diagnose. The best method of diagnosis is by observation of the seizure episode,
and in its absence one has to rely on the description of a bystander. The data
concerning seizures are so important that full information should be made
available to the physician so as to make or revise the diagnosis. Patients with
epilepsy often have travel limitations placed on them, which may cause
difficulties with the different centres involved in treatment of multiple
handicap. Communication between different hospitals and physicians in
difficult-to-diagnose epilepsies can be greatly helped by
telecommunication.2 This can not
only avoid frequent and sometimes arduous visits to experts in different
hospitals and repeated investigations, but also allow the simultaneous opinion
of different physicians to be obtained.

Status epilepticus is an emergency in which seizures recur
without the patient regaining consciousness between two discrete seizures, or
individual seizures continue for at least 30 minutes. Often, a patient is
admitted to a primary centre and is referred to another more specialized centre
when the seizure is not controlled. Finally, when the patient reaches an
advanced specialized centre, he or she may be have been undergoing status
epilepticus for several hours or even longer. This is likely to result in
various complications and a poor prognosis. Early diagnosis and prompt treatment
would assist with controlling the attack and improving the prognosis. According
to a recent study, a telemedicine-based epilepsy service was as safe and
effective as conventional face-to-face consultation.3 In this study,
a neurologist was based at a centre and managed epilepsy patients at a rural
hospital by video link. Patients were usually accompanied by a family member and
always by a trained nurse, who acted as care manager, coordinated medication and
ensured compliance, and was able to reinforce what the neurologist said. A
comparison was made of patients managed by this method and those managed by a
conventional urban clinic. Seizure frequency, emergency room visits and hospital
admissions were used as measures of efficacy and safety. No difference was found
in these outcome measures between telemedicine and conventionally treated
patients.3

Acute stroke

Recombinant tissue-type plasminogen activator (rtPA)
represents a major breakthrough in the treatment of ischaemic stroke. If it is
administered within 3 hours of onset of stroke, it results in improved survival
and outcome.4 Many
institutions lack the specialized personnel and resources necessary to provide
the response for acute stroke patients. These institutions depend on the rapid
transfer of patients to regional stroke centres for therapy. In practice, the
main reason for patients not receiving this therapy is their late arrival after
the critical time window of 3 hours. Telemedicine is emerging as an efficient
means of making early decisions about therapy.

At the medical centre of the University of Maryland, the
tele-stroke service uses videoconferencing and CT image transfer. Between 1999
and 2001, 50 stroke consultations were reviewed. Of these, 23 were managed by
telemedicine and 27 by traditional telephone conversation
followed by transfer. Two of the 23 telemedicine consultations were aborted
because of technical difficulties. Of the patients evaluated by the traditional
method, 1 (4%) received rtPA, whereas 5 patients from the telemedicine group
(24%) received rtPA and there were no complications due to this therapy.
Telemedicine provided a treatment option that was not previously available at
the remote hospital. For administration of rtPA, telemedicine was safe, feasible
and well received.5,6

Assessing the stroke patients and their CT scan by using
videoconferencing offers an opportunity to improve stroke care in remote and
rural areas. In a study from Swabia, seven rural hospitals were connected to the
stroke unit via videoconferencing. One hundred and fifty-three patients were
examined by teleconsultation, and a relevant contribution could be made in more
than 75% of cases regarding diagnostic work-up, CT assessment and therapeutic
recommendations.7

Although the number of emergencies is increasing, there is
growing anxiety about medical errors and an increasing number of medical
negligence cases. Pre-hospital use of telemedicine for stroke is already being
piloted, linking patients in an ambulance to the emergency department.6

Movement disorders

Telemedicine has been found to be useful for diagnosis,
treatment and follow-up of patients with various movement disorders. Live video
or prerecorded video clips can be used for these purposes. In a recent study,
video clips of normal and abnormal gait disorders were used by a geriatrician
for diagnosis and were compared with the diagnosis of the treating clinicians,
i.e. the latter was considered the gold standard. The agreement of the video
clip examination with the gold standard in identifying abnormal gait ranged from
substantial to excellent among assessors, although there was only a low
agreement with the gold standard in the detection of specific gait diagnosis.
This technique appears to be a valid screening procedure for detecting gait
abnormalities, with a sensitivity of 100% and a specificity of 70%.8

Telemedicine has also been used to follow up patients with
Parkinson’s disease in remote areas. Over a 3-year period, 100 teleconsultations
were carried out on 34 patients with Parkinson’s disease. Each teleconsultation
lasted for 30–60 minutes. Patients and providers were satisfied with the
consultations, and they reduced the time and cost of travelling.9

Neurophysiology

Digital technology for clinical neurophysiology allows
teleneurophysiology to be developed. Such a service may improve patient care in
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
data bank. A telemedicine facility of this kind has been established in
Scandinavian countries.10

Neurological outpatients

In remote areas where neurologists are not available,
telemedicine has been used for providing outpatient consultations to
neurological patients. In a randomized controlled trial, the efficacy of
telemedicine consultation was compared with face-to-face consultation, the
groups comprising 82 and 86 patients, respectively.11 The
diagnostic categories were similar in the two groups. The patients in the
telemedicine group had more investigations, but there was no difference in the
number of drugs prescribed. The patients were generally satisfied with both
processes, although they were concerned about confidentiality and embarrassment
in the telemedicine consultation.

Teleneurology, although feasible in the outpatient setting, is
less well accepted than face-to-face consultation, and can lead to
over-investigation.11 However, in a
remote area where there are too few neurologists, telemedicine may become a
viable option, especially in developing countries.

Mobile phones

The telephone has always been used for consultation between
doctors, especially for fixing appointments, calling for home visits or
obtaining immediate advice. Following the mobile phone revolution, most urban
and even rural people have access to a telephone. This has opened up
opportunities for using mobile phones for health care delivery. In developing
countries, the doctor:patient ratio is far too low. Specialized and even primary
hospitals are overcrowded. The use of a mobile phone can help in obtaining
appointments and monitoring therapy, especially in chronic disorders such as
epilepsy, migraine, headaches and stroke. Such patients often have to travel
long distances, and it may take several hours or even days to obtain a
consultation. In such a situation, adjusting the dose of drugs, checking
compliance, monitoring side effects and defining the patients who need an early
appointment may be done by telephone or mobile phone. The difference between a
mobile phone and the ordinary telephone service is not only the former’s
mobility, but also that mobile phones have additional capabilities, including
text messaging, video and Internet facilities.

There is a paucity of randomized controlled trials evaluating
the efficacy and satisfaction level of mobile phone consultations in comparison
with conventional face-to-face consultations. Psychotherapy delivered by
telephone revealed a significant improvement in depression. In
telephone-administered cognitive–behavioural therapy, there was an improvement
compared with usual care.12 Patients can
often capture an event such as a seizure or movement disorder and present it to
a physician for evaluation during consultation.

Medical education

Telemedicine has great potential to transform medical
education at undergraduate, postgraduate and professional levels. The educator
has to select the appropriate context, content and delivery
method to suit the needs of the largest number of the learners. In medicine,
education has to continue throughout the professional’s career. Learning is
greatest when adults act as self-directed, motivated learners, perusing the
topics of their interest in the appropriate context, i.e. interactive, practical
and self-paced.13 These
principles can be incorporated into a distance education programme.14 Online
continuing medical education (CME) and web-based CME have also provided CME
credits for the practising physician. The Internet also has the ability to
support the presentation of complex multimedia presentations to augment
learning. The Internet has created learning communities.

A survey was conducted regarding the motivation and choice of
topics for a journal club and the websites accessed in two institutions. The
institutions were the Sanjay Gandhi Post Graduate Institute of Medical Sciences
in Lucknow and the King George Medical University in Lucknow. The views of
specialty (n = 58) and subspecialty (n = 97) residents were
compared.15 Most of the
residents used Medline and PubMed for choosing their journal club topics. The
choice of Google, the Oxford database, Science Direct and the Cochrane Review
did not differ between the residents of the two institutions. At the Post
Graduate Institute, the choice of articles was based on the availability of good
articles, whereas in the Medical College, it was faculty driven. The choice of
articles related to patient management and examination were not different
between the two institutions. Female residents more frequently selected articles
related to patient management or examination, although the difference was not
significant.

Internet use by residents and faculty members of the Medical
College and the Post Graduate Institute was surveyed by us, and we found that
89% of individuals performed a computer literature search at least once a month.
The reason for a computer-based literature search was for presentation in 90% of
cases, research in 65% and patient care in 60%. The benefit of literature
searching was acknowledged in learning and teaching by 80% of respondents, in
research by 65% and in patient care by 54%. Formal training in computer-based
literature searching was received by 41%, of whom 80% were residents. Of the
participants in this survey, 64% had a home Internet connection and the
remainder used the Internet at their workplace or at a cyber café, suggesting
widespread use of computers and the Internet by medical personnel.16

We have used videoconferencing for neurology teaching in India.
We have conducted a neurology educational conference between the Post Graduate
Institute and the Medical College. These locations are 1500 km apart. Faculty
members and residents of the two departments participated. Desktop
videoconferencing systems were connected by an ISDN line at 128 kbit/s. During
2001–2004, there were 30 sessions, 22 of which were successful and 8 partly
successful (owing to power and communication failure). In each session, two to
four cases were discussed, with clinical pictures, neurophysiological and
radiological data as illustrations. Discussions provided inputs for both
learning and patient management (Figure 24.3).17

Figure 24.3 A videoconferencing session between
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
of telemedicine in India. Mahakumbh Mela is a religious congregation that occurs
every six years and in which millions of Hindus gather for religious ceremonies
and discussions. Such a large gathering of people is associated with inherent
health problems, such as infections and accidents, so that health care for the
attendees is a major public health problem. The Post Graduate Institute used
telehealth to avoid an outbreak of cholera at the Mahakumbh Mela in Allahabad,
Uttar Pradesh.18
Ganapathy19 took the
initiative of providing consultations to distant areas in India in Aragonda and
Sriharikota. Desai et al20 used
teleconsultation between a tertiary cancer centre and a rural cancer hospital.
Ninety-three cases were analyzed in which static pathology and telepathology
were used to obtain a consultation between the Tata Memorial Hospital, Mumbai
and the Nargis Dutt Memorial Cancer Hospital at Barshi. A diagnosis was offered
in 92 (98%) cases.

Resource availability

In developing countries, an increasing population and a very
low doctor:patient ratio represent a difficult challenge for health care. A
total of some 800 neurologists in a country such as India with a population of
1.3 billion is inadequate. It will take more than 20 years to
achieve a ratio of one neurologist for 50 000 population at the rate of 50
neurologists being produced per year. However, it is not only the numbers that
are important. Increasing specialization has reduced the number of physicians
who are good at managing emergencies. Although the number of emergencies is
increasing, there is growing anxiety about medical errors and increasing number
of medical negligence cases.

There is no single solution for upgrading the emergency
services, but a favoured model has been a large central hospital with associated
local hospitals to which patients are discharged. Unfortunately, this may make
the services worse rather than better. Medical emergencies usually occur in a
patient’s home, and are followed by a journey to the hospital, assessment,
admission, treatment and then discharge. A large central hospital means a long
journey, which may delay treatment and influence outcome, as in status
epilepticus and stroke. In developing countries, roads and transportation are
far from satisfactory. Increased distance also causes problems for visiting
families, and weakens the link with primary care, which is crucial when
discharging patients from hospital. Large numbers of patients in emergency
departments lead to long waiting periods. The local hospitals do not share care
or staff with large hospitals, and have poor nursing and medical infrastructure.
They are uncomfortable about managing seriously ill patients, and thus assume
the role of nursing homes, rather than hospitals.

Black et al21 have proposed
a reverse model in which patients are admitted to a local hospital, which acts
as the catchment area of a big hospital. The medical and nursing staff would be
part of the team working in the central hospital, and would rotate between the
hospitals. The local unit would have imaging (CT scanning) and laboratory
support (EEG, ECG and biochemistry), as well as high-quality electronic links
with the central hospital that would allow the specialists to know almost as
much about the patients as if they were examining them directly. Such a system
would result in avoiding delay in treatment. Patients who did not need admission
could be quickly discharged, perhaps within a single day, and some patients
would never need to go to the central hospital at all. Those who went to the
central hospital would not need to be assessed again, so that the transfer and
admission would be faster.21

The cost-effectiveness of telemedicine has been a concern
because, in a study of teleneurology from the UK, a comparison of 65 patients in
a conventional group and 76 in a teleconsultation group revealed that the
telemedicine group needed more investigations and reviews than the conventional
group. The average cost of conventional consultation was £49, compared with £72
for the telemedicine group.22

Legal questions

The use of telemedicine has raised several legal questions.
These include licensing, reimbursement and liability. The question of data
security is also a concern in telemedicine. Thus, accidental loss and data
corruption must be prevented by providing effective data control management and
artefact recognition algorithms. As personal data is involved, the possibility
of loss or criminal access must be considered and prevented.
Special encryption mechanisms to secure data against unauthorized access or
modification are therefore necessary.12 Patients’
right to confidentiality is paramount.

Unless otherwise agreed by both sides, the liability in
telemedicine is normally considered to rest with the consulting rather than the
advising physician. Procedures for reimbursement of logistical costs in
telemedicine need to be developed.

Conclusion

There are concerns that physicians in future may become
‘telecarers’, at least for part of their working time. A telecarer is a health
professional who delivers responsive, high-quality information services, and
supports remote patients or clients by using the most appropriate communication
technology, such as the telephone, email or instant messaging. The advantages of
telecare are the possibility of working from home and better continuity of
patient care. However, there are concerns about over-investigation, clinical
mistakes and confidentiality. There are also worries about commercial
pressures.

A wider market for health service information and products
should be welcome. However, the danger of commercial suppliers or
cyber-physicians undercutting primary health care services is a possibility,
although it may ultimately result in healthy competition. The digital divide in
society may also be a concern. People with low education and old age may be
excluded from telemedicine, and society must ensure that this does not occur.
Telemedicine is a powerful tool, but should be used judiciously and in the
interests of society at large.

Further reading

Bashshur RL, Sanders JH, Shannon GW. Telemedicine,
Theory and Practice. Spring-field, IL: CC Thomas, 1997.

Darkins AW, Cary MA. Telemedicine and Telehealth
Principles, Policies, Performance and Pitfalls. London: Springer, 2000.

Norris AC. Essentials of Telemedicine and
Telecare. New York: Wiley, 2002.

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

References

1.
Krupinski E, Nypaver M, Poropatich R et al. Telemedicine/telehealth: an
international perspective. Clinical applications in telemedicine/telehealth.
Telemed J E Health 2002; 8: 13–34.

2.
Elger CE, Burr W. Advances in telecommunications concerning epilepsy.
Epilepsia 2000; 41(Suppl 5): 9–12.

3.
Rasmusson KA, Hartshorn JC. A comparison of epilepsy patients in a traditional
ambulatory clinic and telemedicine clinic. Epilepsia 2005;
46:767–70.

4.
National Institute of Neurological Disorders and Stroke rt-PA Stroke Study
Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J
Med 1995: 333: 1581–7.

5.
LaMonte MP, Bahouth MN, Hu P et al. Telemedicine for acute stroke: triumphs and
pitfalls. Stroke 2003; 34: 725–8.

6.
LaMonte MP, Xiao Y, Hu PF et al. Shortening time to stroke treatment using
ambulance telemedicine: TeleBAT. J Stroke Cerebrovasc Dis 2004;
13: 148–54.

7.
Wiborg A, Widder B. Teleneurology to improve stroke care in rural areas: the
Telemedicine in Stroke in Swabia (TESS) Project. Stroke 2003;
34: 2951–6.

8.
Salih SA, Wootton R, Beller E, Gray L. The validity of video clips in the
diagnosis of gait disorder. J Telemed Telecare 2007;
13: 333–6.

9.
Samii A, Ryan-Dykes P, Tsukuda RA et al. Telemedicine for delivery of health
care in Parkinson’s disease. J Telemed Telecare 2006;
12: 16–18.

10. Stålberg S. Small
bits to big bites. Muscle Nerve 2002; 11 (Suppl):
S119–27.

11. Chua R, Craig J,
Wootton R, Patterson V. Randomised controlled trial of telemedicine for new
neurological outpatient referrals. J Neurol Neurosurg Psychiatry 2001;
71: 63–6.

12. Ludman EJ, Simon
GE, Tutty S, Von Korff M. A randomized trial of telephone psychotherapy and
pharmacotherapy for depression: continuation and durability of effects. J
Consult Clin Psychol 2007 75: 257–66.

13. Knowles MS.
Andragogy in Action: Applying Modern Principles of Adult Learning. San
Francisco: Jossey-Bass, 1984.

14. Ward JP, Gordon J,
Field MJ, Lehmann HP. Communication and information technology in medical
education. Lancet 2001; 357: 792–6.

15. Misra UK, Kalita
J, Nair PP. Traditional journal club: a continuing problem. J Assoc
Physicians India 2007; 55: 343–6.

16. Kalita J, Misra
UK, G Kumar. Computer based literature search in medical institutions in India.
Ann Indian Acad Neurol 2007; 10: 44–8.

17. Misra UK, Kalita
J, Mishra SK, Yadav RK. Telemedicine for distance education in neurology:
preliminary experience in India. J Telemed Telecare 2004;
10: 363–5.

18. Ayyagari A,
Bhargava A, Agarwal R et al. Use of telemedicine in evading cholera outbreak in
Mahakumbh Mela, Prayag, UP, India: an encouraging experience. Telemed J E
Health 2003; 9: 89–94.

19. Ganapathy K.
Telemedicine and neurosciences in developing countries. Surg Neurol
2002; 58: 388–94.

20. Desai S, Patil R,
Chinoy R et al. Experience with telepathology at a tertiary cancer centre and a
rural cancer hospital. Natl Med J India 2004; 17:
17–9.

21. Black S, Andersen
K, Loane MA, Wootton R. The potential of telemedicine for home nursing in
Queensland. J Telemed Telecare 2001; 7: 199–205.

22. Chua R, Craig J,
Wootton R, Patterson V. Cost implications of outpatient teleneurology. J
Telemed Telecare 2001; 7(Suppl 1): 62–4.

25 Telepaediatric support for a field hospital in
Chechnya

Boris A Kobrinskiy and Vladimir I
Petlakh

Introduction

Emergency situations involving multiple victims require
efficient decisions about medical care. The use of modern telecommunications
allows improved support for disaster medicine. This includes monitoring of the
medical situation, communications about patient transportation problems, and
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
of information about the nature of the emergency, which is needed to plan the
order and scale of evacuation measures

consultations with
medical specialists to support the physicians on site

optimization of the
choice of specialized hospitals for further treatment of the victims.

Modern telecommunications were used for the first time in
disaster medicine by the US National Aeronautics and Space Administration (NASA)
in 1985 after the earthquake in Mexico City. This allowed better estimation of
the medical consequences of the earthquake and facilitated proper rescue
measures.1

In the former Soviet Union, the first use of teleconsultations
in an emergency situation was after the Armenian earthquake of 1988. Telemedical
‘space bridges’ (i.e. video connections) were established by NASA between
Russian and American specialists. This was the first experience of international
telemedical collaboration in an emergency situation.2 The project
included audio–video and fax communication between the disaster area in Armenia,
clinics in Moscow and four medical centres in the USA.

In 1999, after a train crash in Bashkiria, teleconsultations
took place between a hospital in Ufa (Bashkiria), a surgical clinic in Moscow
and the Yerevan Diagnostic Centre in Armenia. Dedicated telephone lines were
used to provide audio communication and slow-scan black-and-white video images.
When connected to the ‘space bridge’, the system enabled consultations about
patients in Ufa with conditions such as burns and psychological trauma,
involving specialists at medical centres in Moscow and the USA.

In 1993, the US Department of Defense started using telemedicine
to support a peacekeeping force (IFOR) undertaking humanitarian missions in a
number of countries. The telemedicine system was called PrimeTime. Physicians at
field hospitals in Macedonia, Croatia and Bosnia were connected to hospital
specialists in Germany, Hungary and the USA.3,4

The most recent use of telemedicine in an emergency situation in
Russia was to support the Children’s Field Hospital of the All-Russia Centre of
Disaster Medicine in the Chechen Republic in 2001. The doctors of the field
hospital had to provide care for patients with various conditions resulting from
explosion trauma and from fire-arms, as well as providing diagnosis and
treatment for children with a wide range of pathologies, including acute and
chronic diseases (e.g. congenital, malignant, neurological and cardiovascular).
This situation required distant medical support, which was realized by
installing a telemedicine unit at the field hospital.

Remote decision support for the Children’s Field
Hospital

By 2001, medical services in Chechnya had been almost
completely destroyed owing to long-term military conflict. Paediatric care was
almost unavailable. The Children’s Field Hospital in the Gudermes district of
the Chechen Republic included an admission and consultation department, a
surgery department, a department of internal medicine and an intensive therapy
unit, as well as laboratory and radiology services (Figure 25.1). The
hospital was equipped for X-ray imaging, ultrasound scanning and basic
laboratory investigations.

The field hospital was admitting not only wounded children, but
also children with various diseases from a number of districts of the Chechen
Republic. This created serious problems for the relatively small medical staff
of the hospital. It was not realistic to refer all the complicated cases to
clinics in Moscow or to other Russian cities.

Figure 25.1 Structure of the field
hospital

Besides, in a number of cases, urgent consultations with
specialists were required, including multispecialist consultations. Therefore,
even from the start of the hospital’s work, there was a need for support from
specialist institutions. Telephone consultations were impractical in Chechnya in
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
required to support the physicians working in emergency situations, including
urgent support from specialists. The consultations had to be provided both in
store-and-forward mode and in real-time, using videoconferencing.

The implementation of this telemedical support – the first
Russian system for disaster telemedicine – was performed by specialists of the
Moscow Research Institute for Paediatrics and Children’s Surgery, the All-Russia
Centre of Disaster Medicine, the Dorodnicyn Computing Centre of the Russian
Academy of Sciences, the State Central Air-Carried Rescue Team and a company
called Web Media Service.5

It was decided that the Medical Centre for New Information
Technologies of the Moscow Research Institute for Paediatrics and Childen’s
Surgery would act as the head telemedicine centre of the system. The
telemedicine centre was equipped with a videoconferencing system and modern
telecommunication equipment, including fibre-optic cables enabling ISDN
connection at 2.048 Mbit/s and IP connection at 1.024 Mbit/s.

Emergency and scheduled teleconsultations were provided by the
telemedicine centre, as well as multispecialty videoconference
consultations.6 The Medical
Centre for New Information Technologies provided technical support for the field
hospital, initially acting as the sole consulting centre. Later on, regular
working contacts were established between the field hospital and the Scientific
Institute of Medical and Biological Problems in Northern Ossetia, the Fund for
Development and Dissemination of New Medical Technologies in Stavropol, the
Stavropol Area Hospital and the Republican Children’s Hospital in
Vladikavkaz.

System architecture

It was clear from the beginning that only satellite
communication would be appropriate for telemedicine (Figure 25.2). One
satellite channel was used to provide the connection between the consultants in
the telemedicine centre and the physicians in the field hospital, and a second
channel was used to send requests to the telemedicine centre. Both
store-and-forward and real-time traffic were sent by satellite.

Originally, the equipment at the telemedicine unit in the
field hospital included:

a VSAT terminal,
including a computer for information transfer at a bandwidth of 1.0 Mbit/s
through the satellite system HeliosNet

a satellite phone
system (GlobalStar) to transfer the date to the telemedicine centre at a
bandwidth of 9.6 kbit/s

a videoconference
system

a workstation for
the preparation of medical documents (in digital form)

Figure 25.2 Comunication architecture for
disaster telemedicine

peripheral devices,
including a digital camera, digital videocamera and flatbed scanner.

The telemedicine unit was set up in one of the tents of the
field hospital. The telemedicine unit included work places for videoconferencing
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
GlobalStar communication system, other solutions were sought. A duplex satellite
terminal (AT&T) was installed at the field hospital. It provided a bandwidth
of 12–16 kbit/s for data transfer. It was also less expensive to use than
GlobalTel or INMARSAT.

The satellite link enabled real-time consulting using an
asymmetrical IP connection between the field hospital and the telemedicine
centre. The experience demonstrated that any reliable communication channel with
a transfer rate of 9.6 kbit/s for audio and 56 kbit/s for video could be used as
a request channel (provided that no fast movements needed to be demonstrated to
the remote party). For the response channel, from the telemedicine centre to the
field hospital, a high-rate satellite channel was used.

Experimental use of the telemedicine system began in August
2001. By the beginning of September 2001, operational usage had begun. Between
October 2001 and July 2002, the telemedicine system was operational 24 hours a
day.

Telemedicine in the field hospital

Teleconsultations were based on asymmetrical access, with a
high-speed channel from the telemedicine centre to the field hospital and a
low-speed channel in the other direction. The process included:

(1) preparation of the patient’s data

(2) digitizing any graphical material

(3) forming the request

(4) transfer of the request and digitized medical
documents

(5) real-time consultation.

Receipt of the request and the documents was done by a
coordinator at the telemedicine centre, who checked the quality of the received
data, referred the documents to a consultant, made journal records about the
nature of the consultation and recorded the subsequent consultant’s
recommendation. The scheme included two main phases: a preliminary phase and the
consultation itself.

During the preliminary phase at the field hospital, the patient
documentation was assembled and then sent to the telemedicine centre with the
consultation request using the low-bandwidth communications channel. The
documentation included textual materials and graphical data (e.g. X-ray and
ultrasound images and photographs). The total file size was on average about 3–5
Mbyte per patient.

The second phase was information exchange between the
telemedicine unit of the field hospital and the telemedicine centre in Moscow
using an asymmetrical duplex IP connection. The high-speed channel was used for
transfer of large volumes of information, including multimedia data, from the
Moscow centre to the hospital, while the low-speed channel was used to transfer
relatively limited volumes of information (text, sound, graphical data and,
rarely, video data) from the hospital to the telemedicine centre.

On establishing the connection, the participants decided which
case to start with. The consultant then opened the relevant document on the
screen of a PC in Moscow. Within 5–15 seconds, the same document automatically
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
Board option to show the consultant some part of an opened document (or image).
All the consultant’s comments (audio, text and graphics) were presented at the
field hospital, being transferred via the satellite channel. All the
consultations were recorded, which allowed them to be reviewed afterwards, if
required.

The subsequent course of a consultation was defined by the
situation. Four main variants were possible:

1. A physician could ask another question on the case or
document being discussed.

2. The parties could begin the discussion of a new case.

3. The parties could move to a decision about organizational
matters.

4. The discussion could be stopped.

Clinical aspects of telemedicine support

During a 14-month period ending in 2002, the Children’s Field
Hospital delivered care for over 30 000 patients from 17 districts of Chechnya.
A total of 2700 inpatients were treated. Telemedicine provided valuable
long-term support for the physicians of the field hospital. A total of 179
consultations were conducted (including those in the trial period). The main
result was that over 40% of patients were able to continue their treatment in
the field hospital after the consultation, instead of being transported to other
medical centres. The severity of the conditions of the consulted patients can be
seen from the two lethal outcomes in children for whom urgent consultations were
requested.

During the period of maximum activity (April–June 2002), there
were 64 teleconsultations. The most common consultations (23%) were for children
with trauma and orthopaedic problems. Other groups had multiple birth defects
(six cases) or congenital hip dislocation (three cases). Trauma consultations
were required in six cases: three with complicated ankle fractures, two with leg
wounds due to mine explosions and one with hip pseudoarthrosis.
Teleconsultations in plastic surgery were required for ten patients: three with
cleft palate, three with nerve and tendon trauma, three with burn scar
contracture, and one with post-traumatic alopecia. Neurosurgeons conducted
consultations for two cases of spinal cord hernia, two of cranial hernia and one
of severe cranial trauma. Burn surgeons were consulted about three patients with
severe burns. There were teleconsultations in medical genetics: two cases of
acrocephalosyndactylia, one of Noonan’s syndrome and one of distal acromelia.
Cardiologists were consulted about three patients: two with myocarditis and one
with rheumatoid arthritis. Two consultations were conducted for children with
Hodgkin’s lymphoma. Lung diseases were found in two patients: bilateral
pneumonia complicated by pyopneumothorax and a severe case of bronchial asthma.
Children with portal hypertension and haemocolitis were consulted by a
hepatologist and a gastroenterologist.

A number of medical institutions participated in the
teleconsultations, including six medical research institutes and five large
hospitals. Most of the consultations were conducted by surgical (32) or
paediatric (11) departments of the Moscow Research Institute for Paediatrics and
Children’s Surgery. Ten consultations involved other medical centres of Moscow,
while 11 consultations were conducted in the hospitals of the northern Caucasus.
The results of teleconsultations during the last three months of the hospital’s
work are shown in Table
25.1.

The ages and numbers of patients were as follows:

under 1 year: 11
patients

1–3 years: 8
patients

4–7 years: 9
patients

8–11 years: 10
patients

12–15 years: 9
patients

over 15 years: 8
patients.

Table 25.1 Teleconsultations at the
Children’s Field Hospital

Number of consultations

Recommendations about treatment at the field
hospital

16

Decision for emergency evacuation

8

Decision for elective transfer outside the Chechen
Republic

37

Not completed

3

Total

64a

a Ten
patients had more than one consultation.

During the first months of operation of the telemedicine
system, the age distribution of the patients remained similar.

Of the 54 patients who received teleconsultations, 8 were
transported to other clinics for further treatment: to Moscow (4), Makhachkala
(2) and Stavropol (2). Thirty-seven patients were referred for further
examination and treatment. For 16 patients, the treatment initiated at the field
hospital was changed. Diagnoses were not made in three cases (one patient died
and two consultations were not completed owing to the closure of the hospital).
In terms of performance, there were 35 scheduled teleconsultations, 19 deferred
and 10 urgent. In addition, five emergency consultations were carried out for
critical care.

In summary, telemedicine was highly effective in diagnosis,
choice of treatment and transportation of patients to specialized medical
institutions in a complicated situation due to the military conflict in
Chechnya.

Monitoring during treatment and
rehabilitation

In large-scale disasters, disruption of the regional health
care system and population migration often occur, which lead to difficulties
with patient transfer and medical data recording. Monitoring of the victims
during all stages of medical care is essential. In the Russian system,
information on the health condition of disabled persons is integrated into a
special registry.7 In the USA, the
TRAC2ES system is designed to control the handling of victims evacuated from
military operations.8

The Russian registry was created for centres of disaster
medicine. The users of the registry are health care and social security
authorities. Electronic medical records include personal data of a child, data
about the parents/guardians, life history, diagnoses, treatment, disability and
need for rehabilitation.

The registry was developed to support decision making on the
scale and duration of rehabilitation of disabled children involved in disasters,
to improve the monitoring of their health status, and rational planning and
control of medical and social measures. The database includes:

assessment of
functional capabilities, pathological conditions and social adaptation of the
child

analysis of the
child’s level of disability

control of
rehabilitation at different stages of medical care

assessment of the
nature of the child’s disability

analysis of the
social adaptivity of the disabled child

the need for
prosthetics and special equipment.

Transfer of the information between the centres providing the
care for the victims of disasters takes place through the Internet.

Discussion

The experience of regular telemedicine support for physicians
at the Children’s Field Hospital has demonstrated high efficiency in diagnosis
and treatment, as well as in solving the problems of patient evacuation to
specialized institutions. Unlike conventional mobile military hospitals, the
Children’s Field Hospital provided medical care for a wide range of
diseases.

It is interesting to compare the results of teleconsulting in
the traditional practice of the telemedicine centre and in emergency situations.
According to the data from the Moscow Research Institute for Paediatrics and
Children’s Surgery (2003–2007), transportation from the Russian regions to
Federal (Moscow) clinics was required in 17–37% of the consulted patients,
depending on the type of pathology. In comparison, 58% of the Children’s Field
Hospital patients required transportation to specialized clinics in Moscow and
other regions. This difference can be explained by the greater severity of the
cases and the limited means of diagnosis and treatment at the Children’s Field
Hospital. Nevertheless, the treatment of 42% of patients was continued in the
field hospital, while previously most such patients had to be transported to
other medical institutions. The decrease in the need for patient transportation
due to the use of videoconsultations has been mentioned previously.3,4

Our experience of teleconsultations in Chechnya was somewhat
similar to the situation in Somalia during the United Nations humanitarian
mission in 1993. During the long civil war in that country, the communication
and transport infrastructure was almost completely destroyed. Medical care was
limited, and not all medical specialties were represented on the staff of the US
military field hospital. However, during 13 months of operation in Somalia, 74
cases involving 248 images were transmitted. For several patients, air
evacuation or on-site surgical intervention was avoided because of the
teleconsultations.3

In other humanitarian operations, a teleradiology (DEPRAD)
system was installed by the Georgetown Medical Center to support PrimeTime
III.9,10 In Russia,
specialists of the Russian Antarctic Expedition, the Institute of Influenza of
the Russian Academy of Medical Sciences, the Baltic Technical University and the
company SVIT developed a modular station for diagnosis, the Ambulance-071
YS.11 The station
enables distant delivery of urgent consultations. It enables:

automatic and
semi-automatic recording of electrophysiological, tactile, descriptive and other
data

preparation and
transfer of documents

automatic and
semi-automatic processing and analysis of the received data

expert assessment of
patients’ functional status

provision of
recommendations for correction of patients’ functional status based on expert
assessment

monitoring of
patients’ functional status.

This station is used in Antarctica. The results obtained
demonstrate the value of the approach,12 which can
also be employed in emergency situations.

Although in Chechnya the satellite system provided a relatively
simple and reliable connection, this was not mobile communication in the full
sense of the term. Recently, fully mobile satellite equipment has become
available, and has been used successfully in military and disaster medicine. For
real-time consultations, a personal digital assistant (PDA) equipped with a
digital camera and telephone has been suggested.13 Wireless
communication for PDAs enables communication between several sites and the
centre in the case of multiple victims.14 Such a
situation occurred occasionally in Chechnya, when multiple patients were
admitted to the field hospital. A full-scale decision support system for a field
hospital could be based on a WiFi network. A wireless network would allow data
transfer from the patient’s bed, as well as interactive videoconferences
directly from the operating room or intensive care unit. Mobile telemedicine of
this kind would have been useful during our work in the field hospital.

Limited on-site data collection was possible in the field
hospital using a mobile ECG recorder. The American system PrimeTime allowed US
physicians to establish video telemedicine sessions anywhere within a war zone
and to connect with medical centres in the USA.4 Direct
interactive contacts with rescue teams, using mobile telemedicine systems, by
remote consultants would significantly increase the efficiency of decision
making in emergency situations.

Prolonged and severe emergency situations often require special
provision for psychological support and rehabilitation of the victims. Such
support can be provided through telepsychiatry,15 although this
was not available in the case of children treated at the field hospital.

In summary, the challenges faced during the implementation of
the telemedicine system in Chechnya were:

insufficient
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
intra-hospital telemedicine system in the Institute for solving medical problems
during videoconsultations

satellite
limitations precluding observation of the dynamics of patients’ movements during
videoconsultations.

Future disaster telemedicine in Russia

To increase the efficiency of teleconsultations provided for
Russian field hospitals, the following are required:

organization of
round-the-clock services in the telemedicine centre

availability of
sufficient medical institutions to provide teleconsulting in emergency
situations

development of the
requisite national telemedicine infrastructure and creation of local information
systems in disaster medicine centres.

In 2006, successful training exercises of the disaster
medicine service were conducted under field conditions using a new, less
expensive mobile telemedicine system. This accords with the government’s concept
of developing telemedicine technologies in the Russian Federation,16 which
provides transition to a new level of information support in disaster
telemedicine to enable efficient control over medical care and consultative
support for medical teams in emergency situations.

The process of equipping field hospitals with mobile
telemedicine units continues. A small Q-band satellite station, developed by Web
Media Service, successfully passed testing in 2007. This allows data transfer at
128 kbit/s, i.e. at almost the same rate as via ground communication lines.5 Mobile
telemedicine units have been developed for the needs of space medicine.17 During the
missions of the US Space Shuttle, a mobile set of medical devices for ear, nose
and throat and skin imaging, electrocardiography, blood oxygen saturation level,
and heart and lung sound auscultation was used.18 Similar
equipment might be used by mobile teams for disaster medicine.

Conclusion

Telemedicine was highly effective in managing paediatric
patients at the field hospital in a complicated situation due to the military
conflict in Chechnya. The Russian satellite system HeliosNet provided reliable
communication, and was not prohibitively expensive. The cost of the equipment in
the telemedicine unit of the field hospital was approximately US$5000 in 2001.
The cost of operating the satellite system (2008 prices) was approximately
US$270 per month (for 10 videoconferences and 15 store-and-forward
consultations). In 2001–2002, the estimated cost was some three to four times
higher. The costs of the telemedicine work in Chechnya were met by charitable
donations from business concerns.

Telemedical support for physicians working in areas of natural
disasters, local military conflicts or humanitarian disasters would increase the
level of urgent and specialized medical care. An important factor in realizing
this will be the presence of a satisfactory telemedicine infrastructure in
neighbouring regions and appropriate organization to monitor patients’ health
during their transportation to hospitals or other specialized medical
centres.

Further reading

Hogan DE, Burstein JL. Disaster Medicine, 2nd
edn. Philadelphia: Lippincott Williams & Wilkins, 2007.

Llewellyn CH. The role of telemedicine in disaster
medicine. J Med Syst 1995; 19: 29–34.

Simmons SC, Murphy TA, Blanarovich A et al. Telehealth
technologies and applications for terrorism response: a report of the 2002
coastal North Carolina domestic preparedness training exercise. J Am Med
Inform Assoc 2003; 10: 166–76.

Teich JM, Wagner MM, Mackenzie CF, Schafer KO. The
informatics response in disaster, terrorism, and war. J Am Med Inform
Assoc 2002; 9: 97–104.

References

1.
NASA satellite aids in Mexico City rescue effort. NASA News Release
1985; 85: 133.

2.
Houtchens BA, Clemmer TP, Holloway HC et al. Telemedicine and international
disaster response. Medical consultation to Armenia and Russia via a Telemedicine
Spacebridge. Prehosp Disaster Med 1993; 8:
57–66.

3.
Crowther JB, Poropatich R. Telemedicine in the US Army: case reports from
Somalia and Croatia. Telemed J 1995; 1: 73–80.

4.
Calcagni DE, Clyburn CA, Tomkins G et al. Operation Joint Endeavor in Bosnia:
telemedicine systems and case reports. Telemed J 1996;
2: 211–24.

5.
Ehrlich AI, Kobrinsky BA, Petlakh VI et al. Telemedicine for a Children’s Field
Hospital in Chechnya. J Telemed Telecare 2007; 13:
4–6.

6.
Kobrinskiy BA, Matveev NV. Teleconsultations at the Moscow Research Institute
for Paediatrics and Children’s Surgery. J Telemed Telecare 2006;
12(Suppl 3): 110.

7.
Kobrinsky BA. Database of disabled children injured in disasters. Prehosp
Disaster Med 1997; 12(Suppl 1): 90–1.

8.
Cook R, Woods D, Walters M, Christoffersen K. The cognitive systems engineering
of automated medical evacuation scheduling and its implications. In:
Proceedings of the Third Annual Symposium on Human Interaction with Complex
Systems, 25–28 August 1996: 202–7.

9.
Levine BA, Cleary K, Mun SK. Deployable teleradiology: Bosnia and beyond.
IEEE Trans Inf Technol Biomed 1998; 2: 30–4.

10. Mun SK, Levine B,
Cleary K, Dai H. Deployable teleradiology and telemedicine for the US military.
Comput Methods Programs Biomed 1998; 57: 21–7.

11. Liaskovik AT,
Senkevich YuI, Chasnik VG, Yaschin AV. [The concept of health services in
regions with low population density and computer stations in the structure of
advisory help.] Inform Technol Publ Health Serv 2001;
8/9: 28–9 (in Russian).

12. Senkevich YuI.
[Development of information technologies for medical maintenance of polar
expeditions.] Ukr J Telemed Med Telematics 2004; 2:
22–8 (in Russian).

13. Garshnek V, Burkle
FM Jr. Applications of telemedicine and telecommunications to disaster medicine:
historical and future perspectives. J Am Med Inform Assoc 1999;
6: 26–37.

14. Grasso MA.
Handheld computer application for medical disaster management. AMIA Annu
Symp Proc 2006: 932.

15. Mack D, Brantley
KM, Bell KG. Mitigating the health effects of disasters for medically
underserved populations: electronic health records, telemedicine, research,
screening, and surveillance. J Health Care Poor Underserved 2007;
18: 432–42.

16. [Concepts of
Development of Telemedical Technologies in the Russian Federation.] Moscow,
2001 (in Russian).

17. Grigoriev AI,
Orlov OI. [Telemedicine in Russia.] Vestn Ross Akad Med Nauk 2004;
10: 30–5 (in Russian).

18. Crump WJ, Levy BJ,
Billica RD. A field trial of the NASA Telemedicine Instrument Pack in a family
practice. Aviat Space Environ Med 1996; 67:
1080–5.

26 Web-based paediatric oncology information and
registries: An international perspective

André Nebel de Mello

Introduction

Cancer registration can trace its origins to the first decade
of the 20th century, when surveys measuring the point prevalence of cancer were
reported from a number of European countries. Permanent registration systems
were implemented in Hamburg in 1926, Mecklenburg in 1937 – both discontinued
during World War II – Massachusetts in 1927 and Connecticut in 1935. The first
national survey on a significant sample of the US population was carried out in
1937–38. By the end of the late 1940s, population-based registries and the
survey system (10 metropolitan areas in the USA) had solved most technical
problems, and the concepts have been widely used ever since.

The first experiences of using nominal rosters of cancer
patients for analytical studies or for linkage with other registries occurred in
the late 1940s. Epidemiologists working on those registries realized that
incidence and mortality statistics should not be considered as alternatives: the
latter are generally valuable, but the former can also provide information on
treatment and follow-up. An expert report for the World Health Organization
(WHO) concluded that:1

the collection of accurate statistics of cancer
incidence and mortality among different … people and … countries may lead to
important indications for … studies … [whereas] the information [provided by
mortality statistics] … is becoming increasingly inadequate, owing to growing
numbers of patients successfully treated and thus not registered in the
statistics of death [Thus], we … make the following suggestions:

1. Great benefit would follow the collection of data
about cancer patients from as many different countries as possible.

2. Such data should be recorded on an agreed plan so as
to be comparable.

3. Each nation should have a central registry to arrange
for recording and collection of such data.

4. There should be an international body whose duty
should be to correlate the data and statistics obtained in each country.

In 1950, the WHO created a Subcommittee on the Registration of
Cases of Cancer. Within a few years, the Nordic countries, the UK and Canada
launched programmes that led to national coverage of registration. The model
followed in the USA was different: no national coverage was attempted, and
instead a number of county- or state-based registries were created. The surveys
on samples of the population were converted in the Surveillance, Epidemiology
and End Results (SEER) programme, which produces incidence and survival rates
broken down by ethnic groups.

The first worldwide analysis was published in 1966 with the
title Cancer Incidence in Five Continents.2 This marked the
beginning of a series of publications appearing at five-year intervals,
supervised by the International Union Against Cancer (UICC), the International
Agency for Research on Cancer (IARC) and the International Association of Cancer
Registries (IACR). The data were not simply and passively accepted, but were
revised and controlled.2–4 Two by-products
of this strategy have been a worldwide standardization of the activity of
registration and the provision through the IARC of technical advice to
developing cancer registries.

In 30 years, the number of countries with cancer registries
nearly doubled and there was a fivefold increase in both the number of active
cancer registries and the total population served by registration (Table 26.1).4 These increases
were concentrated in industrialized countries, whereas in developing countries
there was a substantial decrease in registration, attributable to the political
and economic situation,5 leading to the
inequalities reported in Table 26.2 and
displayed in Figures
26.1 and 26.2.

In the early 1980s, it became apparent that population-based
survival rates of cancer patients could be used as an indicator of the quality
of cancer care in a given area and that registries could play a major role. The
first large-scale international cooperative study, the EUROCARE project,
published its first results in 1995,6 and aimed to
increase cooperation between epidemiologists and clinicians in continental
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
databases and electronic data transfer. The use of the Internet is thus a
natural evolution. Most registries

Table 26.1 Coverage in eight volumes of
cancer incidence in five continents4

Volume

Year of publication

Registries

Populations

Countries

Period (approximate)

1

1966

32

35

29

1960–62

2

1970

47

58

24

1963–67

3

1976

61

79

29

1968–72

4

1982

79

103

32

1973–77

5

1987

105

137

36

1978–82

6

1992

138

166

49

1983–87

7

1997

150

183

50

1988–92

8

2002

186

214

57

1993–97

Table 26.2 Coverage by cancer
registries around 19923

Area

Number of registries

Population served by registries
(millions)

Total population (millions)

Percentage of population
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
Results programme, covering approximately 10% of the population.

bNorway,
Switzerland and Iceland.

Figure 26.1 Individual countries: coverage by
cancer registries 19974

were publishing information online in the early 1990s, and
many have already switched to web-based data entry interfaces.

Cancer in children

Cancer is very rare in childhood – it is predominantly a
disease of elderly people. In industrialized countries, about 1 in 200 (0.5%) of
all cancers occurs in children aged under 15 years. The incidence rate is
typically 110–150 per million children per year, equivalent to a risk of around
1 in 500 during the first 15 years of life. Nevertheless, cancer accounts for
about 20% of all deaths in children aged 1–14 years, making it the second most
common cause of death in children in most of the world (the first is death

Figure 26.2 Cancer registry coverage:
geographical coverage (percentage of total population) of cancer registries by
region4

due to external causes) and the most common cause of death by
disease, with the exception of Africa and some Asian countries.

Cancer in children is often not preventable. Prenatal factors
are considered to affect the incidence of tumours in children under the age of 5
years. It is generally accepted that cancer results from genetic changes. The
carcinogenic process in children is much shorter than in adults. Childhood
cancer incidence rates are highest during infancy, so it is reasonable to assume
that many paediatric cancers result from aberrations in early developmental
stages and in utero.

An increased risk of childhood cancers has been reported to be
associated with certain genetic conditions or syndromes such as chromosomal
abnormalities, DNA-repair disorders, congenital anomalies, hereditary immune
deficiency states and other hereditary syndromes. Racial differences have been
observed in childhood tumours, even within industrialized countries. A peak
incidence in acute lymphoblastic leukaemia (ALL) usually occurs between the ages
of 2 and 3 years in white American children and from 1 to 4 years in European
children, but not among African–Americans. Ewing’s sarcoma is another
well-established example of a cancer with racial differences, with the lowest
incidence rate in black children (African or American).7

Overall, childhood cancer is about 20% more common among boys
than among girls. The male predominance is greater for lymphomas, liver tumours
and nasopharyngeal carcinoma, and less marked for leukaemia, brain tumours,
neuroblastoma and soft tissue sarcomas. Boys and girls have a similar incidence
of retinoblastoma and Wilms’ tumour. The incidence in girls is only greater for
extragonadal germ cell tumours, malignant melanoma, and adrenal cortex and
thyroid carcinomas.

There are also marked variations between populations in the
incidence of specific types of childhood cancers. Nearly one-third of all
childhood neoplasms are leukaemias. International variation occurs in the rate
of ALL, and the higher incidence of ALL in early childhood has usually been
associated with higher levels of socioeconomic status, suggesting that
environmental factors play a role. Although a considerable
number of environmental or exogenous factors have been suggested as risk factors
for childhood cancers, only a few have been proven, and they are mostly
infectious agents, including Epstein–Barr virus, hepatitis B virus, human
immunodeficiency virus and human herpesviruses. These infections are probably
responsible for the international variation in the incidence of some childhood
cancers, such as lymphoma, nasopharyngeal carcinoma, hepatic cancer and Kaposi’s
sarcoma. In addition, some parasitic infections have been implicated,
particularly malaria in tropical Africa, acting as a cofactor for Burkitt’s
lymphoma, and schistosomiasis in Egypt, causing bladder cancer.7

The EUROCARE collaboration has revealed considerable variation
in survival between European countries,8 but, unlike
those for adults, the survival rates of children with cancer in Western Europe
are similar to those in the USA.9 In the
developing countries, where 80% of the world’s children with cancer live, they
are often diagnosed too late or not diagnosed at all and, without access to
life-saving treatment, more than one in two of these children diagnosed with
cancer will die.

The increases in survival rates occurred during a period of
great technical advances in childhood cancer treatment, but there were also
major changes in referral patterns. At one time, most children with cancer were
treated at local hospitals, there were few specialists in paediatric oncology,
and opportunities for participation in collaborative studies of treatment were
limited. Treatment has gradually become more centralized, and more children have
been entered in national and international clinical trials and studies.10 For several
types of cancer, survival has been found to be higher among children who were
treated at specialist centres or who were entered in national or international
clinical trials.

As a consequence of the improved survival rates described above,
the number of adult survivors of childhood cancer has increased substantially
(Figure 26.3). In
1961, there were only about 15 survivors in Britain aged 30 or above, and none
above 40, while in 2000, there were over 26 000 survivors, of whom almost 7000
(about 25%) were aged over 30 years. In 1971, there were 5500 survivors, with
over 1000 above age 20 and 100 aged 30 or above. In 1981, there were nearly 3000
survivors aged 20 and above, but fewer than 100 of them were aged over 40 years,
while in 2000, almost 2500 (almost 20% of those aged 20 and above) were aged
over 40 years. Eventually, more than 1 in 1000 adults of all ages will be
survivors of childhood cancer.11

Cancer information on the Internet

The Internet has become an increasingly common source of
medical information for patients with cancer. For example, over 50% of adults in
the USA have searched online for health information and 80% of all US Internet
users have searched online for at least one major health topic.12

Use of the Internet to access cancer information is related to
age (being more common in those aged under 60 years), higher income, higher
education and being white.13 However,
there has been little research on Internet cancer information use among minority
racial/ethnic groups in the USA and Western Europe, or in populations of
developing countries, or on the appropriateness of the websites available
to

Figure 26.3 Number of (past or current)
childhood cancer patients (by age group) alive at the end of each year in the
UK, 1961–200011

such populations.12,13 Many cancer
organizations have created patient-centred web-sites to provide comprehensive
information about specific cancers, but most of the information available is in
English, limiting its use for non-speakers.

A study of cancer patients’ self-reported attitudes to the
Internet came to the following conclusions:14

Patients are
comfortable giving as well as receiving cancer information and support online;
they are also comfortable in evaluating it.

They are interested
in the experiences of other patients and derive benefit by interacting with them
directly, through venues such as discussion boards and email lists or,
indirectly, through activities such as reading biographies.

They perceive better
outcomes after using online health information and support.

Cancer patients have
a certain level of trust in online information, primarily for information
obtained from established reputable sources such as studies in journals and
advice given by medical doctors; they also trust websites endorsed by health
authorities.

They are confident
in their ability to evaluate information, including comprehension of research
reports.

They display a
healthy scepticism when presented with the option of divulging personal health
information. However, some patients are willing to provide email addresses and,
if they receive personalized information, they are comfortable in disclosing
their identity.

Another study evaluating cancer patients’ and caregivers’
interests about the Internet indicated that most patient and caregiver
respondents were interested in Internet-based cancer-related services such as
information related to treatment (80%), conversations with physicians via the
Internet (70%) and online support groups (65%). In addition, respondents
reported that they would be likely to use such services (70%) and were
interested in home health care services delivered via PCs (60%). No differences
were found between ethnic groups, geographical settings or patient status
(patient versus caregivers) on these variables. Minorities, older individuals
and less-educated individuals were less likely to have knowledge of and to have
used the Internet.15

In the last few years, there have been efforts to improve online
cancer information quality. Good examples include the International Cancer
Information Service (established in 2001), the American Society of Clinical
Oncology (ASCO) website People Living with Cancer (launched in 2002) and the
Oncopediatria.org portal16 (launched in
2004).

Online information about childhood cancer and web-based
initiatives on the subject are less common, even in industrialized countries.
This may be a reflection of the lower incidence of the disease on this age group
or may be a misconception about the similarity of the disease between adults and
children.

International initiatives

While most international initiatives that focus on paediatric
oncology are from cooperative groups in Western Europe or North America, there
are some good examples that focus on developing countries. These include the
following.

SLAOP

The Latin American Society of Paediatric Oncology (SLAOP)
provides information for general paediatricians and paediatric oncologists by
publishing articles, news and presentations in paediatric and evidence-based
oncology on its website.17 SLAOP is also
developing a Latin-American Paediatric Oncology Registry, and has launched the
Latin-American Paediatric Promyelocytic Leukaemia Registry, a web-based registry
available through its website.

St Jude Children’s Research Hospital

The St Jude’s Hospital in Tennessee has an International
Outreach programme with the object to improve the survival rates of children
with catastrophic illnesses worldwide, through the transfer of knowledge,
technology and organizational skills. This is achieved through twinning
programmes and through two websites: Cure4Kids18 and
POND4Kids.19

The Cure4Kids website was launched in October 2002 and provides
medical education for physicians, nurses, scientists and health care workers in
countries with limited resources who treat children with catastrophic diseases.
The main functions are:

online education
about catastrophic childhood illnesses

collaborative work
spaces for document sharing and online meetings; several countries, including
Brazil, Lebanon, Morocco, Guatemala, El Salvador, Honduras and Mexico,
participate in these international meetings

access to
consultation and mentoring by staff of St Jude’s Hospital

technology and
training for better management of patient information.

The core of Cure4Kids is an online digital library of
reference material, a discussion area for exchange of advice and information
between doctors, and access to online seminars and lectures. The website is also
used to host live meetings via web conferencing (video and voice-over-IP).18 In September
2007, there were 11 490 registered users in 157 countries.

The Paediatric Oncology Networked Database (POND4Kids) is an
online, multi-lingual database for paediatric haematology/oncology patients. The
aim is to improve the care of paediatric oncology patients in countries with
limited resources by the exchange of information and experience among
oncologists who practise in a similar medical environment. The major objectives
of POND4Kids are to:

store patient data
for easy retrieval and analysis in a way that ensures quality control

provide uniform data
collection to facilitate comparison of information among centres

provide a single
tool for data storage and retrieval to facilitate training of data managers

develop a
multilingual online system that is available to users at no cost.

POND4Kids is hosted on a web server and is divided into
several virtual sites. Clinicians at different POND4Kids sites can share
information about individual patients, groups of patients with the same disease
or all patients. Shared records have personal identifiers removed, but retain a
unique POND identification number. Information sharing facilitates analysis by
colleagues of specific diseases treated at multiple centres in low-income
countries. Information can also be shared with international experts to assist
with analysis and quality improvement.

Ten centres in nine countries (seven in Central America, two in
Morocco and one in Jordan) currently use the POND4Kids website. In the first two
years of operation (2004–2006), over 9000 patient records were entered into
POND4Kids.20 Many
paediatric oncology services in developing countries have adopted these websites
for registering and discussing their patients, instead of developing a website
of their own.

SIOP

The International Society of Paediatric Oncology (SIOP)
provides information for professionals by publishing best practice guidelines on
its website21 and by making
available the SIOP educational books and conference lectures on the Cure4Kids
website.

International agencies

The IARC publishes the International Classification of
Childhood Cancer,22 currently in
its third revision, and adopted worldwide in childhood cancer registries. The
IARC also publishes the Cancer Incidence in Five Continents report that
is updated every 5 years,2–4 and publishes
cancer registration manuals and papers on the social inequalities of cancer.
Almost all publications are available at the agency’s website.23

The IACR has designed a suite of computer programs to meet the
needs of population-based cancer registries in developing countries. The
software is in its fourth version, named CanReg4, and can be used in a
Windows-based network environment. It is available in English, Spanish, French,
Italian, Turkish, Chinese, Thai, Arabic and Farsi. The software is free and is
available at the IACR website.24

Twinning programmes

Twinning programmes are partnerships between institutions in
industrialized countries and those in developing countries with the goal of
improving survival rates among children with cancer. These programmes have
reduced the rates of abandonment of treatment, relapse and death due to toxic
effects of treatment. The investments that they have attracted have led to
improvements in access to treatment and hospital infrastructure. The best
results have been obtained when local oncologists were recruited as programme
directors and asked to promote the idea of a strong paediatric oncology unit
among their peers and to coordinate the training of providers.25

Most twinning programmes have a telemedicine component, usually
videoconferencing, web-based case report forms or continuing medical education
(CME). Examples are the programme between the King Hussein Cancer Centre (KHCC)
in Amman, Jordan and the Hospital for Sick Children in Toronto, Canada in
paediatric neurooncology26 and the
MISPHO Consortium initiatives in Central America.27

Online childhood cancer registries in developing
countries

Although online cancer registries have became more common in
the last few years, only a few childhood cancer registries have been implemented
by developing nations, and even fewer with a web-based interface. Examples
include the following.

Brazil

The Oncopediatria portal was launched in 2004 and is a
web-based system that offers services and information on paediatric cancer.16 It maintains
a secure online patient registry, a web-based bone marrow transplant registry
tool and online cooperative treatment protocols for the Brazilian Society of
Paediatric Oncology. It is part of a national telemedicine network of
universities, research institutes and medical institutions that has been
established in Brazil to support distance medical practice in oncology, called
ONCONET.28–30

The main objectives are:

to improve the
information flow in research programmes and cooperative treatment protocols

to disseminate and
harmonize treatments through the use of protocols that produce the highest cure
rates

to establish the
basis for a national demographic record of paediatric cancer

to make available
statistics, demographic data and analyses of the results of treatments using the
protocols.

The system is hosted on clusters of computers. It is based on
open-source software, designed to provide high performance, fault tolerance and
high availability.

Some of the Brazilian Society’s cooperative protocols have been
implemented. The first online treatment protocol targets the treatment of
high-risk neuroblastoma.29 A protocol
for multiple subtypes of non-Hodgkin’s lymphoma and another for paediatric bone
marrow transplantation30 are also
available. In these protocols, much of the data is textual, but parts of the
record are medical images. The system allows images to be stored in several
common image formats such as JPEG and DICOM (digital imaging and communications
in medicine).

In June 2007, there were 310 registered paediatric oncologists
from 53 out of 58 treatment centres in 23 states; there were 7000 registered
patients.

Argentina

The Argentinean Paediatric Oncology Hospital Registry (ROHA)
was established in 2000 using the WHO/IARC standards for cancer registration. It
registers children with solid and haematological malignancies. Registered data
can be consulted online at the ROHA website.31

Eastern Europe

The Automated Childhood Cancer Information System (ACCIS) is a
project developed by the IARC and supported by the European Commission, with the
objectives of collecting, presenting, interpreting and disseminating data on
childhood cancer in Europe. The ACCIS database contains some 160 000 records on
childhood and adolescent cancer cases registered over the last 30 years in 78
European population-based cancer registries, covering 2.6 billion person-years.
The Eastern European countries with information stored in this database are
Belarus, Estonia, Hungary, Slovakia, Slovenia and Turkey.32

Belarus

The childhood population-based cancer registry of the Republic
of Belarus was created in August 1999 and registered cases retrospectively to
the year 1989. It was created as one of the international health care
initiatives after the Chernobyl disaster. Consolidated data can be consulted
online at the registry’s website.

Serbia

The Childhood Cancer Registry of Central Serbia was created by
the Institute of Public Health of Serbia ‘Dr Milan Jovanović Batut’. The
registry has consolidated data from 1997 to 2005, available online at the
Institute’s website.34

India

The non-governmental organization South Asian Marrow
Foundation –‘Matchpia’ – has a web-based initiative named Project India,35 which
launched the United South Asian Donor Registry (USADR), an online bone marrow
donor registry. This is probably India’s largest registry. The foundation also
performs matching between donors and patients, including those with paediatric
cancer.

Singapore

The Singapore Childhood Cancer Registry (SCCR) was established
in September 1997 under the auspices of the Paediatric Oncology Group
(Singapore), and registers all children, aged 18 years and below, who have been
diagnosed with haematological or solid malignancies. Physicians voluntarily
register the patients through a secure web-based form on the registry’s
website.36

Paediatric oncology web-based information

Most childhood cancer information websites from developing
countries belong to parents’ associations and support groups. The information
content on these websites is usually focused on the activities and objectives of
the organization, and there is limited information on the most common types of
childhood cancer and only general information about therapy options. For more
complete information, there are usually links to North American, local
governmental or international websites. There are a few exceptions to this rule,
which are mentioned below.

Government websites usually offer general cancer information
targeting adults with cancer. In Brazil and South Africa, local childhood cancer
medical associations and some treatment centres have websites with more detailed
cancer information for parents and professionals.

Latin America

The Brazilian National Cancer Institute (INCA) has a
subsection of its website37 dedicated to
childhood cancer information for parents and professionals, including
statistics, treatment guidelines, early detection and an overview of the cancer
types. There are also many cancer-related publications available for
download.

Over 20 childhood cancer support groups in Brazil offer websites
with disease information for the general public. For example, the Brazilian
Lymphoma and Leukaemia Association (ABRALE) has a website38 that offers
detailed information on leukaemia and lymphoma for parents and health
professionals. It has a subsection dedicated to cancer in
children. Distance learning tools, legal support information, forums and
downloadable information booklets are also available.

The Oncopediatria website16 from Brazil
has an open information section for parents and health professionals that
includes cancer information, articles, summaries of treatment studies and a
biweekly newsletter.

The Organization of Parents of Children with Cancer and Related
Diseases (OPNICER) from Colombia offers on its website39 legal
information for parents and a roadmap of the challenges faced by children and
parents from cancer diagnosis to cure.

The Natalí Dafne Flexer Association from Argentina offers
detailed information for parents, patients, volunteers and professionals, as
well as articles, downloadable booklets and other childhood cancer resources on
its website.40

Eastern Europe

The Romanian Association of the Parents with Cancer and
Leukaemia Ill Children (P.A.V.E.L.) has an information section on its
website41 with
diagnostic information, nutritional orientation and support information for
parents and professionals, as well as best practice guidelines for doctors.

Asia

The Children’s Cancer Foundation of Singapore offers detailed
information and resources for parents and teachers, and downloadable booklets in
three languages on its website.42

Africa

The South African Children’s Cancer Group (SACCSG) has a web
portal43 with
information for general practitioners on early diagnosis of cancer. It also
provides information and support for parents, in partnership with the Childhood
Cancer Foundation of South Africa.

Conclusion

The field of oncology is vast, and knowledge is increasing
rapidly. The main gap between industrialized and developing countries in this
field is not the availability of the newest medications; rather, it is
differences in the information about the types of cancer afflicting the
population and on the best ways to treat them. The increases that have occurred
in the cure rate of children with cancer are mainly due to the use of better
combinations of existing drugs, rather than the use of new ones.

The Internet offers great potential for bridging the knowledge
gap. The instant availability of up-to-date information for medical
practitioners can increase the speed of diagnosis. The availability of accurate
cancer profiles in each country, resulting from work done by the national
registries, can guide professionals to the most likely diagnosis, and help governments and private initiatives to
direct their resources to treat cancer more effectively.

Acknowledgements

I thank Adilson Yuuji Hira, Marcelo Knörich Zuffo and the
staff of the Telemedicine and Bioinformatics Unit from the Laboratory of
Integrated Systems of the University of São Paulo for their advice and
support.

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27 E-health in international networks: New opportunities
for collaboration

Shariq Khoja and Azra Naseem

Introduction

In recent years, there has been a substantial reduction in the
availability of health professionals in developing countries, which has been
accompanied by a rise in the demand for high-quality health care. This
combination has forced health care institutions to collaborate and share their
resources to provide comprehensive, high-quality and accessible health care at a
reasonable cost.

The Aga Khan Development Network (AKDN) is an international
network that comprises several institutions, working for the development of poor
nations in Asia and Africa, in social development (health, education and
housing), disaster relief, economic development and preservation of cultures.
Most of the development in the health sector is carried out through the Aga Khan
Health Services (AKHS) and the Aga Khan University (AKU).

The AKHS operates a private, not-for-profit health care system.
It includes more than 200 health care facilities, including 9 hospitals. The
AKHS provides primary health care and curative medical care in Afghanistan,
India, Kenya, Pakistan and Tanzania. It also provides technical assistance to
governments in health service delivery in Kenya, Syria and Tajikistan. The
community health programmes of the AKHS are designed to reach vulnerable groups
in society, especially childbearing women and young children, through low-cost,
proven medical technologies. Experience has confirmed the efficacy of these
services in improving health status and their cost-effectiveness.1

The AKU is an international university with 11 teaching sites in
8 countries: Afghanistan, Kenya, Pakistan, Tanzania, Uganda, Syria, Egypt and
the UK. The AKU is also associated with university hospitals in Pakistan and
Kenya. The largest of these is the Aga Khan University Hospital, Karachi (AKUH,
K), which has 542 beds and provides services to 38 000 inpatients and 500 000
outpatients annually. The Aga Khan University Hospital, Nairobi (AKUH, N) also
provides tertiary- and secondary-level health care services in East Africa.

The extent and scope of the AKDN’s health activities require
considerable networking between the different agencies. For decades, this
networking was maintained by traditional means of
communication and extensive travel by health professionals between various
institutions. In the last five years, some institutions within the AKDN have
begun to adopt information and communication technology (ICT) to enhance their
educational, research, information exchange and health provision activities. All
these activities can be grouped under the umbrella of ‘e-health’. Although,
e-health in the AKDN is still in its infancy, activities directed towards
learning, care provision and information exchange have already begun.

Benefits of e-health

Institutions within the AKDN have shown interest in adopting
e-health to enhance their education, research, information exchange and health
provision activities. The following benefits are anticipated:

Improved
clinical care. An e-health network will encourage rapid adoption of
e-health applications that will facilitate improved clinical care. For example,
common access to clinical practice guidelines will aid standardization of care,
and use of specific e-health applications such as teleconsulting will raise the
confidence and skills of clinicians in rural and remote locations.

Greater
knowledge sharing. An e-health network, with an emphasis on knowledge
rather than simply information, will ensure greater knowledge sharing.

Greater scope
for research. Interaction through an e-health network will enhance
partnerships and sharing of resources, which will in turn contribute to a
greater scope for research.

Greater capacity
building. Capacity building, in particular, will be strengthened through an
e-health network. Institutions with a common focus (within or outside the AKDN)
could join and contribute their respective skills and experiences.

Administrative
resilience. A successful e-health network will strengthen administrative
resilience.

Although, e-health in the AKDN is still at its beginning,
activities directed towards learning, care provision and information exchange
have already begun. These activities are described briefly below.

Learning

The AKU and the AKHS have worked in collaboration to develop
asynchronous learning for medical and nursing students, and to develop
continuing medical education (CME) for health care providers. Efforts are also
being made to introduce the use of live e-learning software at the AKU. Two
distinct instructional settings can be identified where ICT is used for
learning:

In
technology-enhanced classroom teaching, teachers use PowerPoint slides to
illustrate concepts in their face-to-face lectures and later distribute them to
the class by email. Students submit word-processed assignments for
assessment.

In distance
education, nurses and other health care providers, particularly in East Africa,
complete formal educational programmes at remote locations. In such programmes,
email messages are used, together with online discussions via video-conferencing
or through web-conferencing.

There is also blended or distributed learning as a
combination of these two approaches, with an increasing emphasis on the use of
online learning technologies. E-learning in blended courses can take many
different forms. Examples include:

repository of
learning objects

web-based virtual
learning environment

a database of
Internet links

synchronous
e-learning through Elluminate

remote access for
health professionals.

Repository of learning objects

In 2003, a searchable Library of Images was developed at the
AKU. The aim was to create a repository of learning objects, which could be
searched, reused and shared over the network to avoid duplication of effort in
developing learning resources. Initially, the pictures and other images were
digitized and catalogued with appropriate metadata information. Later,
registered users, including students, faculty members, clinicians, residents and
allied health staff, were also able to contribute images with associated
metadata information. A committee was set up to review each contribution in
order to ensure its relevance and accuracy and to avoid redundancy and
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
EEG charts, animations, and video-clips) are available2 for AKU faculty
members, staff, students and other health care providers through the
Internet.3 The images from
the Library of Images are used in class lectures, presentations and assignments,
and are also linked with course materials available via AKUMed. The material is
shared with other institutions within the network with access to the AKU
intranet.

Web-based virtual learning
environment

The need for a system that would allow access to course
information, lecture notes and a discussion forum for students of the MB BS
programme was felt by the faculty at the AKU Medical College, and led to the
development of an asynchronous virtual learning environment (VLE) called AKUMed.
VLE refers to the components in which learners and tutors participate in online
interactions of various kinds, including online learning.4 With growing
numbers of faculty members using AKUMed, its popularity has increased, and
similar systems are being designed for the School of Nursing and the Department
of Community Health Sciences, in order to offer courses with strong online
components.

Database of Internet links

A portal with links to websites on various health-related
topics has been developed. The portal is accessible through the AKU intranet and
is regularly updated. It is used by the students and faculty members of the
AKU.

Synchronous e-learning

Elluminate Live has been introduced as a live e-learning tool
in all campuses of the AKU. It was chosen because it can be used from areas with
low-bandwidth Internet connections. The software allows recording, and permits
sharing of audio, video, text and image data. Elluminate also allows the use of
white board and document sharing, to facilitate online discussions. Finally, it
supports transfer of medical data and live teleconsultations, which may be an
important feature for the AKU. Several pilot projects have been initiated in
different campuses of the AKU in Asia, Africa and Europe. A summary of the pilot
projects at each campus is given in Table 27.1.

Remote access for health
professionals

Remote access for health staff was conceived as a structured
educational programme for health care providers, which focused on problem-based
learning via a web-based distance learning system. The purpose of this programme
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
in Tanzania. A phased approach was planned, followed by the introduction at
other AKHS institutions. The web interface allows multiple threaded discussions
based on specific interest areas, including sub-specialties such as paediatrics,
cardiology and nursing. This makes it possible for health professionals in North
America to share journal articles, PowerPoint presentations, quality assurance
tools and weblinks to various resources with staff in Tanzania. The long-term
goal is to make this method of learning accessible to health care professionals
associated with the AKHS in East Africa or with other private and public sector
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
communication between doctors working at the Aga Khan Hospital in Dar-es-Salaam
and clinicians in North America. The goal was to create partnerships that would
improve the delivery and quality of health care in the region. The pre-defined
turnaround time for queries was 24–72 hours.

Table 27.1 Summary of the pilot
projects at each AKU campus

AKU-IED, Karachi

AKU-CHS, Karachi

AKU-ISMC, London

AKU-SON, Karachi and AKU-EA,
Nairobi

Objective

Understand changing needs and plan accordingly

Look into all possible options where Elluminate will be
useful

Gain confidence with Elluminate

Pilot Elluminate use for continuing education courses
offered from AKU-SON Karachi to East Africa, Afghanistan and
Egypt

Areas

Distance education courses
Meetings with Professional
Development Centres
Other uses by faculty members in teaching-related
activities

Work in progress (WIP)
Online CME course with East
Africa
Web seminar on health problems in Pakistan
Postgraduate
education programmes

Meetings with different departments, e.g. Finance, IT and
Provost’s Office, once a month or more
Lectures, cultural hour and
lunch-hour seminars (Wednesday afternoons once a month)
Faculty
Assembly (first Saturday), although time and day difference could be a
problem
Lectures organized by Research Department, Special Lecture
Series and AKU-IED
AKU 25th Anniversary Planning Committee
Meeting

Continuing education programme for practising nurses
Online courses for nursing students
Meetings and resource sharing
between nursing faculty staff from different locations

Expected outcomes

Identify problems relevant to the implementation of
Elluminate Live in order to plan for wider implementation of Elluminate
Live at AKU-IED

Skill enhancement of the faculty, staff and
students
User satisfaction (through the help of feedback forms)

Attendance at meeting, seminar or workshop that would
otherwise have been missed
Work closely with other AKDN institutions to
share intellectual or material resources and strengthen the relationship
with other AKDN entities
Follow-up with students and distance
education

Number of online teaching sessions using live teaching
tools
Evaluation of online tools by moderators and participants for
online learning
Identifying problems with online learning in different
locations

In practice, the programme was under-utilized by the
professionals in Dar-es-Salaam. Over a 3-year period, approximately 80
teleconsultations occurred, whereas the estimated number of consultations at the
time of the launch was 2500. The main reasons for this underutilization were
insufficient bandwidth for an effective Internet-based education programme,
discomfort among Dar clinicians in Dar-es-Salaam due to inadequate exposure to
the use of computers, and practice behaviours and the environment preventing the
use of technology to its fullest capacity. The evaluation team found that the
leadership at the Aga Khan Hospital in Dar-es-Salaam was very positive with
respect to the use of technology for the training of health care providers. This
led to the new programme of remote access for health care professionals that has
been described above.

Teleradiology link

The AKUH in Karachi has a partnership with the French Medical
Institute for Children (FMIC), which is an 85-bed paediatric hospital in Kabul.
The primary aim of the telemedicine project was to provide access to
high-quality diagnostic services. As a first step, the project used broadband
technology and wireless video consultation with digital image transfer to
provide teleradiology services. CT scans and X-ray images can be diagnosed and
interpreted and treatment can be suggested from Karachi. A combination of
fibre-optic and radio links is used to transfer images from the FMIC to the AKUH
in Karachi (Figure
27.1). Four or five images are transferred to the AKUH every day, and
reports are sent back to the FMIC in less than 24 hours.

Figure 27.1 Teleradiology link between the
French Medical Institute for Children, Kabul and the Aga Khan University
Hospital, Karachi

Information exchange

Since its inception, the AKU has made patient information
available to all care providers, while being careful to maintain the
confidentiality of patient records. Several programmes have been introduced to
capture medical information electronically and make this available in all
patient care areas. Laboratory records, radiology reports, nursing and physician
records and order entries, and several types of administrative information have
been computerized for rapid access by all care providers. There are still
several missing elements, such as physician notes, outpatient records, decision
support systems and sharing of patient records between campuses. The university
has therefore developed a detailed plan to achieve this. The ultimate goal of
electronic health records is to integrate computerized medical records and
ordering systems with routine care, and avoid any duplication of work in the
form of generating paper records. This will lead eventually to a paperless
organization where all information will be available in electronic form, guided
by policies to ensure privacy and confidentiality of patient data, yet ensuring
rapid access to information for the care providers.

Opportunities and challenges

The above examples of e-health work show that the AKDN has
increased the availability of learning resources, health care and information
for its own institutions, with a view to making health services more affordable
and accessible in the developing world generally. E-health also offers
opportunities for the network institutions to build on each other’s strengths
and expertise by sharing knowledge, expertise, best practices and information.
For example, the doctors and nurses in East Africa possess specialist knowledge
and skills in certain tropical diseases, which could be shared with doctors and
nurses in other institutions of the network. Such collaboration is likely to
encourage the development of a strong knowledge base founded on indigenous,
culturally sensitive, e-health applications.

No innovation is free of challenges, especially if it involves
bringing a change in the everyday practices, attitudes and beliefs of people.
Stemming from the use of new technologies for e-health, there are challenges
associated with the development, delivery and sustainability of such programmes.
For instance, the above examples represent the efforts of small groups of
doctors and nurses from the AKU and the AKHS who are enthusiastic about the use
of ICT for learning and are also familiar with modern technology. However, there
is a wide spectrum of technological access and expertise among other potential
users. Likewise, expertise in teaching and learning, providing patient care and
sharing information through technology also vary considerably between the
network institutions. Moreover, since there has been no previous experience of
such programmes among the participating institutions, there are no formal
polices and procedures to guide the implementation. Furthermore, in most cases,
no systematic evaluation has yet been conducted to assess the outcomes. While
funding for the current projects has been provided through the AKDN, the
availability of funds for future research, development and
evaluation of e-health applications could represent a problem. Clearly, there is
a need for network-wide resource sharing, accountability and coordination for
the development and implementation of e-health programmes, policies and
strategies for AKDN institutions.

Next steps

To enhance the use of e-health in the AKDN, it is important to
develop a network-wide strategy for e-health. Such a strategy would allow
collective learning and sharing of knowledge and experience among people
providing health care within the AKDN. To develop a network approach to
e-health, the following principles have been proposed:

E-health initiatives
should increase access to health care information and services for communities,
and enhance the quality of care among network institutions and partners through
knowledge transfer and educational programmes.

E-health initiatives
should address the needs of health care institutions, identified and prioritized
using sound techniques. The prioritized needs should also guide external
institutions and health care professionals interested in working in the field of
e-health to focus on interventions addressing the most important health needs of
the community.

All e-health
initiatives for the network and partners should ensure that knowledge and
experience gained from these projects are measured, and that the results are
disseminated to the broader community.

All e-health
initiatives for the network and partners should ensure that knowledge especially
public institutions, without compromising the quality of care or the safety and
confidentiality of patients receiving services from AKDN institutions.

All e-health
initiatives should be standardized and planned to enhance networking among AKDN
institutions and partners.

E-health initiatives
for the network and partners should identify suitable platforms and systems that
have universal applications. Proprietary software should be avoided whenever
possible.

E-health initiatives
should promote collaboration with other partner institutions, especially public
institutions, without compromising the quality of care or the safety and
confidentiality of patients receiving services from AKDN institutions.

All e-health
projects should focus on the sustainability of the initiatives by deonstrating a
return on investment and integration with the existing programmes.

To confirm the above principles, a process of needs and
readiness assessment has been started in all the countries where the AKDN
operates. This will:

identify the current
and future needs of health care institutions that can be addressed by using
e-health

define the available
alternatives and provide justification for the use of e-health

determine the
infrastructure, awareness, willingness, capacity, sociocultural environment and
institutional polices required for e-health

define the process
of e-health planning leading to enhanced readiness of health care institutions
in the relevant countries

develop a model for
e-health needs and readiness assessment for AKDN institutions and partners in
other countries (and for other similar institutions).

The needs and readiness assessment exercise is currently being
carried out in Tanzania and Afghanistan. These two countries were selected based
on their needs and existing collaborations between network institutions. The
readiness assessment is focusing initially on teleconsultations and
tele-education. However, the needs assessment will capture institutional needs
in information and knowledge management as well.

The following activities are being conducted during the needs
and readiness assessment exercise in the two countries:

1. Developing a stakeholder team in each country.
Separate teams of key stakeholders are being formed in each country to plan the
needs and readiness assessment in these countries. The stakeholder team decides
on the process of needs and readiness assessment by identifying the relevant
instruments, supervising data collection and compiling results for guiding
e-health implementation in each country.

2. Training the stakeholder team in each country. Once
the teams have been formed, the members will be exposed to e-health
terminologies and concepts. These are required to carry out the planning of
needs and readiness assessment. The training programmes in each country will
last for two days each.

3. Conducting the needs assessment in AKDN
institutions. Identifying the needs of AKDN institutions that could be
addressed though e-health will be conducted using (i) discussions with the
stakeholder team members to document their views and suggestions and (ii) focus
group discussions with different groups of health care providers and managers of
health care institutions. The participants for focus group discussions will be
identified by the stakeholder team, and the sessions will be conducted by team
members from AKU.

4. Identifying appropriate e-health solutions for the
suggested needs. On the basis of the identified needs, appropriate e-health
solutions will be selected by the stake-holder team. The process will be carried
out in consultation with the team from the AKU and a consultant. Efforts will be
made to identify simple, low-cost, low-bandwidth and culturally sensitive
e-health solutions for AKDN institutions.

5. Prioritizing e-health solutions. In the next step,
the stakeholder team will prioritize the e-health solutions. This step will help
in assessing and building the readiness of health care institutions for the
e-health applications that have been identified, and avoid wasting time on
applications that may not be required in the short term.

6. Conducting readiness assessment of network
institutions. Finally, the stakeholder team will choose among the existing
tools for e-health readiness assessment that have already been validated and
tested in developing countries. The teams will also finalize the plan for
analysing the information collected.

Conclusion

The AKDN represents an interesting example of agencies and
institutions working in several different countries towards a common development
goal. Health is a component of the overall development of the
communities, which makes it necessary for the health care institutions to build
strong relationships with institutions involved in other facets of development.
Better coordination within, among and between these agencies, and with the
communities, is necessary for provision of health care in these countries.
E-health offers great potential to enable a network of this size to achieve its
goals of better access and high quality of care, while operating within the
available resource constraints.

The AKDN has developed a plan to move from pilot trials to
routine operations, by developing a network approach guided by an overall
strategy. The strategy is based on the principles of needs and readiness
assessment, community and community-centeredness, knowledge transfer,
networking, open platforms, standardization and evaluation. A broad-based needs
and readiness assessment has already been started in two countries.

Further reading

Aga Khan Development Network. Available at: http://www.akdn.org/.

Harambee: Reinforcing African Voices through
Collaborative Processes. Available at: www.uneca.org/aisi/picta/HarambeeOverview-v1.pdf.

Ministry of Economic Development, New Zealand.
Strengthening Networks and Partnerships. Available at: www.gif.med.govt.nz/aboutgif/networks.asp.

United Nations Development Programme (UNDP). Networks
for Development: Lessons Learned from Supporting National and Regional Networks
on Legal, Ethical and Human Rights Dimensions of HIV/AIDS. Available at:
www.undp.org/hiv/publications/networks.htm.

United Nations Economic and Social Commission for Asia
and the Pacific. Handbook on Strengthening the Women’s Information Network
for Asia and the Pacific through Computer Networking. Available at: www.unescap.org/esid/GAD/Publication/computer.pdf.

Wiley D. Connecting Learning Objects to Instructional
Design Theory: A Definition, a Metaphor, and a Taxonomy. Available at:
www.reusability.org/read/chapters/wiley.doc.

References

1.
Fort V, Obonyo B, Madhavan S. Strengthening the Institutional Capacity of
Aga Khan Health Service, East Africa’s Community Health Department to Support
Organizations Working in Community Health Service. Available at:
pdf.dec.org/pdf_docs/Pdacf019.pdf.

2.
Aga Khan University. Available at: www.aku.edu.

3.
Library of Images, Aga Khan University. Available at: loi.aku.edu/loi.

4.
Joint Information Systems Committee (JISC). Circular 7/00: MLE in Further
Education: Progress Report. Available at:
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
the developing world. However, after reviewing the literature, it is clear that
the evidence base supporting its practical utility is rather slender, and that
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,
in preparing this book, the implicit thesis was that telemedicine can have a
positive effect on health care delivery in developing countries, and that
ultimately it can reduce the global burden of disease. The latter could perhaps
be regarded as the Holy Grail for workers in the field. How does the experience
reported in the book reflect this ideal?

The examples in this book show unequivocally that useful
services can be delivered in the developing world using telehealth. None the
less, viewed from the perspective of telehealth activity in the world as a
whole, it is clear that there has been relatively little use of telehealth in
developing countries so far. One obvious reason is the information and
communication technology (ICT) environment, where there are evident challenges
to the more widespread use of telehealth and to the use of e-health generally.
These are, in fact, general problems concerning the use of ICT anywhere,
including:

the cost of IT
hardware and software

the limited
availability of fast broadband and mobile networks

the slow development
of software in languages other than English.

These and other factors add up to the so-called ‘digital
divide’ between the developing world and the industrialized world (see Chapter 2).

ICT barriers

A useful framework for considering access to ICT is provided
by the Real Access criteria.2 These criteria
have been used to analyse the factors concerning access to ICT and its use,
including the ‘soft’ aspects that are often overlooked. The criteria are
designed to help understand the reasons why ICT development projects fail to
achieve their goals, and to identify the reasons why such projects succeed.
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
way that ICT-based development policies and initiatives are planned, monitored
and evaluated.

Other barriers

Telehealth, of course, is a complex matter. A satisfactory ICT
environment is a necessary, but not sufficient, condition for the successful
practice of telehealth. There are other barriers to the use of telehealth, and
they apply in the industrialized world as well. The barriers include:

organizational
factors, e.g. changing the way in which hospitals and doctors work

human factors, e.g.
lack of staff with the appropriate skills

medicolegal matters,
including ethical concerns.

As the examples in this book show, it is possible to overcome
all these obstacles and bring about successful, and in some cases sustainable,
telehealth operations.

Telemedicine examples

In summarizing telehealth work, it is usual to categorize the
applications under three headings: clinical, educational and administrative.
These categories are not mutually exclusive.

Administrative

This book contains only a few examples of telehealth work in
the administrative category. This is surprising, since facilitating
administrative work – conducting meetings at a distance, providing web-based
data collection forms and supplying online reports, for example – are all
perfectly proper forms of telehealth, and ones that are likely to provide major
benefits in terms of avoided staff travel and improved information flows.
Perhaps this is the unglamorous, and therefore under-reported, face of
e-health.

Education

Although relatively little mention is made of administrative
telehealth work, this book contains more examples of education. One of the most
successful educational projects, and one that appears to be sustainable, is led
from Geneva by the organization Réseau Afrique Francophone de Télémédecine
(RAFT), which provides services in French-speaking African countries. Education
is delivered in real time using interactive web-casting.3 A successful
example of the opposite modality, asynchronous education, is the Pacific
open-learning network of the World Health Organization (WHO).4 The
open-learning network provides online (web-based) courses, course materials and
other resources to health professionals in the Pacific region. In addition, 15
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
are two other significant educational resources that deserve mention. First,
there is the HINARI project (Health Internetwork Access to Research Initiative),
which was established in 2002 by the WHO, when it secured agreement from many of
the world’s scientific publishers to make their journals available in developing
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
the Medline database freely available to the world via the Internet in the
mid-1990s. Using the PubMed search engine, more than 17 million citations and
abstracts of biomedical research articles can be searched via the web. The ready
availability of the Medline database via PubMed, and free access to several
thousand journals via HINARI, are splendid examples of how the industrialized
world can assist less fortunate countries. The indirect health gains of these
initiatives remain to be quantified, but can confidently be assumed to be
substantial.

The educational projects described in this book are undoubtedly
successful. None the less, they should be viewed in a global health care
context. Many countries face critical shortages of health service providers,
such as doctors, nurses and midwives (Figure 28.1).6 This is
important because, unsurprisingly, the number of health workers and their skills
are positively correlated with population health outcomes. The WHO has set out a
framework for improving the global health workforce, by focusing on strategies
related to the stage when people enter the workforce, the period of their lives
when they are part of the workforce, and the point at which they make their exit
from it. The strategy focuses on:

entry:
preparing the workforce through strategic investments in education and effective
and ethical recruitment practices

workforce:
enhancing worker performance through better management of workers in both the
public and private sectors

exit:
managing migration and attrition to reduce wasteful loss of human resources.

Telemedicine has an obvious role to play in improving access
to education, and perhaps in allowing better supervision of a dispersed
workforce. One might expect

Figure 28.1 Countries with a critical shortage
of health service providers. There is an estimated shortage of almost 4.3
million doctors, midwives, nurses and support workers worldwide. (Reproduced
from World Health Report 2006;6 data taken from
Global Atlas of the Health Workforce15)

that greater access to education could be achieved at lower
cost by pooling of resources and by expanding the use of telemedicine and
distance education. Clearly, education represents a fruitful potential area for
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
of the requisite technology and the restricted availability of suitable
telecommunications. The Medical Missions for Children has a videoconferencing
network to a number of hospitals in developing countries, although a good deal
of the telehealth activity that takes place is educational in nature, for
example mentoring of local doctors, rather than direct patient care (see Chapter 10).

In practice, a substantial proportion of clinical telehealth
work in developing countries is done by email or by web messaging (Table 28.1). Successful
examples of the use of email include the Cambodia work managed from Boston (see
Chapter 13) and the
global e-referral network operated by the Swinfen Charitable Trust (see Chapter 19). The latter has
recently moved from a system based on plain email to one based on a secure web
server. Long-running examples of the use of the web for delivering clinical
consultations include the US Army’s system in the Pacific7 (see Chapter 15) and the highly
regarded iPath system for case discussions among groups of pathologists.8

Table 28.1 General-purpose
second-opinion telemedicine networks providing services in the developing
world

Operator

Referring sites

Expert sites

Date of first operation

Mechanism

Description

Partners Health care, Boston, Massachusetts, USA

Rovieng Health Centre, Cambodia
Rattanikiri Hospital,
Cambodia

Sihanouk Hospital, Phnom Penh Harvard Medical School,
Boston

2001

Email

Email consultations are used to support health workers at
a rural clinic in northern Cambodia. The email advice comes from
specialists at a tertiary hospital in Phnom Penh and from the
Massachusetts General Hospital in Boston. In 2003, a second site at a
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
Army hospital in Hawaii to support referrers in hospitals (mainly military
hospitals) around the Pacific

iPath Association, University of Basel, Basel,
Switzerland

Several (mainly telepathology), e.g. Cambodia, Solomon
Islands, Bangladesh
Also more recent teleconsultation work, e.g.
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
several tens of thousands of case conferences have now been conducted –
technically by a number of different organizations who all use the same
software). More recently, the software has begun to be used for general
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
a single hospital in Bangladesh by a UK-based charity. Specialist opinions
were obtained from a small panel of volunteer consultants. The operation
has now grown to service over 100 hospitals around the world, with a panel
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
French-speaking African countries. The core activity is distance education
via webcasting of interactive courses. Some teleconsultation work also
takes place, mainly involving specialists in
Geneva

Intermediate between the two poles of real-time
videoconferencing and store-and-forward messaging lies the VHF radio network
installed in the Peruvian jungle to facilitate communications with remote health
centres.9

Cost-effectiveness

Although the above examples should all be considered to be
successful demonstrations of telehealth in the developing world, it has to be
admitted that strict evidence for cost-effectiveness remains elusive. Analysis
of cost-effectiveness is a health economics tool that enables comparisons to be
made between alternative interventions in terms of their costs and consequences.
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
treatment of tuberculosis? To answer this question requires not only that the
costs be known, but also that the consequences – the health gain – can be
calculated. The latter may be done in terms of life-years gained, for example;
if so, the situation is relatively straightforward. If the health gain includes
other advantages – perhaps improved quality of life or reduced incidence of
medical complications – then assigning a monetary value to the benefits is
likely to be more difficult.

Telehealth research workers know only too well that it is hard
enough to obtain evidence for cost-effectiveness in telehealth work in
industrialized countries; it is even harder to do so in developing countries.
Yet the matter of cost-effectiveness remains a serious question hanging over the
potential future use of telehealth. More than a decade ago, the question was
posed whether it is ethical to devote significant resources to telehealth in the
developing world if the costs and benefits are largely undocumented when there
are health measures, such as vaccination, sanitation and clean drinking water,
with characteristics that are well understood.10

The WHO has provided examples of interventions that, if
implemented properly, can substantially reduce the burden of disease, especially
among the poor, and do so at a reasonable cost (Table 28.2).11 What is
striking about this list is how little tele-health has yet been applied in these
areas. Telehealth may have a place in directly observed treatment of
tuberculosis (DOTS),12 but little is
yet known about its feasibility on a wide scale, never mind its
cost-effectiveness. It is true that telehealth has been used successfully to
provide HIV/AIDS services (see Chapter 9), but again it
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
network that is based on email transmission by VHF radio link. A recent study
has documented fewer urgent patient transfers from health posts and health
centres,9 and there is
emerging evidence of cost-effectiveness.13

A strategy for telemedicine

Given the above, and the need to obtain quantitative evidence
of cost-effectiveness, what is the right strategy for telehealth in the
developing world? The key aspects appear to be:

Table 28.2 Interventions with a large
potential impact on health outcomes11

Examples of interventions

Main contents of interventions

Treatment of tuberculosis

Directly observed treatment schedule (DOTS):
administration of standardized short-course chemotherapy to all confirmed
sputum smear-positive cases of tuberculosis under supervision in the
initial (2–3 months) phase

Maternal health and safe motherhood interventions

Family planning, prenatal and delivery care, clean and
safe delivery by trained birth attendant, postpartum care, and essential
obstetric care for high-risk pregnancies and complications

Family planning

Information and education; availability and correct use
of contraceptives

School health interventions

Health education and nutrition interventions, including
anti-helmintic treatment, micronutrient supplementation and school
meals

Integrated management of childhood illness

Case management of acute respiratory infections,
diarrhoea, malaria, measles and malnutrition; immunization,
feeding/breastfeeding counselling, micronutrient and iron supplementation,
anti-helmintic treatment

HIV/AIDS prevention

Targeted information for sex workers, mass education
awareness, counselling, screening, mass treatment for sexually transmitted
infections, safe blood supply

Treatment of sexually transmitted infections

Case management using syndrome diagnosis and standard
treatment algorithm

Immunization (EPI Plus)

BCG at birth; OPV at birth, 6, 10, 14 weeks; DPT at 6,
10, 14 weeks; HepB at birth, 6 and 9 months (optional); measles at 9
months; TT for women of childbearing age

Malaria

Case management (early assessment and prompt treatment)
and selected preventive measures (e.g. impregnated bed nets)

Tobacco control

Tobacco tax, information, nicotine replacement, legal
action

Non-communicable diseases and injuries

Selected early screening and secondary
prevention

1. Concentrate on areas identified by the WHO as being likely
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
cost-effectiveness.

In 2006, Lord Crisp examined how the UK experience and
expertise in health could best be used to help improve health in developing
countries.14 He made a
number of detailed recommendations, but pointed out that it was necessary for
developing countries to take the lead and to ‘own’ the solutions, which could be
supported by international, national and local partnerships based on mutual
respect.14 This surely
epitomizes any potential use of telehealth.

Conclusion

What then is the future for telehealth in the developing
world? Clearly, telemedicine does not represent ‘the answer’ to all public
health challenges in developing countries. However, it can provide value,
particularly when it is employed to strengthen and support a local team, rather
than simply being used to import expertise from outside to supplement or
supplant local efforts. One important role for telemedicine is in the training
of local health professionals. The place of telemedicine in direct patient care
delivery remains to be established, although there are promising indications of
its success in certain circumstances. Consultations via email and the web should
form an essential part of health partnerships.

The long-term goal of telehealth work must remain the
demonstration of its efficacy in comparison with well-understood measures such
as the provision of safe drinking water and immunization (Figures 28.2 and 28.3). One unanswered
question is the future design of telehealth networks. Whether resources should
be concentrated into a single network or into several, it is clear that the
long-term aim should be to establish within-country telemedicine networks
(supported from out of country where appropriate) that:

demonstrably alter
health outcomes

can be shown to be
cost-effective and sustainable

will act as a model
for other countries to copy.

Figure 28.2 People forced to use one water
source for all daily chores – like this girl in Pakistan – face increasing risks
of gastrointestinal infections and other waterborne diseases. Together, these
diseases kill around 2.2 million people globally each year, mostly children in
developing countries. (Photograph courtesy of WHO/Christopher Black)

Figure 28.3 Child immunization at the Malipur
Maternity Home in Delhi, India. Immunization is considered to be one of the most
cost-effective health interventions. There is a well-defined target group;
contact with the health system is only needed at the time of delivery; and
vaccination does not require any major changes of lifestyle. (Photograph
courtest of WHO/P Virot)

This will enable the success of the telemedicine
second-opinion work that has been performed to date to be exploited on a global
scale.1 Telemedicine is
a small but significant component of ICT in health care delivery. In the future,
it is to be hoped that telemedicine will develop into a proven tool for
facilitating learning and for capacity building, in addition to its role in
direct clinical care.

References

1.
Wootton R. Telemedicine support for the developing world. J Telemed
Telecare 2008; 14: 109–14.

2.
Bridges.org. Real Access/Real Impact Criteria. Available at:
www.bridges.org/Real_Access.

3.
Geissbuhler A, Bagayoko CO, Ly O. The RAFT network: 5 years of distance
continuing medical education and tele-consultations over the Internet in
French-speaking Africa. Int J Med Inform 2007; 76:
351–6.

4.
POLHN. Pacific Open Learning Health Net. Available at:
www.polhn.com.

5.
World Health Organization. HINARI Access to Research Initiative.
Available at: www.who.int/hinari/en.

6.
World Health Organization. The World Health Report 2006 – Working Together
for Health. Available at: www.who.int/whr/2006/en.

7.
Callahan CW, Malone F, Estroff D, Person DA. Effectiveness of an Internet-based
store-and-forward telemedicine system for pediatric subspecialty consultation.
Arch Pediatr Adolesc Med 2005; 159: 389–93.

8.
Brauchli K, Oberli H, Hurwitz N et al. Diagnostic telepathology: long-term
experience of a single institution. Virchows Arch 2004;
444: 403–9.

9.
Martínez A, Villarroel V, Seoane J, del Pozo F. A study of a rural telemedicine
system in the Amazon region of Peru. J Telemed Telecare 2004;
10: 219–25.

10. Wootton R. The
possible use of telemedicine in developing countries. J Telemed
Telecare 1997; 3: 23–6.

11. World Health
Organization. The World Health Report 2000 – Health Systems: Improving
Performance. Available at: www.who.int/whr/2000/en.

12. DeMaio J, Schwartz
L, Cooley P, Tice A. The application of telemedicine technology to a directly
observed therapy program for tuberculosis: a pilot project. Clin Infect
Dis 2001; 33: 2082–4.

13. Martínez A,
Villarroel V, Puig-Junoy J et al. An economic analysis of the EHAS telemedicine
system in Alto Amazonas. J Telemed Telecare 2007; 13:
7–14.

14. Crisp N.
Global Health Partnerships: The UK Contribution to Health in Developing
Countries (‘The Crisp Report’). Available at:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_065374.

15. World Health
Organization. Global Atlas of the Health Workforce. Available at:
www.who.int/globalatlas/default.asp.

Index

Acacia project 75–6

access to ICT services 17–20

administrative barriers to borderless global e-health
initiatives 63–5

and non-adoption of e-health 80–1

administrative telemedicine 300

Afghanistan

AKDN needs and readiness assessment exercise 295

AKDN teleradiology link 290–2

Africa

Acacia project 75–6

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 234–6

policy environment, potentially restrictive policy development
63–4

sub-Saharan Africa 232–41

telecommunication costs 235

Telemedicine Task Team, European Commission and European Space
Agency 237

West Africa Doctors and Healthcare Professionals Network 127see also
South Africa; sub-Saharan Africa

Africa Teledermatology project 124–6

data flow 123(fig.)

African Medical and Research Foundation (AMREF) 237, 239, 240

African Union 236

New Partnership for Africa’s Development (NEPAD) 236

Aga Khan Development Network (AKDN) 287–96

AKDN agencies 290–1

care provision 290–2

education and training 288–90

email-based teleconsultations 290–2

future 294–5

information exchange 293

teleradiology link 292, 292(fig.)

Aga Khan Health Services (AKHS) 239, 287–93

Aga Khan University (AKU) 287–93, 291(table)

continuing medical education (CME) programmes 288–9

Elluminate Live 290

Library of Images 289

remote access for health professionals 290

virtual learning environment (VLE) AKUMed 289

Alliance of Italian Hospitals Worldwide 170–81

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) 91–2

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) 69–70, 76–7

PANACeA project 76–7

Australia

Africa Teledermatology project 124–6

Centre for Online Health at the University of Queensland 206

Swinfen Charitable Trust 128, 206

Austria, Africa Teledermatology project 124–6

Ayurveda medicine 47

Balkans, telemedicine collaboration in emergency situations
263

Bangladesh, Centre for the Rehabilitation of the Paralysed
(CRP), Swinfen Charitable Trust 204–6

barriers to ICT 299–300

borderless global e-health initiatives 63–5

and non-adoption of e-health 80–1

Basel, iPath application and networks 126–8

Belarus, online cancer registry 282

Benin, histopathology store-and-forward service with Paris 238

Bill and Melinda Gates Foundation, assets 60

Botswana–Baylor Children’s Clinical Centre of Excellence 238

Brazil, primary health care 34–42

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’ assistants, procedures 39

online cancer registry 281–2

PACOTAPS software 38–9

Primary Care Information System 36

PROESF study 39

use of computers for professional activities 37, 38(table)

Brazilian Lymphoma and Leukaemia Association (ABRALE) website
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,
India 45, 49, 50

Cambodia and USA 135–48

American Assistance for Cambodia (AAfC) 137, 145

demographics and case mix 140, 141(table), 142(fig.)

economic factors 145–6, 147

health indicators and resources, USA vs Cambodia 136(table)

human factors 146–7

ICT indicators 137(table)

local and consulting clinicians 144–5

map, sites of operation of telemedicine clinics 138(fig.)

proposed characteristics of programme success 143(table)

Rattanakiri Referral Hospital 139–40

Rovieng Health Centre 138

standardized template for history and physical examination 145

technological factors 146, 147

telemedicine programme collaboration 137–40

Canada

funding of Community Health Information Tracking System,
Philippines 28

funding for UHIN project 47–8, 49, 52, 69

Information and Communication Technologies for Development
(ICT4D) 68–78

International Development Research Centre (IDRC) 68

cancer 273–90

information on Internet 277–9 see also
paediatric oncology

case studies, m-health (mobile e-health) 45–50, 55–6

Cell-Life project, South Africa 46, 49, 51, 52, 97

Centre for the Rehabilitation of the Paralysed (CRP)
Bangladesh 204–6

Chad, RAFT programme 238

Chechnya paediatric telemedicine 262–72

Children’s Field Hospital 263–70

clinical aspects 267–8

disaster medicine 268–9

monitoring during treatment and rehabilitation 268–9

process 266

structure 263(fig.)

system architecture 264–5, 265(fig.)

teleconsultations 268(table)

teleradiology (DEPRAD) system 269–70

children, see also Medical Missions for Children;
paediatric

Children’s Hospital at Montefiore, Bronx, New York 106–7

China 212–21

absence of legislation and regulation 219

BYL Telemedicine Network 214

challenges for telehealth 218–19

Fujian Province Telemedicine Network 214–15

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 212–13, 215–17, 216(fig.)

Shuang-wei (Satellite Health Education Network of the Ministry
of Health) network 214

Sino-Japanese Telemedicine Collaboration 214

telehealth opportunities 217–18

telehealth programmes 215–17

telemedicine past and present 212–13

Traditional Medicine Telemedicine Network 214

unbalanced development in different areas 219

citizen-centred care 14

Colombia, Organization of Parents of Children with Cancer and
Related Diseases (OPNICER) 284

Commission on Science and Technology for Sustainable
Development in the South (COMSATS) 242–3

Community Access to Sustainable Health programme, India 45, 50

Community Health Information Tracking System (CHITS)

Philippines, National Telemedicine Center 28–9 see also
m-health (mobile e-health)

community-based health workers, m-health 43–50

COMSATS Internet Services (CIS) 244

continuing medical education (CME) programmes 112, 288–9

costs for ICT 18, 23

return on investment (ROI) 58–9

Crisp report 4, 305

Cuban doctors, working in South Africa 228

cytology 152, 153

Democratic Republic of the Congo, trial store-and-forward
project 238

dermatology 121–34

diagnostic accuracy 128–9

financial aspects 131–2

future developments 132

integration and intercultural context 129–30

legal aspects 129

outcomes 128

practical steps in setting up a teledermatology project 131(table)

telederm.org application and networks 122–4

digital divide 9, 10–11, 299

disaster medicine 262–6

e-commerce and e-learning 61

e-governance 60

e-health, see also telemedicine

e-health in the developing world 299–308

cost effectiveness 304, 305(table)

information and communication technology (ICT) barriers 299–300

telemedicine examples 300–4

administrative 300

clinical 302–4, 303(table)

education 301–2

health service providers shortage (map) 302(fig.)

telemedicine strategies 304–5, 306–7
(figs)

e-health promotion 79–86

Eastern Europe

large-scale infrastructure investments 11–12

online cancer registry 282

Ecuador 193–202

Fundación Cinterandes (Cuenca Ecuador) 193–8

health concerns 193–4

intermittent surgical services 194–202

medical system 194–7

mobile surgery programme 194–7

operating room (truck) 195–6
(figs)

primary care 200–2

local area network (LAN) in Macas 200(fig.)

programme activity 197

telemedical support for surgeons

telemedicine support 197–9

connectivity modalities and bandwidths 198(table)

laparoscopic cholecystectomy postoperative care 198(fig.)

education and training 19, 91–100, 288–90

continuing medical education programmes 112

database of Internet links 290

e-learning 61

e-school project, Uganda 236

examples of projects 301–2

importance of e-health education 81

learning objects repository 289

remote access for health professionals 290

South Africa 229–30

synchronous e-learning 290, 291(table)

telementoring 109–19

teleneurology and telemedicine 256–8, 258(fig.)

twinning 96–7

web-based virtual learning environment 289

EHAS (Hispano-American Health Link) programme (Peru, 2000) 45–6, 49, 50

Eldoret, Moi University 239

email telemedicine 203–11

Cambodia 204–5

disadvantages 204

first use, Bosnia 204

future use 299–308

future work 209–11

origin and numbers of cases referred 2002–2008 207(table)

Partners Telemedicine, Cambodia 204–5

Swinfen Charitable Trust 204–6, 209–11

Tanzania 290, 295

teleconsultations 290–2

web-based telemedicine 203

emergency situations 262–6

endocrine surgery, India 109–19

epilepsy 254

Eritrea, Anesthesia Overseas 238

Ethiopia 238

EUROCARE project, paediatric oncology 274, 277

European Commission and European Space Agency, Telemedicine
Task Team for Africa 237, 238

European eHealth Action Plan (Legally eHealth) 64

European Union (EU)

directive on protection of personal information, potentially
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
University Hospital, Karachi 292(fig.)

future of e-health in the developing world 299–308

impact on potential health outcomes 305(table)

Gabon 238

Gates Foundation 60

Geneva, RAFT (Réseau en Afrique Francophone pour la
Télémédecine) 97–8,
126–7, 237, 301

Geneva University Hospitals 303(table)

Ghana 238

global e-health 57–60

3-dimensional policy matrix model 62(fig.)

breadth of policy issues 61–3

critical shortage of health service providers (map) 302(fig.)

need for global e-health policy 55–6

policy development void 62

policy perspective 59–62

potential benefits 58

potential impact from access to ‘e’ applications 59(fig.)

relationship of major components 57(fig.)

return on investment (ROI) 58–9

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

‘glocal’ e-health policy development 63

governance 60

Governments as policy-making organizations 79–80

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.), 302(fig.)

Healthspan International, telemedicine projects 240

HeliosNet satellite system 264, 265(fig.), 271

HINARI (Health Internetwork Access to Research Initiative) 301

Hispano-American Health Link (EHAS) programme (Peru, 2000) 45–6

HIV/AIDS care 91–100

3 by 5 Initiative 91

AIDSPortal 97

best practice with ICT 74–5

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 91–2

ITG telemedicine, Institute of Tropical Medicine website 127

Johns Hopkins, biweekly HIV clinical case presentations 238

online training modality (eSCART) 95

RAFT 97–8

Satellife (HealthNet) 95–6

sources of information on antiretroviral therapy 73(table)

TELEmedicine website discussion forum 93(fig.)

ICT see also ICT policy; index entries starting
with “tele”

access to ICT services 17–20

administrative telemedicine 300

advantages 3

barriers to ICT 299–300

borderless global e-health initiatives 63–5

non-adoption of e-health 80–1

benchmark targets 23

challenges in global public health 12–15

costs 18, 23

relative to per capita income 18

diffusion and mortality 11(fig.)

driving forces for adoption of ICT 12–13

e-commerce and e-learning 61

e-governance 60

e-health promotion 79–86

examples of use in health systems and services 13(table)

holistic approach to ICT development 22–3

legal framework, skills and protections for a network economy
20–3

national social and economic goals 18

outlook for future 23–4

pilot projects 11

potential telemedicine, impact on health outcomes 305(table)

private sector investment 18

problems 299

speed of ICT services 19–20

store and forward technology study, Nepal 185–90

trends, application to health 24(table)

ICT Diffusion Index 10, 17

ICT policy 15–20, 16(fig.), 19(table)

access to ICT services 17–20

achieving national social and economic goals 18

adjustment to meet local needs 22

administrative barriers to borderless global e-health
initiatives 63–5

core content 17–19

expatriate experts 82

infrastructure development 17

in low- and middle-income countries 21

in middle- and high-income countries 20–1

non-adoption of e-health 80–1

objectives and approaches 4–21

options for global e-health 65

policy options for global e-health 65

policy reform processes 21–2

potentially restrictive policy development 63–5

private sector investment 18

promotion of market competition 18

restrictive ICT policy development 63–4

India

Ayurveda 47

Ca:sh (Community Access to Sustainable Health) programme 45, 50

Community Access to Sustainable Health programme 45, 50

endocrine surgery 109–19

Jiva TeleDoc 47, 49, 51, 52

Mumbai telepathology 149–55

applications 151

constraints 150–1

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 258–9

Sanjay Gandhi Postgraduate Institute of Medical Sciences
(SGPGIMS) 109–12

telemedicine 258

telementoring 109–19

teleneurology and telemedicine 258

Indonesia, Pan Asia Networking (PAN) 69, 70(table), 71(fig.), 72

Information and Communication Technologies for Development
(ICT4D, Canada) 68–78

deficiencies 72

future work 77–8

projects supported 68–9, 70(table), 73–6

Acacia 75–6

AfriAfya survey 73

Pan Asia Networking 76–7

PANACeA project 76

information and communication technology see ICT

INMARSAT satellite link 204

Institute of Tropical Medicine in Antwerp (ITMA) 91–2

Institute of Tropical Medicine website, ITG telemedicine 127

international agencies 82–3

strategies to promote e-health 84–5

International Development Research Centre (IDRC), Canada 68–78, 243

international networks 287–96 see
also Aga Khan Development Network (AKDN)

International Telecommunication Union (ITU) 43

iPath application and networks 98, 126–8, 238, 302, 303

Mauritania 239

Sao Tome 239

Iraq and Middle East, Swinfen Charitable Trust 206–8

Italian Hospitals 170–81, 171–2(table)

Alliance of Italian Hospitals Worldwide 170–81

Alliance power-interest grid 173(fig.)

e-learning 175–7

manual of procedures 179

ontological definition 177, 178(fig.)

policy-making process 172

problems 179

task environment 172–3

teleconsultation 173–9

health equipment inventory 177

new learning courses 176–7

production of learning content 173–5

quality control 177–9

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 20–3

telemedicine 259–60

LT Telepatologija 126

m-health (mobile e-health) 43–50

Africa 235

case studies 45–50, 55–6

funding sources 49(table), 51

project funding sources 49(table)

social effects of m-health on work of CBHWs 50–1

technology summary 49(table)

teleneurology 256

WiFi networks, Ghana 238see also
Community Health Information Tracking System (CHITS); e-mail telemedicine

Malaysia, e-health policy, potentially restrictive policy
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 101–8

case report 104

Children’s Hospital at Montefiore, Bronx, New York 106–7

Giggles Children’s Theatre 103

Global Video Library of Medicine 103

history 102

Medical Broadcasting Channel 102–3

Telemedicine Outreach Programme 102

television programmes 103–4

videoconferencing equipment 102

Medline database, US National Library of Medicine 301

Middle East, Swinfen Charitable Trust 206–8

Millennium Development Goals (UN, 2000) 43–4

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
South Africa 237

mountainous and remote areas, northern Pakistan 232-41CHECK

Mozambique 239

funding sources for UHIN project 52

Mumbai telepathology 149–55 see
also India

Namibia 239

National Aeronautics and Space Administration (NASA),
emergency situations 262

Nepal 182–92

HealthNet Nepal 127, 182–5

cardiology 183

compression 184

dermatology 183

digital photography guides 184

hospital referrals 184–5

image processing 183–4

pathology 183

pilot project 184–5

radiology 183

receiving and reviewing cases 184

security and confidentiality 184

software, data transfer and security 183–4

software development 182–3

Pan Asia Networking (PAN) 69, 70(table)

store and forward technology study 185–90

telemedicine assessment study 185–8

neurology 252–61

teaching, videoconferencing 257see also
teleneurology

New Partnership for Africa’s Development (NEPAD) 236

Niger 239

Nigeria

and Children’s Hospital at Montefiore, Bronx, New York 106–7

national telemedicine association 239

non-adoption of e-health 80–1

non-governmental organizations (NGOs)

big international NGOs (BINGOs) 60

role and challenges 60

Norway, Tanzania store-and-forward project with
Rikshospitalet (Oslo) 240 Oslo 240

oncology see paediatric oncology

Pacific region 156–68

open-learning network, WHO 301

Pacific Asynchronous TeleHealth system 164–8

challenges 167–8

differences from Pacific Island Healthcare Project 165–6

distances involved, map 164(fig.)

future work 168

referrals and consultations 166–7

teleconsultation workload 166(table)

Pacific Island Healthcare Project 157–63, 158(table)

clinical procedure 159–61

Northern Mariana Islands 160(fig.)

Federated States of Micronesia, map 158(fig.)

results 161–3, 161(table), 162(fig.), 163(figs)

second-opinion telemedicine networks 303(table)

Tripler Army Medical Center 156–7 see also
Philippines

PACOTAPS software, Brazil 38–9

paediatric oncology 273–85

cancer incidence 274(table)

cancer registries 275(table)

individual countries (maps) 275–6
(figs)

international initiatives 279–81

Cure4Kids website 279–80

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’s Research Hospital 279–80

online cancer registries in developing countries 281–3

Argentina 282

Belarus 282

Brazil 281–2

Eastern Europe 282

India 283

Serbia 283

Singapore 283

twinning programmes 281

web-based information 277–9, 283–4

Africa 284

Asia 284

Eastern Europe 284

Latin America 283–4

paediatric support, field hospital in Chechnya 262–72

Pakistan 242–51

Commission on Science and Technology for Sustainable
Development in the South (COMSATS) 242–4

computer operator training 249

connectivity problems 248(fig.)

Karachi, AKUH 292

map 243(fig.)

medical staff and physician shortage 249

patient information software 249

project experience 244–7

community trust and confidence in the service 246–7

earthquake effects 247

equipment 245(table)

medical equipment 246

number of teleconsultations 247(fig.)

Skardu centre 246

recommendations 250

service methodology 250

Pan Asia Networking (PAN) 68–9, 70(table), 76–7

Pan Asian Collaborative for Evidence-Based eHealth Adoption
and Applications (PANACeA) project 70, 76–7

Pan-African initiatives 236–7

Partners Telemedicine 204–5, 238, 303(table)

Peru, Hispano-American Health Link (EHAS) programme (2000) 45

Philippines, Pan Asia Networking (PAN) 69, 70(table), 76–7

Philippines, National Telemedicine Center 27–33

Community Health Information Tracking System (CHITS) 28–9

E-Learning for Health Project 29–31

map, locations of educational sessions 30(fig.)

migration of doctors and nurses 31

SMS Telemedicine Project 32

sustenance factor 31–2

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 79–86

PubMed search, telemedicine articles 252(fig.)

RAFT (Réseau en Afrique Francophone pour la Télémédecine) 97–8, 126–7, 237, 301

Mauritania 239

Senegal 239

REACH (Remote Asynchronous Communication for Healthcare) 238

restrictive ICT policy development 63–4

Romanian Association of Parents with Cancer and Leukaemia Ill
Children (PAVEL) 284

Russia

Ambulance-071 YS 269–70

Moscow Research Institute for Paediatrics and Childen’s
Surgery 263

satellite system HeliosNet 264, 265(fig.), 271

support for Children’s Field Hospital, Chechnya 263–70

telemedical collaboration with NASA 262

Rwanda

funding sources for UHIN project 52

videoconferencing 239

St Jude Children’s Research Hospital, Cure4Kids website 279

Sanjay Gandhi Postgraduate Institute of Medical Sciences
(SGPGIMS) 109–12

conferences, CME and workshops held 112(table)

telemedicine network partners 111(table)

telementoring sessions 111–14

teleneurology 257

Sao Tome, iPath 239

Satellife (HealthNet) 95–6, 238

satellite system

HeliosNet 264, 265(fig.), 271

Q-band, Web Media Service 271

Senegal, RAFT 239

Serbia, online cancer registry 283

Sierra Leone 239

Singapore

Children’s 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 222–31

background 224–5

Cell-Life project 46, 49, 51, 52, 97

Childhood Cancer Foundation 284

common challenges associated with starting telemedicine
services 226

Cuban doctors 228

disease burden 222

education and training 228–30

governance 222–3

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 225–8

Free State, teleradiology 227

Medical Research Council (MRC) 224–7

mobile phone technology, HIV patient medication compliance
228

University of KwaZulu-Natal, telehealth and telemedicine 226–7

University of Stellenbosch, primary health care workstation
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’s Cancer Group (SACCSG) 284

South African Defence Force, with MRC 225

Spacedream project, Guinea-Bissau 238

speed of ICT services 19–20

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 185–90

age and gender of users 187–8

collaboration between doctors 188

consultation areas 188

disadvantages 189

breakdown between health professionals 189

organizational problems 189

economic evaluation 189–90

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 185–7

users’ attitudes 188

willingness to participate 187

stroke 254–5

sub-Saharan Africa 232–41

burden of disease 232

demographics 232

doctor/people ratio 233

health care funding 233

initiatives 236–40

international 237

Pan-African 236–7

projects within countries 238–40

Millennium Development Goals (UN, 2000) 234

needs (vs industrialized world), WHO Report 232

obstacles 234–6

plight of rural patients (Ethiopia) 234

population predictions 232–3

potential solution 233–4

telecommunication costs 235

Sudan 239

Surveillance, Epidemiology and End Results (SEER) programme
274

Swedish International Development agency, and Zambia 240

Swinfen Charitable Trust 128, 204–6, 209–11, 238, 302, 303(table)

Centre for the Rehabilitation of the Paralysed (CRP)
Bangladesh 204–6

growth of network (1999–2004) 206

referrals 205(fig.)

Iraq and the Middle East 206–8

origin and numbers of cases 207(table)

referrals 208(fig.)

types of queries 208(table)

U21 consortium 207–9

Memorandum of Understanding 209

referring hospitals 210(fig.)

Switzerland

Basel, iPath application and networks 126–8

Geneva, RAFT (Réseau en Afrique Francophone pour la
Télémédecine) 97–8,
126–7, 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, 288–9

teleconsultation

emergency situations 262

Italian Hospitals 173–9

telecytology 152, 153

teledermatology 121–34

telemedicine

articles published (PubMed) 252(fig.)

categorization of medical specialties according to their
maturity 253(fig.)

legal aspects 259–60

synonyms 3see also
e-health

Telemedicine Outreach Programme, World Bank 102

Telemedicine Sur 127

telementoring 109–19

teleneurology and telemedicine 252–61

acute stroke 254–5

categorization of medical specialities according to maturity
253(fig.)

epilepsy 254

India, telemedicine 258

legal questions 259–60

medical education 256–8, 258(fig.)

mobile phones 256

movement disorders 255

neurological outpatients 256

neurophysiology 255

resource availability 258–9

telemedicine articles in different specialities 252(fig.)

videoconferencing 257

telepaediatric support, field hospital in Chechnya 262–72

telepathology 139–45

teleradiology (DEPRAD) system 269–70

teleradiology link 292, 292(fig.)

television programmes, Medical Missions for Children 103–4

The Gambia 238

TIER (Technology and Infrastructure for Emerging Regions) 238

twinning programmes

paediatric oncology 281

sharing expertise 96–7

U21 consortium 207–9

Swinfen Charitable Trust 209

Uganda

call centre, HIV/AIDS care 95

e-school project 236

Uganda Health Information Network (UHIN) 47–8, 49, 52, 69

UNDP, funding of Community Health Information Tracking
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 135–48

TRAC2ES system, military operations 268see also
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 83–4

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