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

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 Kong.

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Contents

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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.

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

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.

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).

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 LA, Osorio A, Fassa AG. Aplicativo para sistematizar informações no planejamento de ações de saúde pública. [Software program to systematize data for planning public health actions.] Rev Saúde Publica 2003; 37: 800–6.

23. MS (Ministério da 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 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.

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.

References

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

2. World Health Organization. Strategy 2004–2007. E-health for Health Care Delivery. Geneva:, WHO, 2004

3. Tomioka Y, Androuchko V, Nakajima I et al. An aspect of the ITU-D activities from a viewpoint of ehealth and human resource development. In: Proceedings of 8th International Conference on e-Health Networking, Applications and Services, 2006: 283–6.

4. Heeks R. Information systems and developing countries: failure, success, and local improvisations. Inf Soc 2002; 18: 101–12.

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

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

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

8. Hongoro C, McPake B. How to bridge the gap in human resources for health. Lancet 2004; 364: 1451–6.

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

10. 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

11. Martínez A, López DM, Sáez A et al. Improving epidemiologic surveillance and health promoter training in rural Latin America through information and communication technologies. Telemed J E Health 2005; 11: 468–76.

12. Bhattacharyya A. Distance Doc. GPs with GPRS. BusinessToday India 2004; 1128–30.

13. 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.

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

15. Graves M, Grisedale S, Grünsteidl A. Unfamiliar ground: designing technology to support rural health-care workers in India. ACM SIGCHI Bull 1998; 30: 134–43.

16. Graves M, Reddy NK. Electronic support for rural health-care workers. In: Bhatnagar S, Schware R, eds. Information and Communication Technology in Development: Cases from India. New Delhi: Sage Publications, 2000: 35–49.

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

18. Martínez 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.

19. Byrne E, Gregory J. Co-constructing local meanings for child health indicators in community-based information systems: the UThukela District Child Survival Project in KwaZulu–Natal. Int J Med Inform 2007; 76(Suppl 1): 78–88.

20. Martinez A, Villarroel V, Seoane J, Pozo FD. Rural telemedicine for primary healthcare in developing countries. IEEE Technol Soc Mag 2004; 23: 13–22.

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

22. Kimaro HC. Strategies for developing human resource capacity to support sustainability of ICT based health information systems: a case study from Tanzania. Electron J Inf Syst Dev Countries 2006; 26: 1–23.

23. 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.

24. Donner J. The use of mobile phones by microentrepreneurs in Kigali, Rwanda: changes to social and business networks. Inf Technol Int Dev 2007; 3: 3–19.

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

26. Sarriot EG, Winch PJ, Ryan LJ et al. Qualitative research to make practical sense of sustainability in primary health care projects implemented by non-governmental organizations. Int J Health Plann Manage 2004; 19: 3–22.

27. Sarriot EG, Winch PJ, Ryan LJ et al. A methodological approach and framework for sustainability assessment in NGO-implemented primary health care programs. Int J Health Plann Manage 2004; 19: 23–41.

28. Harding R. Social enterprise: the new economic engine? Business Strategy Review 2004; 15: 39–43.

29. Dees JG, Elias J. The challenges of combining social and commercial enterprise. Business Ethics Quarterly 1998; 8: 165–78.

30. Wessels X. Improving the efficiency of monitoring adherence to antiretroviral therapy at primary health care level: a case study of the introduction of electronic technologies in Guguletu, South Africa. Development Southern Africa 2007; 24: 607–21.

31. Singh N. ICTs and Rural Development in India. Available at: ssrn.com/abstract=950322.

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

33. Madon S, Sahay S, Sudan R. E-government policy and health information systems implementation in Andhra Pradesh, India: need for articulation of linkages between the macro and 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.

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

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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

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).

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

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

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 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: 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: 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

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

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

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).

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: 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.

References

1. Schmid-Grendelmeier P, Masenga EJ, Haeffner A, Burg G. Teledermatology as a new tool in sub-saharan Africa: an experience from Tanzania. J Am Acad Dermatol 2000; 42: 833–5.

2. Schmid-Grendelmeier P, Doe P, Pakenham-Walsh N. Teledermatology in sub-Saharan Africa. Curr Probl Dermatol 2003; 32: 233–46.

3. Caumes E, Le Bris V, Couzigou C et al. Dermatoses associated with travel to Burkina Faso and diagnosed by means of teledermatology. Br J Dermatol 2004; 150: 312–16.

4. Fraser HSF, McGrath St JD. Information technology and telemedicine in sub Saharan Africa. BMJ 2000: 321; 465–6.

5. Miot HA, Paixão MP, Wen CL. Teledermatology – past, present and future. An Bras Dermatol 2005; 80: 523–32

6. House M, Keough E, Hillman D et al. Into Africa: the telemedicine links between Canada, Kenya and Uganda. CMAJ 1987 15; 136: 398–400.

7. First World Congress of Teledermatology and Annual Meeting of the Austrian Scientific Society of Tele-medicine, 9–11 November 2006, Graz, Austria. Available at: www.teledermatology-society.org/worldcongress.

8. Kristiansen IS, Poulsen PB, Jensen KU. Economic aspects – saving billions with telemedicine: fact or fiction? Curr Probl Dermatol 2003; 32: 62–70.

9. Eedy DJ, Wootton R. Teledermatology: a review. Br J Dermatol 2001; 144: 696–707.

10. Du Moulin MF, Bullens-Goessens YI, Henquet CJ et al. The reliability of diagnosis using store-and-forward teledermatology. J Telemed Telecare 2003; 9: 249–52.

11. Pak HS, Harden D, Cruess D et al. Teledermatology: an intraobserver diagnostic correlation study, Part II. Cutis 2003; 71: 476–80.

12. Piccolo D, Smolle J, Wolf IH et al. Face-to-face diagnosis versus telediagnosis of pigmented skin tumors: a teledermoscopic study. Arch Dermatol 1999; 135: 1467–71.

13. Granlund H. Aspects of quality: face-to-face versus teleconsulting. Curr Probl Dermatol 2003; 32: 158–66.

14. Taylor P, Goldsmith P, Murray K et al. Evaluating a telemedicine system to assist in the management of dermatology referrals. Br J Dermatol 2001; 144: 328–33.

15. Oliveira MR, Wen CL, Neto CF et al. Web site for training nonmedical health-care workers to identify potentially malignant skin lesions and for teledermatology. Telemed J E Health 2002; 8: 323–32.

16. Braun RP, Vecchietti JL, Thomas L et al. Telemedical wound care using a new generation of mobile telephones: a feasibility study. Arch Dermatol 2005; 141: 254–8.

17. Soyer HP, Hofmann-Wellenhof R, Massone C et al. Telederm.org: freely available online consultations in dermatology. PLoS Med 2005; 2: e87.

18. Massone C, Hofmann-Wellenhof R, Gabler G et al. Global teledermatology: a specific web application for dermatological consultation. Internet Health 2004; 3: e3. Available at: www.Internet-health.org/ih200431e03.html.

19. Massone C, Soyer HP, Hofmann-Wellenhof R et al. Two years experience with Web-based teleconsulting in dermatology. J Telemed Telecare 2006; 12: 83–7.

20. Africa Teledermatology Project. Available at: telederm.org/africa.

21. iPath. Available at: ipath.ch.

22. 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.

23. Brauchli K, Christen H, Haroske G et al. Telemicroscopy by the Internet revisited. J Pathol 2002; 196: 238–43.

24. Solomon Islands Telemedicine Network. Available at: telemed.ipath.ch/solomons.

25. LT Telepatologija – Lithuania. Available at: ipath.ch/site/node/441. Also, in Lithuanian, at: telemed.ipath.ch/lithuania.

26. RAFT. Available at: raft.hcuge.ch.

27. Telemedecina Sur. Available at: telemed.ipath.ch/tmsur.

28. West Africa Doctors and Healthcare Professionals Network. Available at: www.wadn.org.

29. HealthNet Nepal. Available at: www.healthnet.org.np.

30. Teledermatology in Port St Johns, South Africa. Available at: ipath.ch/site/node/22.

31. O’Mahony D, Banach L, Mahapa DH et al. Teledermatology in a rural family practice. SA Fam Pract 2002; 25: 4–8.

32. Telemedicine: Online Support for HIV/AIDS Care. Available at: telemedicine.itg.be/telemedicine/site/Default.asp.

33. Swinfen Charitable Trust Website. www.swinfencharitabletrust.org.

34. Wootton R, Bloomer SE, Corbett R et al. Multicentre randomised control trial comparing real time tele-dermatology with conventional outpatient dermatological care: societal cost-benefit analysis. BMJ 2000; 320: 1252–6.

35. Heinzelmann PJ, Williams CM, Lugn NE, Kvedar JC. Clinical outcomes associated with telemedicine/telehealth. Telemed J E Health 2005; 11: 329–47.

36. Aoki N, Dunn K, Johnson-Throop KA, Turley JP. Outcomes and methods in telemedicine evaluation. Telemed J E Health 2003; 9: 393–401.

37. Qureshi AA, Kvedar JC. Patient knowledge and attitude toward information technology and teledermatology: some tentative findings. Telemed J E Health 2003; 9: 259–64.

38. Massone C, Lozzi GP, Wurm E et al. Cellular phones in clinical teledermatology. Arch 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.

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

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:

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:

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:

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.

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

‘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.