Abstracts

• Experience of, and Hopes for, Telehealth in Tokelau
    â€“  Dr Peter Adam
• Role of the Picasso Phone System in Distance Consultation for Remote Pacific Islands
    â€“  Victor M Yano, MD
• Teleconsultations in Pohnpei State, the Federated States of Micronesia
    â€“  Dr Johnny S Hedson
• The Role of Low Cost Communications in Health to the Redevelopment of the Indigenous Physician Workforce Among Select Jurisdictions of the US-associated Pacific Islands
    â€“  Gregory Dever, MD
• Service-Oriented Training in Public Health. A Model for Enhancing Public Health Surveillance in the Pacific
    â€“  Dr Mahomed Patel
• The PPHSN and PACNET: The Pacific Islands are Now Tuned on the 21st Century
    â€“  Yvan Souarès
• How to Subscribe to PACNET

Experience of, and Hopes for, Telehealth in Tokelau

Dr Peter Adam, Health Development Manager, Tokelau Health Department

The two key factors affecting health care in Tokelau are its small population and its great isolation. Both of these make telehealth a critical issue for the development of health services and it is hard to see how the services can develop to a modern standard without a larger component of telemedicine.

The Situation of Tokelau
Tokelau is composed of three small atolls about 500-km north-west of Samoa. The only access is by boat, usually once a month, but with an irregular schedule. There are roughly equal numbers of people on each atoll, each population is served by a small hospital, and the Department of Health is on the central atoll. There are usually one or two doctors on Tokelau who have to deal with all aspects of medical health care, including all emergencies that there is not time to evacuate by boat. The quota for each hospital is one nurse-manager and two other staff nurses as well as some nurse aides.

No doctor or nurse can work well in isolation, and our most pressing needs in telemedicine are:

1. for the nurses on the atoll without a doctor to be able to consult with a doctor about medical cases
2. for the doctors to be able to consult with each other on management of cases
3. for the doctors to be able to consult with outside specialists on management of cases.

The first two are met quite well by the phone system, but the third is a vital need that is still largely unanswered.

The second greatest area of need is distance education. Even if courses are available and free, a candidate from Tokelau may have to spend a month or two away from Tokelau to attend a course lasting a few days. Also, one person leaving can create critical staff shortages, making it impossible for them to attend an outside course or conference. Distance learning offers quite a lot of hope in our situation.

There are also many secondary needs such as public health networks, disease surveillance, professional associations, ability to search literature and to form groupings with colleagues, which are well summarised in the topics of the meeting.

Relevant Developments in Telemedicine and Information and Communications Technology (ITC) in Tokelau
Although systems are still basic, there have been significant developments in the area of communications over recent years. These have largely arisen because of general administrative needs, rather than from the area of health, but have greatly benefited the health services.

Until about eight years ago, the only form of communication with the outside world was by short-wave radio, which was an unreliable and a difficult system to use. The initial significant move to improve communications came with the installation of PEACESAT terminals on the three atolls. Although there seemed to be a lot of potential, and they had some good use, they largely failed to meet the communication needs.

A full telephone system was installed and became operational towards the end of 1996. It is now the main means of communication, but the cost of long distance calls is a significant barrier.

Recently the management of the Health Department has more fully recognised the needs for ITC [information and communication technology] and has made it a priority area in health development. Initiatives are now coming from within the Health Department. The conference is very timely for us.

As well as being pleased to contribute what seems like the little experience that we have, Tokelau wishes to participate in the conference largely to learn about solutions, and involve itself in the broader initiatives underway in the Pacific.

Dr Johnny S Hedson, MBBS, MMed (Surgery) – General Surgeon, Pohnpei State Hospital

1. Case Presentation
A 6-year-old female sustained a difficult right subtronchanteric fracture of the femur. She was treated satisfactorily and successfully, with local materials, over the Internet with assistance from the orthopaedic surgeons at the Tripler Army Medical Center in Honolulu, Hawaii.


2. Teleconsultations
Pohnpei State, with a population of 40,000, spends 10% of its health budget in referring patients off-island for tertiary treatments, serving less than 1% of the total population. The aim of teleconsultation in Pohnpei State is cost savings, and to enable physicians to be readily accessible and comfortable with its use. Before the Internet connectivity, approximately $US1,500 per month was spent on telephone bills for outside consultations. With the Internet connectivity and the consultation web pages, particularly at Tripler, the bill has gone down to below $US500 per month for consultations, a saving of $US1,000 per month.

Fifty consultations, via the Internet, have been sent so far to the TAMC Consult Web Page since the inception of this teleconsultation process.

More than 50% were surgical cases, of which 35% of the cases were sent and treated at Tripler, whereas 25% of these surgical cases were still pending referrals.

The difficulties so far have been limited on-line access, and the computer illiteracy of most physicians.


3. Conclusions
The recent introduction of the teleconsultation process to the Pohnpei State health services has resulted in considerable cost-savings, in terms of communications, and perhaps in the avoidance of unnecessary off-island referrals.

The Role of Low Cost Communications in Health to the Redevelopment of the Indigenous Physician Workforce Among Select Jurisdictions of the US-associated Pacific Islands

Gregory Dever, MD, Co-ordinator, Pacific Basin Medical Association; Former Director, Pacific Basin Medical Officers Training Program, Pohnpei

Low cost communications in health are the key to the strategic redevelopment of the indigenous physician workforce among select countries of the US-associated Pacific Islands. In conducting the Pacific Basin Medical Officers Training Program from 1986 to 1996, the University of Hawaii established five key strategic objectives to train and support physician graduates from the Freely Associated States of the Federated States of Micronesia and the Republics of the Marshall Islands and Palau. These objectives were:

1. conducting a basic medical education program which graduated 70 physicians
2. promoting regional internship training programmes
3. assisting in establishing formal postgraduate training opportunities
4. re-establishing a regional physicians’ professional organisation
5. promoting both regional and local continuing medical education activities.

Inherent in the medical school training process was familiarising students with hands-on research methodologies, use of computers and information systems and the processes of “store and forward” distance medical consulting.

Traditional medical communications, such as the development of the Pacific Health Dialog, a journal of community health and clinical medicine for the Pacific, have been augmented by rapidly developing electronic communications technologies. Recently, e-mail and Internet processes have promoted access to and the use of low cost communications in health, thereby further reducing professional isolation among the new physician workforce in Micronesia. This paper documents the regional development of expanded access to medical information and distance medical communications technologies and processes, including CD-ROM, Epi-Info, Picasso Phone, e-mail, and web-site-based consulting and medical information search activities, which have been implemented to support the professional needs of the regional health workforce. Such activities have enhanced, and are currently enhancing, the further implementation of the strategic objectives for intern training, in-country postgraduate training development, professional association development and continuing medical education.

Service-Oriented Training in Public Health. A Model for Enhancing Public Health Surveillance in the Pacific

Dr Mahomed Patel, National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australia

1. The Need
Every country needs the capacity to continuously measure and analyse the health status of its population. It does so through public health surveillance. Surveillance is not simply the collection and reporting of health data. Surveillance tells us where health problems are, who is affected, and where prevention and control activities should be directed. It helps us to define priorities for health programmes and policies, and also to evaluate their effectiveness.

Without practitioners skilled in managing a system of public health surveillance, the quality of assessment of a population’s health status will be deficient and the resultant public health responses may even be harmful. Without valid surveillance data, the allocation of scarce health resources will be more likely to be driven by other vested interests, and not primarily by the needs of the community.

In December 1995, SPC (the Secretariat of the Pacific Community) in collaboration with WHO and UNICEF sponsored the Inter-agency Meeting on Health Information Requirements. This meeting recorded the concerns related to the accuracy, quality and usefulness of surveillance data in the Pacific. Later on, the Pacific Public Health Surveillance Network was formed to develop and implement strategies for enhancing surveillance.


2. The Challenge
While various agencies conduct training in surveillance for health professionals from the Pacific, such training is not done in the co-ordinated and efficient manner needed to ensure professional and institutional development aimed at capacity building.

Training in surveillance should not be conducted as another vertical programme. It should embody the principles for training articulated in the Pacific through the Yanuca Declaration, the meeting on Postgraduate Medical Education in the Pacific, and at the conferences on Community Health in Medical Education held between 1991 and 1997.


3. The Response
The Pacific should adopt the service-oriented model of training that integrates training in surveillance with training in public health.

In this model, the trainee is based in the workplace, and the process of training itself contributes immediately and directly to enhancing surveillance and other public health activities and capacity building.

Who to train?
Training should be offered to all health professionals.

As many public health practitioners and generalist clinicians in the Pacific provide clinical and public health services concurrently, they could participate in the same training pathway in public health.

Clinical specialists are important role models in society; their commitment for enhancing surveillance must be secured.


How to train?
The training model is integrated with public health practice and incorporates continuing education and graduate degree training.

It would include training in data collection and using the data for decision-making at the point of collection, ie at the primary health care level.

Specific educational objectives for continuing education and graduate degree training should be based on the needs of the practice environment. Training should be hierarchical so that it provides the competencies that are necessary for effective performance at different levels of the health system.

Graduate degree training in surveillance should be integrated with public health training (basic, intermediate and advanced).

The graduate programme includes the Field Epidemiology Training Programme with its major strength in enhancing competencies for managing all aspects of surveillance, including public health responses and policy making.


Where to train?
Continuing education and graduate degree training should be conducted primarily in the workplace.

Some didactic work will be required, but tutorials and exercises or assignments should be anchored to the real-life experiences in public health units to be accredited as training centres based on specified criteria.


How to organise the training programme?
The organisational framework of the training programme should incorporate all the potential partners.

The SPC should provide leadership as the Centre for Co-ordinating Service-Oriented Training in Surveillance, appoint an advisory board constituted of the programme partners, and co-ordinate the development of the continuing education programme.

The University of PNG and the Fiji School of Medicine should be invited to submit expressions of interest in developing and incorporating training modules in surveillance into their graduate degree programmes.

Graduate degree trainees should have supervisory academic and field support. Field support should be provided through the senior public health practitioner based in public health unit and in health agencies.

4. Looking Ahead
Options in planning, implementing and evaluating the training programme should be considered and judged against criteria for ensuring sustainability and capacity building.

The benefits should be sustained through the efforts of trainees and graduates, as well as through the national health departments, training institutions and regional and international agencies. The result should be strong surveillance programmes with national and regional capability for responding to adverse health problems and for promoting a healthy Pacific.

The PPHSN and PACNET: The Pacific Islands are Now Tuned on the 21st Century

Yvan Souarès, Epidemiologist, Secretariat of the Pacific Community, Noumea, New Caledonia

In this age of jet travel and global tourism, few places, few people and fewer pathogens are more than two days from any other. Potentially epidemic diseases are moving easily and rapidly throughout the Pacific. Health information and resources must travel faster to prevent outbreaks of communicable diseases. Yet health professionals in the Pacific face some difficulties in getting timely and accurate information. This results partly from a lack of integration of data requirements between international agencies and national institutions.

The Pacific Public Health Surveillance Network was established in December 1996 to decrease the pressure on the data providers and to improve the regional public health surveillance.

A new communication network was established in 1997 to enhance information dissemination within the PPHSN and between the Pacific region and the rest of the world. The network takes advantage of advances in information and communication technology. The system called PACNET primarily uses e-mail, and fax to a much lesser extent, to network health professionals, national ministries of health, universities, regional and international agencies (e.g., Unicef, World Health Organisation, the Pacific Community). Its purpose is to share timely information on outbreaks, so that Pacific island countries and territories might take appropriate actions, when a threat for the communities is identified. Moreover, PACNET gives its members access to diagnostic facilities not available in-country, and help them to mobilise appropriate resources for outbreak prevention.

Since its launch in April 97, PACNET has been used mainly as an early warning system. E-mail membership increased by 275% in the first 18 months. The system currently links 215 health-related professionals, working in operational areas such as public health laboratories, epidemiology, virology, immunisation, general practice, and travellers’ clinics. While slightly over one-half of the members are based in the Pacific Islands, 80% are in the Pacific, including Australia, New Zealand and Hawaii. In 19 months’ operation, the efficiency of PACNET has been demonstrated through its contribution to the prevention and control of epidemics in the Pacific Island countries and territories. Major health problems and expenditure have been avoided. The fact that PACNET has cost SPC (the Secretariat of the Pacific Community) and PPHSN only US$850 to date highlights its role in cost-effective regional public health surveillance.

PACNET is accessible on e-mail and through the web (http://www.spc.org.nc/phs/).

Among aims for PACNET are increased access for Pacific Islands health professionals and the development of specialised discussion lists, for example on communicable diseases and climate changes, fever surveillance and laboratory networking, operational research, distance education for public health training, regional networking and professional associations.

How to Subscribe to PACNET

Send the following e-mail message :“subscribe PACNET“ (not using quotes, not case-sensitive) to the following address : LISTSERV@LISTSERV.SPC.ORG.NC

OR

go to the SPC web site and consulting the Public Health Surveillance page at the following address : http://www.spc.org.nc/phs/.