Ebook: Establishing Telemedicine in Developing Countries: From Inception to Implementation

Telemedicine is not new. As is the case for many innovations, it has taken decades for telemedicine to enter the mainstream as a health care delivery system. Even today, in economically developed countries, the percentage of patients receiving their health care by telemedicine is relatively small although there are exceptions. For example, inmates in correctional facilities in certain jurisdictions in the United States are heavy users of telemedicine services. In some rural communities, nearly all hospital-based radiology imaging is done by teleradiology. There is a growing number of successful telepsychiatry and teledermatology practices in the United States. Many other subspecialties are having their successes as well.

Implementation of telemedicine in unique environments can present special challenges. The multi-author book, “Establishing Telemedicine in Developing Countries: From Inception to Implementation”, touches many factors that may be unique to developing countries. However, the main theme is the state-of-the-art in telemedicine. The volume is based, in part, on the presentations at the First Intensive Balkan Telemedicine Seminar, held in Prishtina, Kosova, 25-27 October, 2002. Topics ranged from telemedicine applications, including robotic surgery and home health, to telemedicine and telehealth economics.

The books' editor, Dr. Rifat Latifi, is a brilliant academic surgeon who played a key leadership role in implementing telemedicine in Kosova. Currently, he practices surgery in Arizona. Dr. Latifi is attuned to factors that affect the sustainability of telemedicine programs and he understands the differences between health care systems in economically developed countries and in developing countries. He is also a technophile who correctly sees innovation as a cornerstone to future improvements in health care for his patients. To some extent, this book reflects his interests and priorities, and these are rock solid.

The book consists of 26 chapters by international experts in a number of fields. Dr. Latifi encouraged the authors to be forward thinking and they have responded well to this challenge. The chapters present a broad vision of the future of health care as pictured by individuals who understand the potential importance of information technologies, telecommunications, and robotics as enabling and transforming technologies for health care.

Whereas the book's title indicates a focus on establishing telemedicine in developing countries, the authors often paint their pictures with somewhat broader strokes. From the perspectives of this book and it's editor, all countries are “developing countries” with respect to telemedicine. Although there is a world of difference between economically developed countries with fully functional health care delivery systems and those with little or no health care infrastructure, no country can fully leverage the power of computers, information technologies, telecommunications, and robotics, at this point in time. Today's rapid rate of innovation precludes health care systems from catching up with the state-ofthe- art in technologies. Even in economically developed countries, health care systems have gaps between system-wide implementations of technologies and the promising technologies that are in the pipeline for future implementation. Latifi's “developing countries” are, in some ways, a metaphor for twenty-first century health care systems everywhere. There will always be gaps between what visionaries foresee and what exists today. Latifi's edited volume underscores this disparity and showcases a glimpse into the future. These progress reports are informative and often thought provoking. Hopefully, the developing countries as well as the underdeveloped nations will be among the beneficiaries of these inspirations and visions.

Ronald S. Weinstein, M.D.

President, American Telemedicine Association

When a topic so synonymous with advanced technology as telemedicine needs a written history, perhaps a discipline has come of age. Telemedicine has had an oral history among visionaries and technophiles over the last thirty years or so. Tales of grand projects, technical failures and fabulous successes abound at telemedicine meetings. One is reminded of the film footage of early efforts at flight where extravagant engineering approaches failed time and time again until the elegant solution of the Wright brothers took to the air on the beach at Kitty Hawk in December 1903. It is hard to imagine the frustration and excitement of initial efforts at telemedicine or manned flight when current expectations are for information on demand and on time departures. However, from very early efforts in telemedicine the vision was consistent: overcome the huge liability of distance in patient care by creating an electronic continuum between the site of need and the site of expertise. The vision continues to strive toward technical transparency and clinical results, which assure a patient that no matter who, no matter where, no matter when medicine will care for you with consistent professionalism. Technology took us from the patient home to the technology-rich hospital. Perhaps technology will transfer the majority of patient management back to the comforts of home, convenience of workplace or the exigencies of travel and mobility.

It is a great honor to contribute in a small way to this book which in a way celebrates the continued evolution of telemedicine in Kosova. I was privileged to visit this brave land on several occasions in the last years. Severe circumstances were repeatedly resolved through great personal and professional sacrifice. Revolutionary solutions have been applied where evolutionary development was simply too slow in the realization of a new land in a complex world. In some ways telemedicine is emblematic of such struggle and success. We aspire to world health when world peace is elusive and hunger haunts us in the midst of plenty. Telecommunications have made it easy to report the failings of medicine, the injustice of health care and the unmet promise of political endeavor. It is the promise of telemedicine to use those same channels of information to empower, unify and advance the cause of health rather than only report the failings. Telemedicine entails the use of telecommunications and information technology to support the delivery of health care at a distance.(1,2). There are critics who believe telemedicine is a waste of precious resources, which are needed urgently for higher health priorities. Telemedicine is dismissed as an expensive irrelevance, another distraction from the real needs of medicine in a chaotic world. That is patently ridiculous. Telemedicine is a part of the wider phenomenon of information and information is arguably the strongest change agent in play for medicine and other societal elements as well. A well-informed public armed with the tools for self-determination and the evidence for efficient action cannot be corrupted. Telemedicine is a part of the great change information brings to the world order, a drastic change toward a better world of health and justice.

Malaysia's experience in implementing the Integrated Telehealth Project has placed her way ahead in the arena of world Telehealth. Thus, she has become the focus point, reference point and benchmark for similar endeavors around the world. In fact, it would not be presumptuous to state that the Integrated Telehealth project is a trail-blazing pioneer with e-leadership experience and skills developed over the last few years. It is hoped that the Integrated Telehealth concept will find acceptance and credence globally.

The collection of data is a vital step in assuring that a system works, a method is correct and the process is adequate. As data is collected databases are created. These databases could be nothing more than a box or it could be in a computer-based, indexed database. Over the past 200 years, technology has played an increasingly larger role in health care delivery. With the advent of telecommunications capabilities and information systems, medicine has embraced these two disciplines, resulting in a new tool – telemedicine. This new tool is undergoing rigorous peer review and scientific challenge. This has lead to a plethora of data, which indicates telemedicine is an excellent tool for medicine.

Implementing a telehealth program can be a financial challenge due to associated costs such as hardware, software, networking, administration and clinical expertise. To maximize potential and minimize costs, it makes sense to leverage existing telecommunications infrastructures and tailor the program based on what is available.

This chapter is based on a study of the characteristics that drive successful and unsuccessful telemedicine programs. In 2000 the International Society for Telemedicine (ISfT) asked AMD Telemedicine to present our observations of what characteristics appeared to be common to successful telemedicine and telehealth programs. To find out, AMD Telemedicine conducted a study of over 60 telemedicine programs in three countries. During this review, we identified ten basic points and documented successful and unsuccessful approaches to each. There are exceptions, but the approach to each of these issues appears to maximize the likelihood of success or failure. The findings were initially presented to the ISfT membership at their conference in Denmark. The study has been updated continuously as new information becomes available. The most current observations are as follows.

The evolution of telemedicine information systems involves the general processes of acquiring useful knowledge from medical data sets for diagnosis, intelligent efficient patient record transmission and autonomous adaptation of biomedical devices and their related software environments using quality of service attributes. Knowledge engineering concepts and methods allow application to the design of intelligent telemedicine platforms, satisfying the performance requirements and the quality assurance criteria of each specialized telemedicine application.

The Integrated Telehealth Project of Malaysia is considered a principal enabler for the nation's Vision 2020 as well as the National Health Vision. Being in such an unenviable position, of being not only the pioneer for such an integrated project, but also with no benchmark to compare with, the project implementers have faced manifold challenges along the way. This chapter deals with some of the challenges and lessons learnt that have accumulated as the project progressed.

The provision of healthcare from the distance is extremely important in primary care for all nations in the world and especially as a humanitarian response for developing countries. International experience has demonstrated the clinical value and the technical feasibility of telemedicine-based patient care and service collaboration in primary care. Various models are proposed herein on the basis of the available technological driving forces, arrangements and current practices.

The new information and communication technologies, telematics – such as the Internet, telephone services and videoconferencing – are simultaneously both an instrument and a symbol – a sign of progress – but also a potential addiction problem. Sensitive topics – like substances or mental health – bring out all these characteristics of telematics. Therefore the computer world, substances and addictions are closely connected.

Every year many disasters cause thousands of injuries, deaths, refugees. Earthquakes and war often cause severe injuries (burns; amputations; Crush-Syndrome; gunshots; landmines; nuclear, biological or chemical warfare / hazardous material; infectious diseases; pediatric specialties). Referring to big earthquakes in the last few years up to 20.000 thousand people were killed (India 2001). 310.000 deaths were caused by war in 2001.

The Mass Casualty Incident is characterized by the disbalance between victims and the normal community emergency response. Because of this a lot of different institutions and organizations are involved in coping with the disaster. This produces an extensive demand of qualified Command, Control and Communication (C3). Furthermore a lot of data has to be collected during the treatment and the injuries need special medical treatment.

The use of health telematics in disaster response helps to cope with the scenario. Modern technologies provide support for building up medical aid although the normal infrastructure is destroyed. To cope with disaster scenarios there are some telematic tools which can be used: computer based Command and Control System, telemedical support, and data-resources-network/Medical Intelligence.

The International Center for Telemedicine at the University of Regensburg Medical Center provides support for Health Care Professionals as a competence center for telemedicine. For the eastern part of Bavaria it develops a telemedical network with many components: The mobile emergency care system NOAH (Notfall-Organisations-und Arbeits-Hilfe) supports the Emergency Medical Service. Local Health Networks and the Clinical Network of Eastern Bavaria connect physicians and hospitals with the Regensburg Medical Center. With an online-education tool participants from all over the country can take part in trainings and courses.

That distribution of specialists in neurological sciences worldwide is lopsided is an accepted fact. That, increasing the number of specialists, providing them with the requisite infrastructure and maintaining high standards to provide neurological and neurosurgical surgical care worldwide is just not possible, is also accepted. Patients from suburban areas are sent to the limited number of tertiary neurosciences referral centers, incurring expense and time and resulting in overwork at these centers. It is easier to set up an excellent telecommunication infrastructure, to increase the reach of the limited number of urban specialists, than to put them in suburban areas.

This chapter will review the current state-of-the-art of home health services in the telemedicine environment. Special attention will be paid to some of the studies that our telemedicine program has conducted in the past few years. The chapter will conclude with some recommendations and a look to the future.

Training and instruction are activities deeply ingrained in human relations and derive from the critical need for the young to learn survival skills. The responsibility in primitive society for such training almost certainly fell to parents who continued their pedagogical role after childhood issues to include hunting, gathering, fine motor activities and other life skills needed for personal or family survival. Such instruction only ended when the young were ready for independent life and contribution to tribal well-being. Delegation of teaching to others was inevitable. Teaching has become a specialty and has at least one interesting story in ancient literature. Ulysses was certain to be away at the Trojan War and subsequent adventures for many years. He would not be able to provide his son, Telemachus, with the guidance and training to prepare him for adulthood [1]. Therefore, he asked Mentor to act In Loco Parentis and instruct the young man toward competence and adult success. Teaching as a profession and discipline has been through many stages and many controversies. Socrates was a great teacher with a distinct technique for learning by questioning. His influence on his students was profound. Plato was such a good student he recorded all the master's works. Socrates has never been credited with even the briefest lecture note. As great as he was Socrates was forced to drink the bitter hemlock because his teaching was considered a corruption of youth rather than a proper preparation for effective adulthood [2].

Dissonance between the expectations of learners, parents and teachers has a rich history. Certainly even now education is not something the professoriate may invent for the naïve learner and then expect grateful acquiesce with faithful learning. Learning has -dimensions in human psychology and communication. The learners' autonomy, privacy and motivation cannot be denied. Learning is collaboration with teacher and the endpoint is the acquisition of new knowledge or skill.

At the Department of Surgery of the Karl-Franzens University Hospital, a number of programs are available that use new technologies for training of students, interns and residents. The first project, the Virtual Medical Campus Graz (vmc.uni-graz.at) is one of the “New Media in Teaching at Austrian Universities” projects. The general objectives of this initiative are innovation in teaching, intensification of contacts and easier access to education: The second project is virtual laparoscopy and surgical training. Unlike the traditional training modalities, computer-based training provides efficient and effective learning through an objective training tool that can assess learners' performance. It is to be expected that new media and technologies will continue to provide innovative approaches to learning and that the competition between new and traditional systems will continue to enliven the educational scene.

Although the many advantages of laparoscopic surgery have made it an established technique, training in laparoscopic surgery posed problems not encountered in conventional surgical training. Virtual reality simulators open up new perspectives for training in laparoscopic surgery. Under realistic conditions in real time, trainees can tailor their sessions with the VR simulator to suit their needs and goals, and can repeat exercises as often as they wish. VR simulators reduce the number of experimental animals needed for training purposes and are suited to the pursuit of research in laparoscopic surgery.

The idea to create the Telemedicine Project of Kosova and the International Virtual e-Hospital Network of Kosova, was presented at G8-Meeting, in Berlin May 4-5, 2000, by the senior author (RL) then Assistant Professor of Surgery at Virginia Commonwealth University, in Richmond, Virginia during the presentation, the “The anatomy of war and destruction of Kosova: The alumni view on reconstruction of heath in Kosova”. Following wide spread acceptance by many countries and institutions around the world of the idea of creating a virtual e-hospital in Kosova” became a reality. To ensure the creation of a telemedicine center and realization of the project in Kosova, the Telemedicine Association of Kosova was created in Prishtina, September 30, 2000. On February 2, 2001 a Memorandum of Understanding (MOU) for the implementation of TPK was signed between all stakeholders in health in Kosova.

After extensive preparation, with the funding from the European Agency for Reconstruction, the Telemedicine Center of Kosova (TCK) was inaugurated on December 10, 2002, making way for the official beginning of the first phase of development of the TPK. This historical moment for Kosova and for the Balkan countries received extensive media coverage locally and abroad.

Currently we are at the second year and phase of TPK realization. The Telemedicine Center of Kosova (TCK) is a state-of-the-art telemedicine center, the best in the Balkan and southeastern Europe. As such TCK is providing basic foundations for development of educational medical programs within the Kosova's medical system; as well it is establishing the standards of regional and international consultations and collaboration in the Balkan Peninsula. Furthermore, it is providing a solid basis for creation of human capacity that will lead and implement telemedicine program in the nine regional telemedicine centers of Kosova, for many years and decades to come.