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Volume 3 - No.2 - 1998

Telemedicine Meets the Global Village
By Daniel Epstein and Richard L. Vernaci

While the idea looks new, it really is not. In a sense, telemedicine has been around for more than three decades, pioneered by the space programs of the former Soviet Union and the United States to allow medical teams on the ground to monitor the physical conditions of astronauts in orbit or journeying to the moon.

In the time that has passed, this space-age technology has become more accessible to people on Earth, aided by the development of personal computers and the Internet. During the last few years, the equipment has become cheaper and better, while the Information Highway is reaching into some of the most inaccessible places on the planet.

A few notable examples:

  • Varig Airlines of Brazil recently has become one of a growing number of commercial air carriers to purchase onboard equipment, including defibrillators and monitoring devices that will allow crew members to deal with serious medical emergencies in flight under the direction of doctors receiving electronic data on the patient via airphone.
  • A team of climbers attempting to reach the summit of Mt. Everest earlier this year were wired with tiny sensors and transmitters to give doctors half a world away real-time views of the effects of altitude, cold, and fatigue on the team members. In addition to monitoring standard vital signs, plans even called for transmitting information on neurological function.
  • Prison inmates with conditions that warrant examination by specialists no longer get to venture outside the walls for a trip to the doctor. Instead, the prison physicians transmit data via telemedicine networks to the specialists, who can examine X-rays, see videos, and look over EKGs to render a diagnosis and prescribe treatment.

Information Access Closes Distances

In more everyday situations, medical professionals working in some of the most challenging areas of the Americas are becoming empowered through access to medical libraries and databases around the world, as well as to reach specialists for consultation on difficult cases.

"Most of public health and preventive medicine involves the transfer of information," says Dr. Ingrid Libman of the University of Pittsburgh. "The difficulty we face is that the methods of information transfer in public health and prevention are still those that were used 50 years ago: word of mouth, postal systems, and telephones. If we can apply telecommunications to preventive medicine, we will expect great improvement in health in the developed and developing countries alike."

"Healthcare practice will change dramatically in the coming years," says Dr. Roberto J. Rodrigues, Coordinator of the Health Services Information Systems Program at the Pan American Health Organization (PAHO). "Applications that use telecommunication-based technologies are rapidly entering the mainstream of health practice well beyond the institutional environment where they were initially developed. The motor behind the interest in these technologies is their growing availability and affordability, the drive to extend access to and improve quality of health services for a larger number of individuals, and the desire to establish sound evidence-based health practices."

According to Professor Ricky Richardson of WorldCare UK, one of the pioneers in the field of telemedicine, "This process is creating the largest repository of medical skills and academic expertise in these areas in the world today. In this way, vast medical resources, normally locked inside major health care institutions, will become readily accessible to the global health care community."

The new technologies have applications that reach beyond the clinical setting and into the medical classroom.

"At the University of Pittsburgh, for example, a master's degree in public health costs about US$ 50,000," Libman says. "We are developing a distance education program through the Internet where instructors from Mexico or Chile can train students in Bogotá, New York, or Lima. The core training is by low-bandwidth electronic mail, but those with higher bandwidth capacity can use more sophisticated technology, including the World Wide Web."

"Applications that use telecommunication-based technologies are rapidly entering the mainstream of health practice well beyond the institutional environment where they were initially developed..."

In Barbados, the University of the West Indies has made the leap into the information age, offering full degrees at home using communications technology. The concept of distance education at UWI, which operates campuses in Jamaica, Trinidad, and Barbados, began in 1982 when its Distance Teaching Enterprise linked five Caribbean islands with teleconferencing sites.

Now the university has expanded its telecommunications system, using a "faculty-driven" model of distance education that accepts student correspondence and exams and issues responses at 26 sites set up in its 11 non-campus territories from Bahamas in the north to Trinidad in the south. UWI's Allyson Leacock says each site has 10 workstation computer labs with Internet connectivity, electronic mail, file transfer, and electronic library services that will allow students to tap into information around the world. Nowadays, Leacock says, "distance is no longer the poor second cousin that it was perceived to be in the past. It is in fact the way forward. Very few universities in the world don't have distance education components and UWI will ensure that there will be no discrepancy."

Previously, a student in Montserrat, for example, who wanted to pursue a management degree would have had to move to Barbados, Trinidad, or Jamaica to study. Now that same student can stay at home and register at the university center to complete the program, Leacock says.

Putting the Tools to Work

Success stories in telemedicine come from Costa Rica, where the Ministry of Health, the Costa Rican Social Security Agency, and other partners currently are implementing a nationwide telemedicine network linking hospitals, clinics, and research and learning centers; Peru, where the Red Científica Peruana (Peruvian Scientific Network) joins together a vast and growing network of researchers; from Brazil, where the Oswaldo Cruz Foundation and many others serve to disseminate technical information; from the Caribbean, a pioneer in distance education; and from other parts of the Americas, which as the Internet expands, are becoming a real virtual hemisphere in which it doesn't matter where people live.

The spread of this technology into the developing world is following what has become a fairly typical pattern, reaching first into the urban centers and then making its way into the countryside-just as radio did a half century ago.

In Peru, for example, the Red Cientifica Peruana has found a new way to bring the Internet to low-income users in underdeveloped areas, at low cost. Cabinas públicas, or public computer centers, are now installed in 27 locations throughout Peru. They typically contain 20 computers with dedicated Internet lines, which users rent for as little as US$ 1 for one hour. The centers also provide training, personal e-mail accounts, Web page development, and other services. They are popular with people who don't have a phone line or computer at home-more than 95 percent of all Peruvians. Plans are underway to finance 1,000 more centers in Peru with help from the Inter-American Development Bank. And the Peruvian network has direct links to clinics and hospitals, conference proceedings, and information on such topics and child health and mental health, so that anyone in Peru, for a modest fee, can access information globally.

In Mexico, according to Dr. Gladys Faba, director of the National Health Information and Documentation Center, "the rapid growth of information networks, which started during the early years of this decade, has been astounding." In 1990, the National Autonomous University of Mexico had 7,000 user stations. Today, 40,000 computers are connected to the UNAM network. "The development of Bitnet and Internet and the appearance of domestic networks in the country have played a decisive role in stimulating the expansion of information services in educational and health care institutions," she says.

In Argentina, the University of Buenos Aires has connected its academic units to the national and international Internet community, and integrated that network with 33 national universities and foreign institutions. "The increase of computer communications in our country and the development of medical informatics in the last few years in Argentina has been very significant, with a greater number of physicians and paramedics using computers for self-teaching," says Dr. Daniel Jares of the Medical Informatics Foundation.

PAHO succeeded in putting health technology on the agenda of the Summit of the Americas, held in Santiago, Chile, in April 1998, noting in a proposal that the Health Technology Linking the Americas initiative has enormous potential to reduce today's social inequities and will help governments achieve through partnerships what they cannot achieve alone. By sharing technologies and information networks, countries can better prepare themselves for disease outbreaks or natural disasters; they can share ground-breaking news on emerging health issues and discoveries in vaccines research and development; and they can empower public health workers at all levels to make timely, well-formed decisions by providing them with access to the crucial data and knowledge they need.

PAHO Director Dr. George A.O. Alleyne says, "Most activities designed to improve the operation and management of the health services or to address such public health issues as sanitation, nutrition, maternal and child care, and lifestyle changes are highly dependent on information. Conse-quently, the health sector must harness these new information tools if it is to fulfill its goals in the best and most efficient way possible."

PAHO and other organizations involved in health informatics, Dr. Alleyne adds, "have already engaged in initiatives to tap into the advantages of the current information revolution. These efforts emphasize the importance of garnering telecommunication support as the health sector seeks improvements in health service delivery, health promotion, consumer education, and environmental protection and pursues equity, quality, and efficiency."

Narrowing the Development Gap

According to World Health Organization (WHO) experts, information and telecommunication technology, as "one of the main driving forces in the current globalization of trade, economics and politics, has equally important implications for health."

At a recent meeting on health telematics policy in Geneva, a worldwide group of experts concluded that WHO should take immediate action to incorporate appropriate health telematics measures in its goal of health for all for the 21st century, as well as in the operations of all its divisions and regional offices. Equally, they said, Member States will need to take similar action at global, regional, national, and local levels.

The new technologies have applications that reach beyond the clinical setting and into the medical classroom.

The experts also concluded that WHO should recognize that information and communications technologies are evolving rapidly with significant declines in cost. Health telematics offers such significant potential for developing countries that WHO's support of its wider use for health development where appropriate is highly desirable. Investment in health telematics can help ensure that the gap between developed and developing countries does not grow even wider. They recommended the development of a network of existing and new WHO collaborating centers on health telematics applications, policies, and programs.

One of the experts' 18 specific recommendations was to "strengthen the global surveillance system of WHO to map health hazards, pathogens, vectors, and diseases, comprehensively and in appropriate detail, using health telematics surveillance systems for the generation and dissemination of valid, up-to-date and continuous information for disease control and health promotion."

What lies ahead? Richardson says: "The health care industry is currently undergoing a massive and irreversible transformation and change. The traditional ways of practicing medicine, which have evolved over 3,000 years, involving a pyramidal structure, will be overturned in the course of the next 10 to 20 years. I see health care becoming a commodity almost like a soap powder. The 'entry port' will be a PC based at home or a 'health kiosk' in a shopping mall. Patients are already able to surf the Net and discover more about the various treatment options for their condition than in some cases their general practitioner is aware of. " The process also will be beneficial, he adds, with the consequence "that the global deployment and active use of telemedicine will result in a truly universal standard of medical practice becoming available throughout the world."

Daniel Epstein is a Washington, D.C.-based journalist in charge of media relations for PAHO's Office of Public Information. Richard L. Vernaci is an Internet consultant and writer who heads Broad Run Consulting, Inc., in Warrenton, Virginia, U.S.A.

The Word Game

As the telecommunications field evolves, the terminology changes. Regional preferences emerge, and some terms seem to be interchangeable, resulting in confusion about whether we are all on the same wavelength. Here is a brief glossary depicting how information is transferred and how different terms relate to one another:

Bandwidth: The size of the electronic "pipeline" through which information is carried over communications lines, measured in bits per second (bps).

Bitnet (Because It's Time Network): One of the world's earliest computer networks, set up in the 1980s by the University of Chile and the U.S. National Aeronautics and Space Administration (NASA). PAHO was an early participant in Bitnet, which also linked with universities in Colombia, Ecuador, Mexico, and Costa Rica. As medical traffic on the Bitnet increased, a direct link with the U.S. National Library of Medicine was formed so that health researchers could use NASA's system to access the library's vast data banks.

Dedicated Lines: A permanently available circuit between a user and the Internet service provider. While many individual users connect to their Internet service provider via a telephone dial-up connection, many businesses and large institutions maintain these permanently available circuits for faster access.

Health Informatics: An umbrella term adopted by the World Health Organization and the Pan American Health Organization and used in most scientific and international fora. It encompasses the rapidly evolving discipline of using computing, networking, and communications to support such health-related fields as medicine, pharmacy, nursing, and dentistry. Telematics, a term frequently used in Europe, is one component of informatics, and generally refers to computer-based networking and communications.

Telehealth: A broad term used to describe the provision of health services over distance through the use of electronic networks. Telehealth, as a branch of health informatics, includes the exchange of highly detailed medical data between health professionals, the education of health personnel and the public, health promotion activities, epidemiological surveillance, and health services management. Telehealth is frequently referred to as "telemedicine," particularly in the United States, although telemedicine carries the connotation of being restricted to direct patient care.

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