Email is emerging as key component of telemedicine infrastructure

A report from the World Telemedicine Summit in Buenos Aires

The certified elimination of smallpox from the face of the earth in 1986 was the greatest public health success story in the world. The second -- but less well known -- success story was the use of IT and telecommunications in the control of river blindness in West Africa earlier this decade.

It involved sensors, telephone lines, satellite links and computers for the surveillance and tracking of the deadly black fly larvae living along 50,000 kilometers of the Volta river, which runs through 11 West African countries.

"Today, new forms of communications and information technology like the Internet are becoming an important part of the national infrastructure for health care around the world," according to Dr. Salah Mandil, health informatics director at the World Health Organisation (WHO).

Participants from around the world gathered recently in Buenos Aires, Argentina, for the International Telecommunications Union's Second World Telemedicine Symposium for Developing Countries.

A Multidisciplinary Approach

Around the world, costs of health care are going up -- but IT and telecom costs are dropping. Governments are also coming under increasing pressure to cut costs, make their services more economically affordable, and privatise sectors like telecommunications and health care.

"The challenge in telemedicine systems is to harness new technologies and operating models while also improving equity in access to high-quality health care," said Mandil.

Telemedicine requires a multidisciplinary approach involving varied sectors like telecommunications, IT, medical experts, general practitioners, hospitals, equipment suppliers, logistics companies, government agencies, social workers and universities. It also brings to the table a wide range of technologies like radio, analog land lines, e-mail, Internet, ISDN, satellites, and tele-sensors.

Telemedicine systems harness information and communications technologies in several ways: for administration and management of health care systems, transferring and storing of clinical data, surveillance during epidemics, publication and search of medical literature, and education and training for healthcare workers, students and individual citizens.

Benefits

Theoretically, telemedicine can provide crucial benefits and savings by reducing the time to travel for doctors, providing faster access to medical expertise (especially during emergencies), using health care resources more effectively, and upgrading skills and knowledge for medical professionals.

For instance, satellite links between hospitals in Mexico City and ten rural hospitals in the Mexican province of Chiapas reportedly reduced unnecessary referrals by 60 per cent. Cancerology resources in France were tapped from Tunisia via satellite connections. E-mail is used heavily by health care researchers at the University of Lusaka in Zambia.

A conference on Alzheimer's disease in Argentina greatly benefited from participation via the Internet. Many cases have been documented on the use of the Net to save lives of patients in countries ranging from China to Turkey.

Medical Literature and Data

Though the Web is not yet well suited for the kind of broadband realtime communications that videoconferencing for remote diagnosis sometimes calls for, it is superbly geared towards the publishing and search of health care literature as well as transmission and archival of image data.

"The function of information sharing, now expanding in developing countries via Internet access, may be the most valauable of all telemedicine applications," said Heather Hudson, author of "Global Connections: International Telecommunications Infrastructure and Policy" and a coordinator at the International Develpment Research Centre (IDRC) of Canada.

In early 1998 the Caduceus Project was launched in Peru for the establishing of a biomedical information system in Spanish on the Internet.

Computer networks are now used to coordinate health monitoring of 700,000 victims of the Chernobyl disaster in Ukraine. Web-based telemedicine projects have been launched by the Ukrainian Association of Computer Medicine, which provides access to online medical information in three languages: Ukrainian, Russian and English.

There are also gateways to online medical resources of Europe such as EuroTransplant, to coordinate services for organ, tissue and cell transplants. Medical universities and research institutes are linked via a three-tier network called "UkrMedNet."

"The Net has helped accelerate the intergation of our medical system into the world informational space," said Dr. Oleg Mayorov, chief medical informatics advisor at the Ukrainian minsitry of health care.

Online academic literature and tele-education systems are becoming an important component of the medical education system and national health infostructure. The growing muscle of the Net can also be evinced from the vast array of resources available from sites like the Telemedicine Information Exchange and Telemedicine.com.

Email

Though full connectivity to Web-based databases may be a long way off for the medical sector in many developing countries, email messaging lists and email-based database gateways can come to the rescue here.

"For example, reliable email services via the Internet have been introduced and used in parts of the health sector of at least 38 of Africa's 49 countries," according to Dr. Mandil of WHO. Over 80 per cent of telemedicine traffic in the world is over store-and-forward messaging networks, he said.

One of the best success stories of email-based medical support comes from SatelLife. This Massachusetts-based non-commercial organisation provides free store-and-forward messaging services for developing countries via a low earth orbiting (LEO) satellite called HealthSat-2.

The HealthNet email service provides literature summaries, expert commentary, event information, and community discussion facilities in numerous fora like the cardiovascular health forum ProCOR, which has participation from health professionals in 51 countries.

The HealthNet network has also been used by burn surgeons in Mozambique, Tanzania and Uganda to consult with one another on surgery techniques.

The Latin American Healthcare Link programme provides email-based discussion and document access services to health care professionals in Peru, Nicaragua and Spain.

Moving Forces

The growing importance of telemedicine was formally recognised during summits like the First World Telemedicine Symposium for Developing Countries, held in Portugal in 1997 by the ITU. The ITU and WHO have formed study groups around the issue, and also conduct pilot projects in partnership with private sector players. The ITU published the "Report on Telemedicine and Developing Countries" last year.

The Midjan Group, part of the European Health Telematics Observatory, provides European telemedicine services to developing countries like South Africa and Senegal. The Observatory has five national language affiliated sites in France, Portugal, Spain, Greece and Finland.

Satellite consortia like Intelsat and Inmarsat have been involved in numerous telemedicine projects. Other telecom and datacom projects to watch for include AT&T's Africa ONE project and Project Oxygen. WorldSpace has three three geo-staitonary satellites AsiaStar, AfriStar and CaribStar for digital audio broadcasting in developing countries.

International NGOs like the Association for Progressive Communciations also provide low cost Internet solutions for non-commercial use in dozens of developing countries. IDRC's Acacia project specialises on providing such Internet resources to African countries.

Till 1995, most telemedicine projects involved cooperation between developed and developing countries, but the Net has helped more South-South collaboration between developing countries in recent years.

Project Challenges

Many telemedicine pilot projects have been launched around the world, but several have faced challenges in areas like measuring the clinical and cost efficacy of telemedince, and in devising norms and standards for the tools, languages and quality control mechanisms used.

Formats for the reportage and documentation of telemedicine experiments and mechanisms for guaranteeing security of patient data are other key concerns. In addition to infrastructure shortages in developing countries, there have been several project assessment challenges as well.

An ambitious teleradiology experiment using imaging equipment and special "telecursors" for interactive diagram discussion was launched by Mauritius Telecom.

But there were was no clearly defined mechanism for evaluating the project, and the equipment was not adequately used by the intended audience, said R. Seenundun, technical head for terminal services at Mauritius Telecom.

"For effective telemedicine, IT use in hospitals should be increased to improve computer literacy. Telemedicine systems should be integrated into the traditional working environment. Adequate training should be provided, and key personnel should be trained," he said.

South Korea launched major telemedicine projects for local medical care centres in farming and fishing villages with satellite and Internet links to the Seoul National University Hospital and Korea University Hospital.

"But such services were not covered by the medical insurance system. There was also lack of clarity on how doctors and hospitals were to charge for such services," said Sung-Ok Lee, informatics director at the Korean ministry of communication.

A mix of Internet and Intranet delivery is used by Argentina's ARGONAUTA service for tele-radiology from hospitals in the city of Cordoba. According to designers of the project, challenges arise in standardisation of medical care protocols, especially with regard to integration with inter-regional or global systems.

Legal, Cultural and Political Issues

Though Web-based aceess to medical literature has skyrocketed, many experts warn that literature published on the Web needs to be carefully checked for authenticity, credibility and copyright conformity.

Telemedicine is meant to augment - and not replace - traditional practices and channels of medicine, but several doctors tend to feel threatened by such new technology-based approaches. Legal liability issues, especially for trans-border communications, are not easily resolved.

Affordable access to quality health care is a fundamental human right, but care needs to be taken to bridge the growing "digital divide" between urban and rural areas, developed and developing countries, and English and non-English speaking nations.

Sustainability of telemedicine projects -- many of which do not go beyond a pilot project stage -- is a key concern, and care needs to be taken to ensure private sector participation in such issues.

A growth industry is booming around telemedicine technologies and services. For instance, the Vision Technology Group in Bogota, Colombia, uses the Internet, satellite and proprietary software for tele-radiology services; it plans to extend its offerings to other Latin American countries.

Many countries are thus in a position to convert their telemedicine expertise into an export earning, but challenges also arise in regulating and monitoring cross-border trade in such practices.

Telemedicine in Asia

The Interactive Medical Curriculum Project is a major APEC (Asia Pacific Economic Cooperation) project for online tele-education cooperation in medicine.

Medical schools in Indonesia, Malaysia, Papua New Guinea, China, Japan, Philippines, Thailand, South Korea and the U.S. are collaborating in this initiative for electronic delivery of interactive medical curricula, according to project manager Anne McLennan.

The HealthNet email service has been available in Nepal since 1995. For a country with scarce medical expertise and uneven distribution of population like Nepal, it is more appropriate to concentrate on simple telemedicine solutions involving low-cost PCs and basic text-based email, said Dileep Agrawal, CEO of the ISP Worldlink Communications in Kathmandu.

His company is working on providing PCs to hospitals, training health professionals on the use of Internet email, and create email discussion lists for consultations.

Multipurpose community telecentres are being launched in Bhutan by an initiative of the International Medical Centre of Boston, with funding from international donors.

In India, telemedicine projects will be implemented next year by the Department of Telecommunications, according to P.K. Agarwal of the Telecom Engineering Centre in New Delhi.

Numerous first-generation Web sites focusing on ayurveda and homeopathy have been launched by Indian entrepreneurs, but Internet-based telemedicine is still at the embryonic stage in India.

One of the best examples of telemedicine in Asia comes from Jordan. In 1997, telecom engineers, heart specialists and two major hospitals founded the teleradiology service HeartBeat Jordan to help reduce the "symptom to needle time" for treating partients of heart problems, which accounted for 45 per cent of the country's mortality rate.

Heart specialists in Amman receive and diagnose ECG data via satellite, land lines and the Internet from medical centres, corporations, hotels, holiday resorts and even the Royal Jordanian Airlines.

Pilot tests have shown that the service can cut down unnecessary referrals and provide better service in many situations, and the company is even becoming profitable this year, according to Dr. Khalil Zayadin of Heartbeat Jordan.

The service is being extended via the Net to other Gulf countries; inquiries are also coming from European countries like Germany. Unfortunately, there is not enough support and recognition coming for the project from health ministry officials.

"The public health sectors in many developing countries have limited resources and even more limited vision. Information and communications technologies tend to be dismisssed as expensive -- but a well-developed solution using these technologies is sometimes the only economically viable solution," said Zayadin. (Madanmohan Rao)