Telemedicine in the Pacific

• The Need for Telehealth in the Pacific
• Telemedicine as a Cost-effective Approach to Off-island Referral Care
• Technology for Networking Health Professionals
• Developing an Operational Plan for Integrating Methods and Resources for Distance Consultation
• The Action Plan for Integrating Methods and Resources for Distance Consultation

The Need for Telehealth in the Pacific

Medical practitioners in the Pacific often operate in relative isolation, dealing with diverse health care needs, many of which arise infrequently because of the small populations served.

Dr Kamal Gunawardana, TeleMed Co-ordinator, Ministry of Health and Environment, the Marshall Islands, identified professional isolation as a key consequence of the geographic constraints imposed on physicians working in an atoll-like environment such as the Marshall Islands.

Dr Peter Adam, Health Development Manager, Tokelau Health Department, described the health care situation in Tokelau, which provided a good example of the types of issues facing isolated health professionals in Pacific communities.

Key issues affecting health care in Tokelau are its small population and its isolation. One or two doctors work in Tokelau’s three atolls. Each atoll is served by a small hospital with one nurse manager, two staff nurses and a number of nurse aides.

The most pressing telemedicine needs of those operating in this relative isolation are for systems or processes that allow:

• nurses to consult doctors on medical cases when doctors are not available on the atoll
• doctors to consult one another on case management
• doctors to consult external specialists on case management.

A recently installed full telephone system, replacing the PEACESAT terminals on the three atolls, addresses the first two needs but the cost of long distance calls is a significant barrier to its use. The third requirement is as yet largely unmet and telemedicine is seen as key to the development of health services that operate to a modern standard.

Recently the management of the Health Department in Tokelau has recognised more fully the need for information and communication technology and has made a such technology priority area in health development. [Click here for Adam abstract]

Telemedicine as a Cost-effective Approach to Off-island Referral Care

New communication technologies have numerous cost-effective applications in medicine and health. A key role is in allowing health professionals to network, especially in the field of off-island referral care.

Victor Yano, President of the Pacific Basin Medical Association, outlined the need for better communication links between local practitioners and overseas specialists.

In general, the US-affiliated Pacific Island nations spend over 10% of their total health budget on off-island referral care to tertiary centres in Guam, Hawaii and the Philippines. The Tripler Army Regional Medical Center (TAMC) in Honolulu, Hawaii, provided this service almost exclusively in the pre-Compact years (1980) and continues to support the islands in the Compact years. The Compact Agreement established between the different Micronesian political entities – the Republic of Palau, the Republic of the Marshall Islands and the Federated States of Micronesia – and the United States in the early 1980s, relates to grants available to the political entities. The Agreement formalised the way that development aid is channelled from US federal agencies to the US freely associated states.

The process of getting a patient transferred off-island depends on factors both at a local level and at the receiving end. Transfer protocol differed in each jurisdiction, specialists at TAMC often changed and local providers had individual levels of access to the consultants. There was a clear need for better communication links.

Prior to 1995, communication largely relied on long-distance telephone calls, faxes and regular mail.

The situation has changed with the use of new tools such as still-image telephone systems. With this small device, freeze-frame images are captured at the sender’s end by a camcorder and are transmitted to a remote receiver unit where they can be displayed and stored. A typical medical consultation involves transmission of about three images, with each transmission over the 28.8 kbps modem taking approximately one minute. A separate consultation form about the patient is faxed to specialists of the referral hospital.

This approach is the first that allows colour images of patients, patient data, and x-ray images to be transmitted with the submission of a written medical report. [Click here for Yano abstract]

Dr Johnny Hedson, from the Federated States of Micronesia, highlighted that Pohnpei State, with 40,000 people, spends 10% of the health budget referring patients off-island for tertiary treatments, serving only 1% of the total population.

The aim of using teleconsultation in Pohnpei State is to create cost savings and to ensure that physicians are readily accessible. Before the Internet era, approximately US$1,500 per month was spent on telephone bills for outside consultations, mainly with overseas specialists. The TAMC consultations web page was set up to allow practitioners to follow up cases sent to TAMC, where most of the referral patients are treated, and exchange views with specialists. With Internet connectivity and the web page the bill has decreased to below US$500 per month for consultations.

In addition to cost savings in communications, the recent introduction of the teleconsultation process to the Pohnpei State health services may mean the avoidance of unnecessary off-island referrals.

Fifty consultations have been submitted via the Internet to the TAMC Consult web page since this teleconsultation process was established.

A case study presented by Dr Hedson was that of a 6-year-old girl who sustained a difficult right subtronchanteric fracture of the femur. She was treated satisfactorily and successfully, with local materials, with assistance provided over the Internet from orthopaedic surgeons at the Tripler Army Medical Center in Honolulu, Hawaii. [Click here for Hedson abstract]

Other Pacific countries and territories benefit from these communication tools which link practitioners to overseas colleagues. For example, telemedicine activities have been operating in Majuro, the Marshall Islands, for over seven months, mainly confined to referrals and teleconsultations, as highlighted by Dr Gunawardana, Ministry of Health and Environment, the Marshall Islands.

While there is widespread support for the development of e-mail and Internet applications in medicine and health, some issues still exist. The main difficulties so far are limited online access and the computer illiteracy of most physicians.

Technology for Networking Health Professionals

Dr Yvan Souarès, Epidemiologist, Secretariat of the Pacific Community reviewed the different approaches used for networking health professionals, which were based on the initial objectives of the two regional health networks operating throughout the Pacific.

The Pacific Basin Medical Association and WPHNet have focussed on doctors and telemedicine primarily because their objectives were closely associated with the sustainability of the Pacific Basin Medical Officer Training Program training efforts.

The Pacific Public Health Surveillance Network, which is served by the e-mail-based communication tool PACNET, started by targeting a wider audience, both geographically and professionally, because the key objective was public health surveillance at national and regional level.

The actions of the two networks in pooling resources should mean an expanded scope of services for Pacific Island-based health professionals, through an integrated ‘network of networks’ and enhanced efficiency in Pacific Island nations’ health care systems. [Click here for Souarès abstract]

Developing an Operational Plan for Integrating Methods and Resources for Distance Consultation

An operational plan for integrating methods and resources for distance consultation was developed through panel discussions at the conference. As part of this process, the panel considered the development of a single entry point for requests for service in the form of a joint PACNET/WPHNet web site.

The discussion highlighted that the web site should serve audience needs, providing information and services that met core objectives, and should not offer too many superfluous features. However, technological sophistication was recognised as necessary, for example, to transmit digital images for long distance medical consultation.

The panel identified the following concerns to be addressed in relation to the development of the web site:

• legal considerations, particularly as they relate to clinical consultation
• policy concerns
• issues related to service groups’ existing relationships and obligations [eg TAMC obligations to US-affiliated Pacific Island nations, New Zealand Overseas Development Assistance (NZODA) obligation to certain South Pacific jurisdictions]
• equity of service issues (endeavours should be made for all jurisdictions to have access to the same range of services and technologies)
• issues related to dissemination of information, for example, limited e-mail access.

Establishing the site will also demand that the following be defined:

• core goals of the web site and their priority order
• the need to archive cases within the proposed web site – reasons for and against
• requirements for countries participating in the web site
• clinical and public health needs
• government commitment to low cost telecommunications for health and education usage, including, but not limited to, money issues and bandwidth
• skills that need to be learned to efficiently use a clinical consultation service given the available technology.

The proposed development of such a site also raised a number of technology-related questions:

• What technology is currently available to all of the countries?
• Who will programme the site; where should it be housed; what format is most practical?
• What types of complementary technology, for example, phone, fax, e-mail, are currently in place?
• Which location, offering a large bandwidth, is the most cost-efficient?

The panel summarised perceived service needs as follows:

Clinical medicine

• to identify and access appropriate medical consultants and resources
• to provide distance consultation to remote providers for urgent/immediate consultation and referral
• to transmit digital images for consultation
• to provide a forum for general discussion in matters related to clinical care.

Public health

• to provide an early warning for disease outbreak investigation as a surveillance system
• to obtain assistance on managing a disease outbreak
• to assist in confirming a disease outbreak through laboratory assistance
• to provide a forum for general discussion in matters related to public health.

Provision of materials/information/data

• to supply literature searches related to research or to clinical care
• to supply health education materials
• to allow access to medical libraries and other medical information resources.

The requirements for ongoing education and an archival service to record previous PACNET and WPHNet activities were also raised.

An area for concern was the risk of losing functionality from merging the clinical system WPHNet and the public health system PACNET. Other concerns related to the cost of and access to available communication technologies, and the possible difficulties convincing politicians and leaders of the need and value of the service. The requirement for smaller entities and jurisdictions to be able to voice their concerns and objectives so that the project reflected all real needs, not just those of the larger more vocal groups, was also raised.

The discussion identified the need for project sustainability through measures such as adequate funding, local training, technical support and service of components.

The following were proposed for consideration with respect to the suggested actions:

• preparing of an incremental development plan with a focus on providing distance consultation to remote providers
• defining the scope of services desired to identify needed resources and develop services
• considering cross-hosting the two existing services as a first step (mirror or link)
• developing sub-lists on particular subject areas for each existing service
• considering the desirability and advantages of developing a centralised entity, for example SPC (the Secretariat of the Pacific Community) or the Fiji School of Medicine that could:
  
  
  • identify and liaise with consultants/resources in clinical medicine
  • identify and liaise with consultants/resources in public health
  • triage consultation requests
  • monitor and evaluate the consultation process
  • co-ordinate action and funding
  • triage requests for materials and information
  
  
• utilising and capitalising on existing functional relationships
• pursuing activities to raise awareness among jurisdiction leaders/policy makers to gather support (conceptual and financial) for necessary activities and changes
• forging common relationships and concerns, and developing common objectives
• using local health and library associations for developing local health related projects.

The Action Plan for Integrating Methods and Resources for Distance Consultation

The following action plan was proposed: