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PAPERS & DOCUMENTS
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TELEMEDICINE
AND TELEHEALTH IN THE PACIFIC ISLAND REGION: A SURVEY OF APPLICATIONS,
EXPERIMENTS, AND ISSUES
Bice, S., Dever, G., Mukaida,
L., Norton, S., and Samisone, J. (1996) Telemedicine and Telehealth
in the Pacific Islands Region: A Survey of Applications, Experiments,
and Issues, Proceedings of the Pacific Telecommunications Conference
'96, pp 574-581.
Primary
Author:
Lori Mukaida
Table
of Contents:
1.
Abstract
2.
Introduction
3.
Telemedicine and Telehealth in Remote Areas
4.
Telemedicine Experiments in the Pacific Islands Region
5.
The Telecommunications Barrier
6.
The Issues and Questions
7.
Summary
Notes
Bibliography
Figure
1 (52 k)
Figure
2 (55 k)
Figure
3 (58 k)
1.
ABSTRACT
"Telemedicine"
and "telehealth" are promising and important applications
of the revolution in telecommunication and information technologies.
These applications, for the most part, will be based on inexpensive
broadband telecommunication and information networks, which
in the next 10 years, will be "ubiquitous" in developed
countries. These applications, however, are not certain for
lesser developed countries that may only have access to narrowband
telecommunications, even though there are significant experiments
in telemedicine and telehealth in the Pacific Islands Region.
The purposes of this paper are to: (a) broadly describe telemedicine
and telehealth and review some of the emerging applications;
(b) discuss some of the experiments that are being conducted
in the Pacific Islands Region; and, (c) identify some of the
issues and questions that have emerged at the forefront out
of the experiments with Pacific Islands Region telemedicine
and telehealth.
2.
INTRODUCTION
Telemedicine and telehealth are the emerging medical and health
applications of telecommunications and information technologies.(1)
Telemedicine applications are those directly related to medical
applications and treatment. Telehealth applications are focused
more on the holistic health related programs defined generally
by practitioners in public health. Both rely heavily on the
use of distance education and learning technologies.
Telemedicine applications use audio, text, image and video through
computer, facsimile, scanners, camera light box, cameras, multimedia,
electronic mail, remote monitoring systems, video conferencing,
and other associated technologies to enable the delivery of
medical care as an attempt to lessen the gap between the availability
of expertise and services at remote locations. Some of the medical
and support services of these technologies include:
- medical
consultation;
- diagnostics;
- CAT
scan, electrocardiogram, x-ray, and ultra-sound data transmission
and interpretation;
- patient
transfers/referrals;
- medical
records transfer;
- transmittal
of prescriptions and doctor's orders;
- medical
database access;
- general
administration;
- research
links;
- central
data collection and organization;
- retrieval
of medical literature;
- continuing
education for doctors, nurses, and other medical personnel;
and,
- training.
Telehealth, as a complement to telemedicine, uses many
of the same technologies as telemedicine but focuses
on the holistic
treatment of medical and health needs. "Telehealth" encompasses
the larger concerns involved in both public health and medical
care. Some of the telehealth applications supported
by these technologies include preventive programming, education
and training for health care providers, medical staff, patients
and the community in the following areas:
- prevalent
health problems and promotion of methods of prevention
and/or control;
- personal
health care and proper nutrition (wellness programs);
- promotion
of environmental concerns, especially for an adequate supply
of safe water and basic sanitation;
- maternal
and child health care, including family planning, pre-natal
care and well child care;
- immunization
against major infectious diseases;
- prevention
and control of locally endemic diseases;
- appropriate
treatment of common diseases and injuries; and,
- training
in and provision of essential life saving therapies (drugs
to control hypertension, insulin for diabetes, etc).
Telecommunications can assist local physicians, health care givers,
policy and decision makers to: (a) reach out to their communities
(b) acquire a better understanding of basic primary health care
goals, and (c) discuss and analyze appropriate interventions. In
essence, the term "telehealth" connotes the use of telecommunications
technologies for the enhancement of the health of a population,
and does not limit that use to medicine alone.
3.
TELEMEDICINE AND TELEHEALTH IN REMOTE AREAS
Telemedicine and telehealth applications have advanced rapidly during
the past five years and may have a significant, practical impact
on improving the delivery of medical and health care in remote
areas that suffer from isolation, small size, sparse and dispersed
populations, a limited resource base, and great distances. As noted
by Dena Puskin (1995: 54) of the Office of Rural Health, U.S. Department
of Health and Human Services, telemedicine and telehealth "have
the potential to reduce the isolation of rural practitioners and
patients, and facilitate integration of services across communities
that individually cannot sustain a full range of health services."
Significant portions of the Pacific Islands Region populations are
underserved by their health care system due to geographic and socio-economic
constraints. Some of the areas in which health care systems may
lack sufficient support are: (a) in the number of or the lack of
physicians and/or specialists necessary to serve the population;
(b) continuing education for existing health care providers; and,
(c) appropriate facilities and technologies to serve their populations.
Telemedicine and telehealth applications can improve Pacific Island
health care systems by providing affordable, quality health care
to patients, where and when they need it.
Telemedicine and telehealth may also help to lessen the cost
of services. For example, the current practice of the U.S. affiliated
countries is to evacuate patients in the Pacific Islands once a
determination for critical or acute care is made. Family members
are often allowed to accompany the patient. The cost of evacuation
is extremely excessive and represents a large proportion of health
and medical expenditures in the Pacific region. Telemedicine could
conceivably help to lessen the number of evacuations and the attendant
costs by assisting in diagnosing the need for evacuation and by
providing remote consultation.
Further, and just as significant, are the travel costs for follow-up
care. Family members are often allowed to travel with the patient
even for follow-up care. By delivering health and medical services
through telecommunications, the cost of follow-up care could be
lessened, thereby enabling resources not spent for evacuations to
be reallocated to other areas of health and medical program needs.
Certainly, there are indications that the economic condition of
the '90's may require health care systems to discriminate among
priorities in critical and acute care based upon available funding
and resources. Delinquent hospital and medical bills in Fiji, Guam,
Hawaii and elsewhere might not be tolerated. The use of telemedicine
and telehealth applications should be examined as a means to improve
medical and health care while reducing costs in the Pacific Islands
Region.
4.
TELEMEDICINE EXPERIMENTS IN THE PACIFIC ISLANDS REGION
There are several current and planned telemedicine and telehealth
experiments in the Pacific Islands Region. These experiments are
intended to develop a base of experience and knowledge that will
help to determine the usefulness of these telecommunications applications.
Since these trials are still in the initial stages of development
and experimentation, it is far too early to determine their long-term
programmatic value and costs.
These trials are further important to: (a) assess the needs within
communities, which vary significantly across the region; (b) identify
cultural and other issues with the introduction of such services;
and, (c) identify other barriers and problems that might affect
the usefulness of these applications in the region. These experiments
in telemedicine and telehealth applications may provide the base
of experiences that will lead to substantive, appropriate services
and programs to promote health, increase medical responsiveness,
and lessen the costs of providing these services and programs in
remote island environments.
4.1 TRIPLER ARMY MEDICAL HOSPITAL AND KWAJALEIN MISSILE RANGE
HOSPITAL
One of the first experiments in the Pacific Islands Region was initiated
by the Tripler Army Medical Center (TAMC) located in Honolulu, Hawaii.
The TAMC Telemedicine Program was originally developed to support
the hospital services at Kwajalein Missile Range (KMR) Hospital
in the Republic of the Marshall Islands. The TAMC uses a Department
of Defense T-1 link between TAMC and Kwajalein for video-based teleconsultation
twice a month between doctors and patients. Results of experiments
demonstrate that TAMC has had a significant impact on the number
of medical referrals by the KMR Hospital.
Adjacent to Kwajalein is Ebeye which supports a dense population
of 14,000 on an atoll comprising less than two square miles. Since
medical conditions are unsatisfactory on Ebeye, patients on Ebeye
are also seen through teleconsultation under TAMC's mandate to provide
specialty care to the Republic of the Marshall Islands.
Over the past two years, more than 200 teleconsultations in 23 specialties
have been conducted. The TAMC telemedicine program provides the
means for intervention before the condition of the patient deteriorates
to the point of requiring costly referral and evacuation.
The initial goals of the TAMC telemedicine program are to provide:
(a) primary care services; (b) specialty consultations; (c) continuing
health education programs; (d) patient and community health education;
and (e) communications links among providers in the region.
In order to achieve these goals, TAMC is collaborating with the
Pacific Basin Medical Officers Training Program (PBMOTP), in Pohnpei,
Federated States of Micronesia (FSM), and PEACESAT. Both PBMOTP
and PEACESAT are University of Hawaii programs.
4.2 PACIFIC BASIN MEDICAL OFFICERS TRAINING PROGRAM
The Pacific Basin Medical Officers Training Program, located in
Kolonia, Pohnpei, was introduced to the Telemedicine Program at
Tripler Army Medical Center (TAMC) in early 1994. Through experimentation
with the AT&T Picasso Still-Image Phone, TAMC began to expand
its telemedicine program to specific sites in the U.S. affiliated
Pacific Islands in the Western Pacific.
The Picasso Still-Image Phone is a still-frame, video phone system
which, when used with a video camera and a TV monitor, can digitize
and transmit freeze frame color pictures of high quality over regular
telephone lines. The Picasso Phone unit, which is the size of a
desk top executive telephone, is a computer capable of storing,
sending, and receiving high quality, freeze-frame color video pictures
with simultaneous voice communications. The Picasso Phone unit costs
under $5,000 and certain models have battery storage capacity to
insure against loss of picture memory due to power failures. Connected
to a camcorder, a TV monitor, and a dedicated telephone line, the
unit is user friendly and operates much like a VCR.
4.2.1 PACIFIC BASIN MEDICAL OFFICER TRAINING PROGRAM EXPERIMENTS
Since 1994, the Pacific Basin Medical Officers Training Program
has participated in and has documented the following telemedicine
experiments:
- At
the Charter Meeting of the Pacific Basin Medical Association
(PBMA), April 3-5, 1995, in Pohnpei, the TAMC Telemedicine
Program team gave two demonstrations using the Picasso Phone
to over 75 participants of the meeting: (a) a patient consultation
from Pohnpei to the Republic of Palau, which assisted in the
prevention of a costly, off-island referral, and (b) a lecture
from TAMC in Honolulu to the PBMA conferees on Pohnpei regarding "HIV
in the Pacific - 1995."
Facilitated by TAMC, AT&T donated four Picasso Still-Image Phones
to the region. PBMOTP (Pohnpei) received 2, Kosrae State Hospital
(Kosrae) received 1, and PEACESAT (Headquarters, Hawaii) received
1. Since then, other demonstration activities have been documented
using the Picasso Still-Image Phone for teleconsultation and distance
learning.
- PBMOTP
Weekly Director's Rounds and Lectures have been teleconferenced
with participants in the PBMOTP campus in Pohnpei, the Pohnlangas
Dispensary (a 2 hour drive from Nett, Pohnpei), and the Kosrae
State Hospital (KSH) which is 45 minutes away from Pohnpei
by air;
- Teleradiology
experiments involving teleconsultation over pediatric x-rays
between PBMOTP, Pohnpei, and TAMC, Honolulu, have been initiated.
PBMOTP pediatricians present problematic x-ray films over the
Picasso Phone system to pediatric pulmonologists at TAMC. Pohnpei
is nine hours away from Honolulu by air, separated by three
time zones, and the International Date Line.
- PBMOTP
has also documented emergency telemedicine applications. For
example, KSH physicians in Kosrae requested emergency x-ray
teleconsultation services. The PBMOTP internist in Pohnpei
assisted KSH physicians in the management of a trauma patient
with a hemothorax.
- At
the Annual Waianae Primary Health Care Conference held on Oahu,
Hawaii, in which 146 representatives from the Community Health
Centers of Hawaii and the Pacific Islands participated, there
were two telemedicine demonstrations from Pohnpei and Palau:
(a) the PBMOTP Associate Director lectured from Pohnpei to
the Waianae Conference on the "Management and Treatment
of Leprosy," and (b) Dr. Victor Yano, President of the
Pacific Basin Medical Association, and Dr. Stevenson Kuarte,
the Medical Director of the Palau Community Health Center spoke
from the Republic of Palau to the Waianae Conference participants
about integrating telemedicine into the Pacific health care
system.
- On
July 7, 1995, the PBMOTP Director lectured from Pohnpei to
the Western Alaska Telemedi-cine Conference in Nome regarding "Telemedicine
Demonstration Projects in the Western Pacific." The Alaska
audience included senior representatives from the following
organizations: Indian Health Service, Alaska Native Medical
Center, the U.S. Air Force, Native Health Councils, Alaska
Regional Health Agency, the Alaska Telemedicine Project at
the University of Alaska, and the TAMC Telemedicine Program
team.
On
July 26, 1995, the PBMOTP gave a telemedicine presentation to
the 14th General Assembly of the Association of Pacific Island
Legislatures on Pohnpei connecting the legislative representatives
from the Pacific Islands with both the Telemedicine Program at
TAMC, Honolulu, and the Kosrae State Hospital (KSH) for a brief
introduction lecture on telemedicine and an x-ray teleconsultation
with the staff of KSH. Every Wednesday, the PBMOTP supports scheduled
medical teleconsultations with KSH medical staff in Kosrae. KSH
physicians have the opportunity to present patients and x-rays
and obtain second opinions by the PBMOTP specialty physician staff.
Additionally, the PBMOTP provides mini-lectures in continuing
medical education for the KSH medical staff.
4.2.2
CURRENT STATUS OF PBMOTP TELEMEDICINE EXPERIMENTS
Efforts are underway to link the Picasso Still-Frame Phone system
through the PEACESAT satellite system to introduce this technology
to remote Pacific Island countries supported by PEACESAT earth stations.
Experimentation may then focus on the regular use of Picasso-based
telemedicine applications among remote island countries and become
the experimental base for the documentation and evaluation of its
potential, audio conferencing and still-frame video, to benefit
Pacific Island health care.
The major expense in the PBMOTP experiments has been the international
transmission costs incurred. When the still-frame video phone technology
is adapted to the PEACESAT Public Service Telecommunications Network,
transmission cost will no longer be a deterrent in the growth of
this telemedicine network. Utilization of PEACESAT's 44 earth stations
in 22 countries will create a virtual geographical extension of
the experiments with very few new funding dollars.
The use of the Picasso Still-Frame Phone System as a telemedicine
application is an example of a relatively low cost, user-friendly,
narrowband system. The system requires purchase of the phone system,
access to the public switched telephone network, and/or use of PEACESAT
for the remote link. Additional equipment for remote sites could
be added as budgets permit.
The PBMOTP experiments in telemedicine applications have shown the
utility of the system in many arenas: (a) international telecommunications
between developed and developing country urban centers (Hawaii to
Pohnpei, Hawaii to Kosrae), (b) telecommunications among developing
countries (Pohnpei to Kosrae, Pohnpei to Palau), and (c) domestic
telemedicine applications from developing urban centers to remote
dispensaries (Nett, Pohnpei to Pohnlangas, Pohnpei).
4.3 TELEMEDICINE AND FIJI: THE FIJI SCHOOL OF MEDICINE
The Fiji School of Medicine (FIJI-SM) has trained well over one
thousand medical officers.(2) More than one-third of the graduates
are nationals of American Samoa, Western Samoa, Tonga, Cook Islands,
Tokelau, Niue, Tuvalu, Kiribati, the Solomon Islands, Vanuatu, Nauru,
the Republic of the Marshall Islands, the Federated States of Micronesia,
and the Republic of Palau.
The FIJI-SM recently implemented a unique layer to its undergraduate
medical training program. Fourth year FIJI-SM students are attached
to rural health care facilities in their own communities. As an
apprentice, the student receives practical, on-the-job training,
and is required to undertake an applied health research project
in primary health care. For this phase of training, the students
come under the supervision of practicing medical officers from within
their own communities who have been specifically selected and trained
to be supervisors and Public Health Care tutors. These medical officers
are also appointed as Honorary Clinical Instructors to FIJI-SM and,
in this way, become non-salaried members of the faculty. In this
context, the FIJI-SM is effectively decentralized throughout the
region by the actual physical presence of students in the region
and the Honorary Supervisors in those communities.
The FIJI-SM and the Fiji government have endorsed the School of
Medicine as an institution of Post-graduate Training and Continuing
Medical Education. The FIJI-SM is currently developing a strategic
plan for the implementation of postgraduate training and continuing
medical education within the region. The decentralization of FIJI-SM
resources throughout the Pacific Islands in support of the undergraduate
medical training program has strengthened the regional nature of
the institution. Consequently, the FIJI-SM has established an enhanced
human network among Pacific Island health care centers through its
tutors and students which could support other cooperative and collaborative
endeavors to improve medical and health services throughout the
region.
The FIJI-SM is also strengthened through its affiliation with the
Colonial War Memorial Hospital (CWMH), which has recently expanded
and upgraded its technology and services in support of diagnosis
and management of secondary and tertiary care problems. Currently,
remote Pacific Island countries can not access these resources or
facilities remotely.
At this time, a cost-effective telecommunications capability does
not exist to support real-time, interactive voice, data, or video
applications between and among the FIJI-SM and the participating
Pacific Health Care Centers.
In order for the FIJI-SM to successfully implement its undergraduate
medical training, postgraduate training, and continuing medical
education programs, the FIJI-SM must have access to public health
care constituents in the Pacific Islands region on a real-time,
interactive, and daily basis. The FIJI-SM followed the PBMOTP experiments
very closely, and will adapt these experiments and applications
under its new Office of Postgraduate Training and Continuing Medical
Education.
4.4 PACIFIC ISLAND HEALTH OFFICERS ASSOCIATION
The Pacific Island Health Officers Association (PIHOA) is a non-profit
organization with members in the six Pacific countries and territories
affiliated with the United States: American Samoa; the Commonwealth
of the Northern Mariana Islands; the Federated States of Micronesia;
the Territory of Guam; the Republic of the Marshall Islands; and,
the Republic of Palau. The members of PIHOA are the principal health
officials from each island jurisdiction. PIHOA is committed to improving
health within the region, and focuses on health issues and special
projects of regional significance.
In 1995, the U.S. Public Health Service funded a PIHOA training
project to work collaboratively with PEACESAT to ensure that health
personnel in the region would be able to use remote dial-in services
for access to Internet electronic mail and file transfer services.
PIHOA and PEACESAT have implemented this network and are examining
other alternatives for improving information access and electronic
mail communications in the region.
5.
THE TELECOMMUNICATIONS BARRIER
One of the major barriers to extending telemedicine and telehealth
applications throughout the Pacific Islands Region is the state
and cost of the telecommunications and information infrastructure.
In this regard, the international telecommunications and information
infrastructure is viewed as an important and significant barrier
in the development of telemedicine and telehealth applications.
If the region is to benefit from the sharing of resources and the
emerging telemedicine and telehealth experiments, the international
telecommunications infrastructure must be able to support these
applications.
The problem of the state and cost of the telecommunications infrastructure
is not limited to the Pacific, but extends to rural communities
in the United States and other developed countries as well. The
barrier of the telecommunications infrastructure to telemedicine
and telehealth applications is clearly stated by Dena S. Puskin
of the U.S. Department of Health and Human Services. In an article
describing barriers to the development of rural telemedicine systems
in the U.S., Puskin notes that:
"[t]he
best designed systems still face barriers to implementation. While
much has been said about building the nation's electronic highway,
we in rural America are often dealing with the equivalent of the
dirt road. The lack of an adequate telecommunications infrastructure
is a key barrier to development of telemedicine systems in rural
communities." (1995:55)
Puskin is not only concerned with the nature of the infrastructure,
she is also concerned with costs. She states that:
"Clearly,
transmission costs must be lowered if telemedicine is to become
economically feasible for many rural communities."
The statements of Puskin regarding the telecommunications infrastructure
and costs are appropriate not only to rural areas in the United
States, but also applies to the Pacific Islands Region as well.
Unfortunately, for reasons beyond this paper, the cost of international
telecommunications is prohibitive and is a deterrent to more experimentation.
For example, a direct dial telephone call from Honolulu to the Pacific
Islands region varies from U.S. $1.20 per minute to over U.S. $2.00
per minute. The cost of a call from the FSM to Fiji is close to
$3.00 per minute. These costs severely restrict the ability of health
and medical organizations from sharing resources and expertise,
and prohibits other countries in the region from participating in
the trials.
Fortunately, in the Pacific Islands Region, there are two public
service telecommunications test-beds for telemedicine and telehealth
application experiments. One is Japan's PARTNERS network. Another
is PEACESAT.
5.1 PARTNERS
The Japan Ministry of Posts and Telecommunications (MPT), following
technical experiments on the Engineering Test Satellite-V or "ETS-V,"
made the satellite available for application experiments in 1989.
The project was named the Pan-Pacific Regional Telecommunications
Network Experiment and Research by Satellite or "PARTNERS"
Project.
There are two types of network systems supported by the PARTNERS
Project. Network I was designed by the Communications Research Laboratory
(CRL) of MPT as a 64-Kbps digital satellite link to support video
conferencing for distance learning.
The PARTNERS Network I distance education program includes the King
Mongkut's Institute of Technology Ladkrabang (KMITL) in Thailand,
the Institute of Technology Bandung (ITB) and LAPAN in Indonesia,
the University of Technology (UNITEC) in Papua New Guinea, the University
of the South Pacific (USP) in Fiji, the University of Hawaii (PEACESAT)
in the U.S.A., the Communications Research Laboratory (CRL) of the
Ministry of Posts and Telecommunications in Japan, the National
Institute of Multi-Media Education (NIME) of the Ministry of Education
in Japan, and the University of Electro-Communications in Japan.
Network II was developed by Tokai University, Japan, for the transmission
of precise still pictures via an FM satellite link, making it useful
for telemedicine experiments in teleconsultation and diagnoses.
Network II includes seventeen hospitals in Thailand, Papua New Guinea,
Fiji, and Cambodia.
After five years of experimentation, the ETS-V PARTNERS Project
plans to migrate to another satellite system in 1996.
5.2 PEACESAT
PEACESAT is a Pacific region satellite telecommunication network
supporting application experiments in narrowband satellite communications
and international public service telecommunications.(3) Public service
telecommunications is defined as non-commercial, international communication
services used by educational institutions, government, medical,
and other non-profit organizations to support distance education
and learning, emergency management, medical and health, research,
technical assistance, economic development, and community service
programs.
PEACESAT uses the Geostationary Observation Environmental Satellite
(GOES-2) on a dedicated basis for use by the Pacific Islands Region.
This is an obsolete weather satellite with a functional, although
limited, communication transponder. The network may not be used
for personal or commercial communications.
PEACESAT currently has 44 earth stations in 22 countries within
the Pacific Basin. PEACESAT offers voice and data services, but
also provides access to Internet in both on-line and batch transfer
modes. The earth stations are 3m in size, have a 50W HPA, audio
processor, phone patch, and analog data modem.
There are two major limitations of the network. First, the earth
stations can only perform one function at a time. For example, the
PEACESAT 3m earth station can be used for voice teleconferencing
over a simplex circuit, voice teleconferencing over a full duplex
circuit, or data communications over a full duplex circuit. However,
it is not possible to perform more than one of these functions at
the same time.
A second limitation is that there are only 3 full duplex circuits.
This essentially means that the users must schedule data transmission
time for use of these circuits.
PEACESAT has developed plans for a digital "Hub Site"
network using the residual bandwidth and power of the GOES satellite
which will significantly improve services.(4) Each of the Hub Sites
will support multiple concurrent voice circuits, a dedicated data
(28.8 Kbps) circuit, and shared use of compressed digital video
circuits. These Hub Sites will use a 6m antenna, 75W HPA, and other
digital compression and switching capabilities to provide a medium
for the Pacific Island countries to offer and to connect to public
service telecommunications programs and services throughout the
region and the world.
The digital network will further enable a significant extension
of the TAMC, Kwajalein, FIJI-SM, PARTNERS, PEACESAT experiments
and other telemedicine/telehealth initiatives. Some of the planned
health and medical users and uses of the PEACESAT Hub Site network
are briefly described below:
- Medical
teleconferencing using Picasso type systems or compressed digital
video teleconferencing at 128 to 256 Kbps.
- Hospitals
and clinics would be able to communicate with the Tripler Army
Medical Center and other physicians for remote health and medical
consultations.
- The
Pacific Basin Medical Officers Training Program in the Federated
States of Micronesia, in collaboration with the Fiji School
of Medicine, the University of Hawaii School of Medicine, and
School of Public Health will be able to provide continuing
education to medical officers in the field throughout the Pacific
Islands Region and receive instruction as well as diagnostic
assistance from hospitals and other educational institutions.
- Medical
officers and clinicians in the field will be able to transmit
their digital image data through inexpensive dial-up devices
to medical institutions located in Guam, Honolulu, and elsewhere
for medical consultation.
- Public
health and medical personnel will have access to Internet electronic
mail, file transfer, and gopher applications through dial-up
modems.
- On
a scheduled basis among the countries, the public health and
medical institutions and staff will have access to the World
Wide Web of Internet.
- Distance
learning and educational programs (e.g. seminars and workshops)
will be held through one-way digital video with voice and data
return.(5)
This network should be in place in 1996, providing that appropriate
funding for the Hub Site technology is obtained. The Hub Sites will
include American Samoa, the Commonwealth of the Northern Mariana
Islands, the Federated States of Micronesia, Fiji, Guam, the Republic
of the Marshall Islands, the Republic of Palau, and the Solomon
Islands.
6.
ISSUES AND QUESTIONS
The initiation of the trials in telemedicine and telehealth in the
Pacific Islands Region are valuable in helping to raise questions
and identify issues. Although the experiments are only in its infancy,
the trials have already raised many issues and questions. The following
is a brief discussion of a few of these issues and questions.
6.1 ISSUES
The following describes some of the application specific issues
that have emerged during these trials.
- Language.
Language has emerged as a problem among some of the sites,
especially in the PARTNERS network. Working in the field of
telemedicine may require considerable working knowledge of
a common language such as English.
- Standards
and Licensing. Does a physician have to be licensed in
a country receiving the service? If so, what are the standards
and how should they be administered?
- Operational
Protocols. The protocol for providing a telehealth or
telemedicine service has not been fully developed. The PBMOTP
teleconsultation and distance learning experiments in telemedicine
applications clearly indicate a need to establish standards
for operations and the need for the development of training
manuals to address operations and content protocol and procedure.
- Financial
Reimbursements. How should the cost of medical consultation
and other services be valued and assessed across the region?
Relationships and commitments for support of the Pacific
Islands region are complex given the different relationships
among the territories and Freely Associated States. When
one adds in the complexities of other countries, the financial
relationships may become extremely complex.
- Culture.
Telemedicine is certainly not the only or sometimes even the
best answer to medical problems suffered by people in developing
countries. In fact the same kind of coordination needed to
achieve success without telemedicine will be required with
the technology:
- physicians
at the referral site and at the local jurisdictional hospital
will need to discuss the case at some length sharing what
physical findings and laboratory evaluation they have available
(this will take time and patience and will often be frustrating
for both professionals);
- the
follow-up or discharge planning necessary to return a patient
from a referral hospital to a hospital set in a developing
country will be required in the future as it is today (and
just as it is not always done today, technology will not
ensure that it will be done tomorrow);
- the
local customs and traditions will play as large a part
in medical interventions with telemedicine technology in
the future as it does today. And the providers of care
at the referral or consultation site must endeavor to understand
these customs/beliefs today and in the future.
- Appropriate
expenditures. Should funds be allocated to the purchase
of the telecommunication and information technologies or
should they be used in other ways?
There are many other issues that should be examined, including,
but not to be limited to: professional and/or educational level
of medical organizations and individual physicians providing services
through telecommunications; ethics and standards; reimbursement;
liability; application of insurance benefits; and inter-cultural
and inter-personal perspectives. These issues suggest a need for
a parallel research effort into the many social, economic, and policy
issues raised in telemedicine and telehealth. Unfortunately, the
extent of these studies will be constrained by many of the same
barriers of funding, distance, cost of telecommunications, and so
on.
6.2 QUESTIONS
As with many application experiments in telecommunications, the
initiation of a trial often raises more questions than answers.
Some of the questions that have been raised are:
- Do
the telemedicine technologies and applications improve medical
services and/or the health of a community?
- Do
telemedicine applications reduce the number of evacuations
or lessen the amount of travel required for emergency and/or
follow-up care?
- What
is the actual value of the reduction in evacuations and travel
for emergency and follow-up care?
- What
level of documentation is necessary to measure such improvements?
- Are
the technologies that are being tested appropriate?
- Has
the use of these technologies "transferred" to the
user community?
- If
the success of an experiment is to be deemed limited or a failure,
then, is it a theory failure or an implementation failure?
How can we be sure that poor implementation or an external
intervening factor did not affect the overall success of an
application?
- How
did the patients react to the use of these telemedicine applications
(e.g. video conferencing)?
- How
did the doctor and patient feel about video teleconferencing?
- Do
the doctor and patient feel that video teleconferencing improved
the level of service?
- How
has the provision of information been transferred?
- Do
doctors and other medical officers access the available information
services?
- Do
they feel that the service was valuable?
These are only a few of the questions that have arisen. There is
a need to codify and begin to analyze the experiments in relationship
to the promises of the technology. However, as stated earlier, it
is too soon to undertake such an evaluation since the trials have
just begun.
7.
SUMMARY
Telemedicine and telehealth applications are important emerging
applications for the Pacific Islands Region. Experiments are being
proposed and/or conducted in the Pacific Islands Region under many
venues, such as PARTNERS, PEACESAT, Tripler Army Medical Center,
the Pacific Basin Medical Officers Training Program (PBMOTP), and
the Fiji School of Medicine (FIJI-SM). Although it is far too early
for an in-depth evaluation of these programs, the efforts so far
have been useful in identifying many important issues and questions.
International cooperation and collaboration in the development of
telehealth and telemedicine programs in the Pacific Islands Region
could expedite experiments exponentially. The basis of cooperation
and collaboration among and within the region appear to be developing.
A dialogue on telemedicine and telehealth experiments should be
initiated among the service providers, experimenters, end users,
and beneficiaries. Such a dialogue could begin to discuss the need
to document, evaluate, analyze, and report on the telemedicine technologies,
services, applications, methodologies, and evaluation techniques;
and will aid greatly in developing an understanding of appropriate
applications of these technologies in the Region.
NOTES
- There
are philosophical differences in emphasis in the fields of public
health and medicine that are also present in telemedicine and
telehealth. These philosophical differences are not discussed
here.
- The
official acronym for the Fiji School of Medicine is "FSM."
For the purposes of this paper, the acronym "FIJI-SM"
is used to minimize confusion with the acronym of the Federated
States of Micronesia (FSM).
- The
PEACESAT program is funded, in part, through a Cooperative Agreement
between the National Telecommunications and Information Administration
(NTIA) of the U.S. Department of Commerce and the University of
Hawaii (UH). The program has been in place since 1971, and has
been mentioned in the ITU's Maitland Commission Report
(International Commission, 1984) as critical in facilitating communications
during outbreaks of diseases and other medical emergencies. It
has also been mentioned in the U.S. Global Information Infrastructure:
An Agenda for Cooperation for the same reasons.
- The
plan to upgrade the PEACESAT Network is called the PEACESAT Services
Improvement Plan and is documented in Okamura and Mukaida (1995
and 1994).
- This
capability could be implemented among the Hub Sites. However,
to extend the service beyond the Hub Sites, digital video receive
only with voice or data return would have to be developed.
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