Telemedicine Networks in Developing Countries

This chapter will give an overview over different telemedicine networks which are active in developing countries. We will create a searchable database with project descriptions and conditions for participation.
 
At the moment, a preliminary list can be found here:

• http://ipath.ch/weblink/view/63 

International Pathology Consultations

Existing Applications

• Samedan: The hospital in Samedan is a small regional hospital in the Swiss Apls without a resident pathologist. iPath-Telemicroscopy is used regularly to provide frozen section diagnosis. If a pathologists advise is requested during an operation in Samedan, tissue is prepared and placed under the microscope there. A pathologist from the Department of Pathology in Basel can remote control this microscope from his PC and give his diagnosis to the surgeon in Samedan.
• AGKT: Memebers of the German bone tumor working group are regularly using iPath to discuss difficult cases with their collegues. Images and case description are stored on the server, the server sends an email notification to all members of the working group who then give their oppinions which are collected on the server. Within a week, there are usually half a dozen of second oppinions on a new case.
• The 'Ukrainian Swiss Neonatology Programme' is using iPath for second opinion consultations between several provincal neonatology centres in Ukraine and partner specialists in Switzerland.
• Telepathology Network in Washington State: The INHS (Inland Northwest Health Service) has funded a telepathology network for the Spokane (WA) region which is mainly intended to provide support for the rural hospitals of the inland region. Pathologists and Lab Techs at the Sacred Heart Medical Center and at the Holy Family Hospital in Spokane are now able to back up labs in rural hospitals, help with remote frozen sections and do consultations among each other. The network is based on iPath Software.
• Pathology for the Solomon Islands: In September 2001, we had the chance to start a very exciting experiment. At the National Referral Hospital of Honiara, Solomon Islands, we helped to install a tiny histology lab. Specimen are now prepared there and digital images are sent to our server in Basel, where a number of Pathologists from Europe and US review the cases and give their diagnosis. In the Solomons itself, there is no pathologists at all.
• A peronal report from the Solomons can be found here ...
• This project is supported by South Pacific Medical Projects
• Telehealth in West Africa The Norwegian Krooman Group has started providing a e-health vortal for West Africa, called West African Doctor's Network (WADN). The WADN is providing health information for health workers in West Africa and a platform for inner African consultations as well as collaboration and consultation with specialists from overseas. The telemedicine part is implemented with iPath-Server.
• Telemedicine Network for the Eastern Cape province of South Africa: The Walter Sisulu University in Mthatha, South Africa, has launched a regional telemedicine network based on iPath-Server. The network is already used successfully to provide dermatology consultations to rural clinics in the former Transkei. (http://telemed.utr.ac.za)

Teledermatology in Port St. Johns, South Africa

Port St. Johns is a small town on the Indian Ocean in the Eastern Cape Province of South Africa. It has +- 8000 inhabitants and another 75'000 in the region around and 2 doctors. Roughly 14% of the patients that see Dr. O'Mahony are suffering from a dermatological problem. The next dermatologist would be in East London, 300km from Port St. Johns Since 1999, Dr. O'Mahony has been using teledermatology to provide specialist dermatology services for patients in Port St. Johns. Besides, teledermatology has helped him to improve his own clinical dermatology skills in family practice.

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Methods

Dr. O'Mahony uses a simple store-and-forward teledermatology. In the beginning, images were sent by email directly to a dermatologist. Since 2002, Dr. O'Mahony has been using the iPath server to submit consultations, first the server in Basel and now the regional telemed server: at the University of Transkei.

Images are captured with a conventional digital camera (Olympus 1.4 Mega-pix, Fujifilm 2 Mega-pix). Then images are resized with Adobe Photoshop or GIMP: and then submitted to the iPath server by ordinary email. The dermatologists are automatically notified with an email. Later, they review the case and enter their diagnosis and possible suggestions for treatment. These comments are automatically returned to Dr. O'Mahony by email.

Results

A preliminary study is being conducted. The figure below shows the basic outcome. In 105 out of 110 consultations a dermatological diagnosis was possible. In 57 cases, the teledermatology consultation has lead to improvement of the treatment, while in 46 cases the GP had already come to the same conclusion. The GP rated the teledermatological consultation as helpful. Besides the direct outcome for the patient, teledermatology greatly helped Dr. O'Mahony to improve his clinical skills with dermatological problems.

 

References

• O'Mahony D et al. Teledermatology in a Rural Family Practice SA Fam Pract 2002, 25(6)

Tsilitwa - Teleconsultations in rural clinic

Tsilitwa is a small clinic in the region of the former Transkei, now part of new South Africa. The cinic is run by 3 nurses and does not havy a doctor. The next doctor is located in a small hospital, approximately 20km over a mountain - too far for a patietn to walk. At the Tsilitwa Clinic, CSIR has established a wireless network link that allows the sister in the clinic to contact the doctor using a simple web-camera. Besides, the nurses also take still images for dermatology and submit them to a dermatologist in East London, 600km away. More about the project can be found on their website.

Figure 1: the (old) clinic building in Tsilitwa with the external aerial for the wireless connection. The new building should be opened in 2005. 

Donetsk Region Telemedicine Center

The regional Telemedicine resource center of the Donetsk region in the Eastern part of Ukraine is located at the Institute for Research and Development in Traumatology and Orthopaedics at the Regional Trauma Hospital in Donetsk and is run by Dr. Anton Vladzymyrskyy.

Telemedicine in the Donetsk Region 

Nowdays Donetsk Region has unique experience and decisions for Ukrainian telemedicine. Its provided scientific, practical, organizational, technical, medical, economic, methodical decisions and information for another telemedical and e-health orgnisation.

First telemedical work-outs appeared in Donetsk Region in 1970ies. It was telemetry of physiological parameters for miners. Today telemedicine is basically developed as teleconsultations and distant learning.

1999 in Donetsk State Medical University we had started first ukrainian theoretical researches and investigations in telemedicine. After a few months we had published book “Introduction to Telemedicine” (full text russian version).

During next three years after this we studied the world experience of the use of telemedicine for the health care service, elaborated and implemented our own systems, evaluated the effectiveness of teleconsultations and analyzed the data.

On the 25th of January, 2000 we carried out our first teleconsultation: professor M. Nerlich from Regensburg (Germany) consulted the patient with serious pelvis trauma from Donetsk (Ukraine). Since that time we have done about 200 teleconsultations in 15 medical specialtity.

In 2001 in Donetsk R&D Institute of Traumatology and Orthopedics was founded Department of Informatics and Telemedicine – first special telemedical unit in Ukraine. The main achievments:

• development of theoretical bases of telemedicine for Ukraine;
• ukrainian-russian telemedical glossary;
• development of indicies for teleconsultations;
• improvement teleconsultations in daily clinical practice;
• 200 teleconsultations, 15 medical speciality, partnership with M.D.s and patients from 32 countries;
• special partnership with Norwegian Telemedical Center, AFCEA (1999-2000), ISFT (2004), CAOS-India, Med-E-Tel etc.
  
• creation of Internet based system for distant education “TeleTrauma”;
• scientific investigation and researches in theory of telemedicine, in using of teleconsultations in treatment of polytrauma, joints diseases etc, economical and mathematical problems of telemedicine, equipment testing, laws and ethics etc.
• dissertation “Treatment of polytrauma on pre-hospital and in-hospital stages with using of the telemedical systems”;
• web-design and content-managering of www “Telemedicine in Ukraine” (www.telemed.org.ua);
• about 30 journals’ articles, 3 books (“Telemedicine: Glossary”, 2001, “Telemedicine”, 2002, “Clinical Teleconsultations: Manual for Doctors”, 2003).

In 2003 we was found "Ukrainian Journal of Telemedicine and Medical Telematics".

In 2004 was began creation of the telemedical network of Donetsk Region. We hope that this network should become the prototype for all country.

In 2005 a Telemedical Work Station in Volnovakha (rural area) and Gorlovka (small town) have been opened and carried out 10 teleconsultations, including 3 urgent with using of mobile phones, MMS/SMS and e-mail.

GOOD/BEST PRACTICE MODELS

First in Ukraine Good/Best Practice Models for telemedicine and eHealth were created in Dep.of Informatics and Telemedicine of DRDITO (head – dr.A.Vladzymyrskyy, avv@telemed.org.ua). This Models were recognised by ISfTeH.

Links :

• http://www.telemed.org.ua/BPM/bpmtm.html
• http://www.isft.net/cms/index.php?good_practice_models

Telepathology on Solomon Islands

In June 2001, we were approached by an emigrated Swiss surgeon who has been working at the National Referral Hospital in Honiara for over 8 years. Their current service for pathology consists of sendeing specimen to Brisbane (AUS) for processing and diagnostics. This process is very unsatisfying as it takes often 8 weeks or more for the diagnosis to return to Honiara and the Royal Brisbane Hospital has announced a long time a go that they cannot provide this service free of charge ad infinitum.

In September 2001, a small histology laboratory could be established in Honiara and specimen can now be prepared there. As there is no pathologist in the State of Solomon Islands who could diagnose these specimen, we are now trying to find out if it is possible to give these diagnosis over internet.

Pictures of the slides are taken with an Nikon OptiPhot microscope and a Nikon CoolPix 990 in Honiara and then sent to our iPath-Server in Basel where they are reviewed by a number of Pathologists from Europe and USA. If additional pictures are needed for a diagnosis they are requested from Honiara and added to the existing case on the server.

4th International Conference on Successes and Failures in Telehealth

Dr. Rooney Jagilly from the National Referral Hospital in Honiara presented the project at the 4th International Conference on Successes and Failures in Telehealth in Brisbane, Australia, held from 22nd to 23rd July 2004. It was hosted by the Centre for Online Health of the University of Queensland. The presentation was awarded the best presentation of session.

Dr Jagilly at the presentation	The certficate	The award
Photos R. Jagilly, 2004 more details at hermannoberli.ch

Histology Lab at the National Referral Hospital in Honiara

The first step for telepathology is the preparation of histological slides. This document gives a short description how the histology laboratory at the National Referral Hospital (NRH) was set up.

 

Basic infrastructure

The basic infrastructure that is necessary to operate a histology lab is access to running fresh water and a reasonably cooled room. If temperatures are exceeding 25°, it is more difficult to make fine sections from paraffin blocks.

• Incubator (or an oven that can keep a temperature of 70-80° over night)
  
• Bunsen-burner (or access to gas flame)
• Microtome
• Microscope & Camera

 

Preparation of specimen

The specimen are cut up by the surgeon in the OT. A lab technician writes down the notes of gross appearance and clinical information and puts the cut sample into the cassettes with a label (crayon on paper)

left surgeon cutting interesting region from specimen. above casstette for processing specimen. allways process a label along with the specimen. use crayon on paper as this is not sffected by alcohol or xylene.

Material: Blades, Cassettes, Paper & Crayon and forms for notes (good forms help to produce good notes that provide information needed by pathologist for diagnosis. Important: write down the question regarding the specimen!)

 

Tissue processing

To dehydrate the tissue a simple manual process is used. A stack of cassettes is put into each of the jars and stays 2h in each jar. 1x 80% alc, 3x 95% alc, 3x 100% alc, 3x Xylene and finally 3x paraffin (liquid 60-70°). It is left in parrafin over night.

 

Making blocks

The processed specimen - after staying overnight in paraffin in the incubator (temperature depends on type of paraffin) - are taken out of the cassettes on a hot-plate to keep paraffin liquid. Specimen are put cut face down onto a glass plate. Two L-pieces. are fitted as form for the block and liquid paraffin is poured into the block - paraffin is heated in a steal tea-pot in the incubator and kept warm on hotplate. For handling use a heated forceps (one without teath, or remove teath by grinding them off. use bunsen burner to heat forceps). Finally, place paper label onto block so that it solidifies into the block.

left L-pieces to produce flexible shape or mould for block (made out of brass). above pouring of paraffing into block.

 
Material: Hot-plate, forceps, l-pieces, glass plate, bunsen burner

 

Cutting slides

The paraffin blockes are cooled with ice blocks to prepare for cutting. The blocks are cut with an old type mechanical sledge microtome and knives (or if available disposable blades). After cutting, the slices are transferred with a paint brush to a waterbath - simply a metal dish filled with hot water and kept warm on the hot-plate. When the slices have stretched they are mounted onto a glass slide. slides are labelled with crayon according to label on block. To dry, the slides are put for 15 min into incubator/oven (60-70°).

Material: Microtome and Knife/Blades, waterbath, glass slides, paint brush.

 

Staining

The staining bench is made out of cut plastic medicine jars. They are unbreakable, chemical proof and easily replacable. To prevent evaporation, the rows are covered with a glass plate (from window louvres) when not in use for short time. For long time, the chemicals are poured back into glasses. For staining, slides are put into a staining rack and then manually processed through the staining row. After finishing, slides are dried in incubator before mounting the cover slip. For "blueing", running fresh tap water is needed.

The staining is performed in this order:

• Heat slides in incubator for 15min to liquify paraffin.
  
• xylene
  
• alcohol 100%
  
• alcohol 100%
  
• alcohol 95%
  
• alcohol 95%
  
• alcohol 70%
  
• alcohol 50%
  
• Stains: e.g. H&E .. according to your stains
  
• alcohol 70%
  
• alcohol 95%
  
• alcohol 95%
  
• alcohol 100%
  
• alcohol 100%
  
• xylene dry in oven and then mount cover slip.

above 1) rehydration row to remove paraffin and make tissue susceptible for dye. 2) dehydration to cover with rasin and glass slip.

Material: Jars (bottom of plastic bottles. note: plastic must be resistant to Xylene, but many bottles from pharma products are - test before use!), staining rack, chemicals and containers for chemical:

 

The finished lab

Workbench for blocking and cuttin.

workbench for staining

 

Teaching needed:

Most important is to provide training to the surgeons on how to identify the parts of the specimen that are important for the pathologist and how to describe the gross appearance. Training for the lab technicians must include how to maintain the lab: how to recognise when chemicals need to be exchanged and how to exchange with minimal loss - e.g. roate 100% alcohol, ie. replace last in row with fresh alcohol and swap the others one step up and remove the first one. The most tricky part to learn is how to use the microtome and how to strech slices on the water bath. But the technicians from NRH had learned all this in their training on PNG - They just needed some time to practise.

Cambodia :: Telepathology at Sihanouk Hospital

The telepathology project at Sihanouk Hospital Centre of Hope in Phnom Penh, Cambodia, was established in 2002. Since then over 1000 cases have been diagnosed using the iPath server at University of Basel.

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Results

The SHCH project is the most successful telemedicine project in Cambodia, more than 1.000 requests are answered by experts mostly within 24 hours.

Analysing the cases, the questions are related to GI tract, thyreoid, serous membrane and skin diseases.

There is an increasing concordance between the senders and the experts diagnosis is mostly due to an continuous training effect of the Khmer Pathologists by more than 15 Experts involved in the project. The diagnostic security of the Experts increased by better slide quality caused by continuous training of the technician and introducing of new techniques  and Immunhistochemistry.

Analysing the situation of Telepathology in the Department of Pathology there is a shift from Histology to Cytology because of a higher diagnostic cost efficiency and a shift from diagnostic matter to education at purposes.
 

Pictures from SHCH