Document(s) 12 de 31

Introduction

Advances in information and communication technology (ICT) have provided new ways of delivering health care.¹ The World Health Organization (WHO) has recognized the role of ‘health telematics’ in improving access to medical and health care, health education, global health promotion, training of health personnel and the management of emergency situations.² This is particularly relevant in developing countries, where there are often growing health disparities, and where children are particularly affected by inequalities of access.

Telemedicine has become increasingly popular in both industrialized and developing countries.¹ In developing nations, telemedicine has important effects on many aspects of health systems.³ It has the potential to improve health care by removing time and distance barriers, providing medical education and medical care, and optimizing the use of the limited health services available in these under-served communities.⁴

There have been many reports suggesting the potential advantages and benefits of telemedicine as a useful technique for delivering health care in the developing world.^5–8 However, few authors have described the actual clinical experience of using telemedicine there.^9–13 The reported use of telemedicine for children in developing countries is even more limited.^14–17 Medical Missions for Children (MMC) is a US not-for-profit organization that operates a global videoconferencing network. It delivers expertise from medical specialists and technicians based in hospitals in the USA to children needing care in developing countries by using telemedicine.¹⁸

Medical Missions for Children

The goal of MMC is to improve health care for children in medically under-served communities by using telemedicine. It has the following aims:¹⁸

1. To provide medical diagnoses and treatment via telemedicine to children and mothers in under-served communities around the world.
   
   
2. To facilitate medical knowledge transfer from those who have it to those who need it using the latest in communication technology.
   
   
3. To support applied medical research utilizing state-of-the-art communications infrastructure.

MMC works with a network of 27 American hospitals, who mentor participating hospitals in under-served countries.¹⁸ It provides videoconferencing equipment for the hospitals in the developing world, as well as satellite time for the communication. Videoconferencing equipment (donated by Polycom) includes ViewStation HXD 9000, ViewStation VSX 7000 and HDX equipment, which communicates at band-widths from 384 kbit/s to 4 Mbit/s. Physicians from the mentoring hospitals volunteer their time and expertise to participate via videoconference in remote examinations of patients, consultations about diagnosis and treatment, and education about new procedures, drugs and medical equipment.

History

MMC was founded in March 1999 by Peg and Frank Brady at St Joseph’s Children’s Hospital in Paterson, New Jersey, as a way of screening ill children from developing countries prior to doctors travelling to treat them. After eight years of operation, MMC serves children in over 100 countries throughout Latin America, the Caribbean, Europe, Africa, Asia, the Pacific and the Middle East. At least three patient consultations or diagnostic sessions are held by videoconference each day, with 1000–1200 direct consultations conducted every year. Since its inception, MMC has provided diagnostic consultations to almost 25 000 children, using the expertise of more than 600 physicians from 27 mentoring hospitals via telemedical support.

Programmes

MMC’s work is accomplished through five programmes.

1. Telemedicine Outreach Programme

MMC operates a distance medicine network in more than 100 countries, called the Telemedicine Outreach Programme. This programme, a partnership with the World Bank, allows physicians to be electronically linked to patients in remote locations. MMC maintains a network of 27 mentoring hospitals in the USA and Europe that participate in the programme.¹⁸

2. Medical Broadcasting Channel

The Medical Broadcasting Channel (MBC) was launched in November 2005. It was developed as a means of helping physicians and other health care professionals to stay abreast of the latest developments in the medical field. High-quality, up-to-date medical education is delivered to physicians and allied health care workers around the world by satellite broadcasting and Internet streaming. The Intelsat 903 satellite is used to broadcast medical content to an area that encompasses 9 million physicians, 14 million nurses, 5 million health care workers, 89 000 hospitals, and 16 000 universities and medical schools.¹⁸

MBC is also available via the Internet2, the high-speed research version of the Internet. This network can support the transmission of TV-quality video and is available in 88 countries around the world.¹⁹ The network is available to more than 300 000 institutions, including universities, government agencies, hospitals, medical schools, corporations and research facilities.

Eight daily seminars on different medical topics ranging from paediatrics to geriatrics are transmitted three times a day via satellite and the Internet. By providing and disseminating this latest medical information, MMC helps to increase the level of expertise in each participating hospital, as well as alleviating the disparity of care between industrialized nations and the developing world.

3. Global Video Library of Medicine

The Global Video Library of Medicine (GVLM) provides health care workers around the world with free access to an archive of more 25 000 hours of medical video. GVLM is the digital repository of thousands of video-based medical lectures, news programmes, symposia and training sessions, all of which are available to health care providers throughout the world. It provides a reliable source of clinical and medical research content via the public Internet.¹⁸ It is available to health care professionals as well as the general public. Its Video-on-Demand capability allows researchers to search for and retrieve medical content. GVLM also serves as the content source for MBC.

4. Giggles Children’s Theatre

The Giggles Children’s Theatre performs three times each week to bring the healing powers of laughter and entertainment to hospitalized children in the city of Paterson, New Jersey (Figure 10.1). From the comfort of the Giggles Theatre, children are able to travel the globe on interactive virtual field trips that include swimming with sharks, visiting zoos and museums, and exploring rainforests.

The theatre provides a short escape from the fear and monotony that often accompany a hospital stay. Giggles presentations are also delivered via closed circuit television to the bedside of children too ill to come to the theatre and are broadcast via satellite and Internet2 to other children’s hospitals around the world.¹⁸

5. MMC-produced television shows

The belief in creating knowledgeable patients who can work as a team with the physician to manage their illnesses led MMC to produce three television programmes for the Public Broadcasting System and MBC. The programmes educate individuals about health problems that could affect them and their families. The programmes are:¹⁸

• Plain Talk about Health, which was designed to take the medical jargon out of important conversations about health.
  
  
• Tomorrow’s Medicine Today, which includes interviews with the directors of the 27 institutes of the US National Institutes of Health (NIH) and researchers from around the world.
  
  

• Take Care, which presents a patient describing his symptoms and the subsequent review and diagnosis by specialists.

Figure 10.1 A Giggles Children’s Theatre presentation of Aesop’s Fables

Case report

The first child helped by MMC, Yordano, was an 11-year-old boy from rural Panama who was born with a cranial deformity resulting in the absence of one eye, difficulty in swallowing and learning difficulties. Yordano comes from a family of six. His father is a painter and his mother is a seamstress. He has an 18-year-old brother, a 5-year-old brother and a healthy twin brother. Yordano was the first child to use the MMC telemedicine network. He was examined by the physicians at St Joseph’s Children’s Hospital in New Jersey, and it was decided that he could be helped. A computer model of his head was created with the help of interactive telemedicine to collect the measurements. Then, using a computer, physicians designed titanium implants to correct his deformity. A physical model was made to confirm that all the parts fitted properly. Yordano’s doctors in Panama were involved with the preparation. However, it was decided that his surgery should be performed at St Joseph’s. Yordano and his mother arrived in the USA in November 2001 for the initial surgery. Subsequently, Yordano had 11 surgical procedures performed at St Joseph’s to reconstruct his skull and jaw, to create an eye socket for a prosthetic eye and to receive a new titanium jaw (Figures 10.2–10.4). After this surgery was completed, educational sessions were held by the surgeons from the USA, who used the MMC network to review the procedure with 50 physicians from Panama. The plan is for Yordano to have one more operation in Panama to align his jaw. He is now 17 years old and doing well.

Figure 10.2 Yordano with Dr Hillel Ephros

Figure 10.3 Yordano, post surgery

Figure 10.4 Yordano, seven years after the first operation

MMC and the Children’s Hospital at Montefiore

The Children’s Hospital at Montefiore in the Bronx, New York, acts as a mentoring hospital for the University College Hospital in Ibadan, Nigeria. The object is to provide health education and better access to medical care for children in Nigeria. The International Center for Child Health at the Children’s Hospital at Montefiore (CHAM) houses telemedicine equipment to facilitate encounters between CHAM staff and Nigerian medical professionals, providing a forum for medical information exchange in the form of training sessions, seminars, symposiums and consultations via videoconferencing.

Working in partnership with the MMC, CHAM is sponsoring the College of Medicine at University College Hospital in Ibadan. MMC has provided the telemedicine equipment for the hospital in Nigeria. A curriculum of the hospital’s educational needs and interests is being developed by medical staff in Nigeria in collaboration with CHAM faculty members. An agreement between MMC and the World Bank allows CHAM to connect with the Medical Missions site (via three ISDN lines) and access the World Bank satellite to reach the College of Medicine via Ibadan’s satellite dish. The World Bank pays for the satellite time.

Our Nigerian partner has responsibility only for providing space for the telemedicine equipment and administrative support to ensure the quality and sustainability of the programme. They also provide an appropriate mechanism for assessing and discussing the medical and educational needs of Nigeria, to ensure that the programme contributes to the enhancement of paediatric health care.

Conclusion

There are many potential benefits of using telemedicine to deliver health care in the developing world.^7–9 However, there are few reports that describe the use of telemedicine for children in developing countries. MMC, a non-profit-making organization, has a well-established telemedicine network between mentoring hospitals in the USA and hospitals in developing nations. Since its inception, the programme has provided direct medical consultation and services to some 25 000 children in developing countries.

Further reading

Reznik M, Marcin JP, Ozuah PO. Telemedicine and under-served communities in developing nations. In: Wootton R, Batch J, eds. Telepediatrics: Telemedicine and Child Health. London: Royal Society of Medicine Press, 2005: 193–8.

Swinfen Charitable Trust Website. Available at: www.swinfencharitabletrust.org.

References

¹ Wootton R, Craig J, Patterson V, eds. Introduction to Telemedicine, 2nd edn. London: Royal Society of Medicine Press, 2006.

² World Health Organization. Health-for-all Policy for the Twenty-First Century (Document EB101/INF. DOC./9). Geneva: WHO, 1998.

³ Edworthy SM. Telemedicine in developing countries. BMJ 2001; 323: 524–5.

⁴ Zhao Y, Nakajima I, Juzoji H. On-site investigation of the early phase of Bhutan Health Telematics Project. J Med Syst 2002; 26: 67–77.

⁵ Einterz EM. Telemedicine in Africa: potential, problems, priorities. CMAJ 2001; 165: 780–1.

⁶ Fraser HS, McGrath SJ. Information technology and telemedicine in sub-Saharan Africa. BMJ 2000; 321: 465–6.

⁷ Groves T. SatelLife: getting relevant information to the developing world. BMJ 1996; 313: 1606–9.

⁸ Kastania AN. Telemedicine models for primary care. Stud Health Technol Inform 2004; 104: 89–98.

⁹ Wootton R. The possible use of telemedicine in developing countries. J Telemed Telecare 1997; 3: 23–6.

¹⁰ Wootton R. Telemedicine and developing countries – successful implementation will require a shared approach. J Telemed Telecare 2001; 7(Suppl 1): 1–6.

¹¹ Vassallo DJ, Swinfen P, Swinfen R, Wootton R. Experience with a low-cost telemedicine system in three developing countries. J Telemed Telecare 2001; 7(Suppl 1): 56–8.

¹² Patterson V, Hoque F, Vassallo D et al. Store-and-forward teleneurology in developing countries. J Telemed Telecare 2001; 7(Suppl 1): 52–3.

¹³ Latifi R, Muja S, Bekteshi F, Merrell RC. The role of telemedicine and information technology in the redevelopment of medical systems: the case of Kosova. Telemed J E Health 2006; 12: 332–40.

¹⁴ Lee S, Broderick TJ, Haynes J et al. The role of low-bandwidth telemedicine in surgical prescreening. J Pediatr Surg 2003; 38: 1281–3.

¹⁵ Person DA, Hedson JS, Gunawardane KJ. Telemedicine success in the United States Associated Pacific Islands (USAPI): two illustrative cases. Telemed J E Health 2003; 9: 95–101.

¹⁶ Graham LE, Zimmerman M, Vassallo DJ et al. Telemedicine – the way ahead for medicine in the developing world. Trop Doct 2003; 33: 36–8.

¹⁷ Qaddoumi I, Mansour A, Musharbash A et al. Impact of telemedicine on pediatric neuro-oncology in a developing country: the Jordanian–Canadian experience. Pediatr Blood Cancer 2007; 48: 39–43.

¹⁸ Medical Missions for Children. Global Telemedicine and Teaching Network. Available at: www.mmissions.org/index.html.

¹⁹ Medical Missions for Children. List of Countries Aided by MMC’s Telemedicine Outreach Program. Available at: www.mmissions.org/top/countries.html.

Document(s) 12 de 31