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Introduction

Telementoring – mentoring through the use of telecommunication – provides access to more experienced staff. This is an application of tele-education in general. In surgery, telementoring allows a remotely located surgeon to obtain the help of centrally located, more experienced surgeons in performing complicated procedures. This may occur before, or even during, surgery, when expert advice can improve intraoperative decision making.

Intraoperative assistance has been described by several authors.^1,2 At the Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS) in Lucknow, we have developed telementoring further, so that a mentor’s input is continuously provided for the overall clinical care of the patient, to assist in diagnosis, preoperative treatment planning and postoperative care.³ Telementoring has been incorporated into the training and teaching programme of the Department of Endocrine Surgery at the SGPGIMS. This department is one of only two in India that provide curriculum-based training in this relatively new subspecialty. Hence, the short-course training given in house to general surgeons is further consolidated with telementoring. This model may be relevant to other developing countries where there is a shortage of staff in certain subspecialties.^4,5

Telemedicine in India

Public health care in India is primarily a responsibility of the state or province. The health system has a three-tiered structure: the primary health care centres cover a group of villages, secondary level health centres are at district level and medical colleges, located in big cities, provide tertiary care. Private sector hospitals account for almost 60% of health care.

Both government and private agencies have begun telemedicine projects. Government agencies that support these activities are the Indian Space Research Organization (ISRO), the Department of Information Technology, the Ministry of Communications and IT, the Department of Science and Technology, and the Ministry of Defence. In addition, self-funded activities are being carried out by various corporate hospitals. A few mobile telemedicine units using satellite connectivity provided by ISRO have been introduced for community ophthalmology care. At present, ISRO’s telemedicine network consists of about 200 nodes spread across the country.

The Department of Information Technology has produced guidelines and standards for the practice of telemedicine in India, which are aimed at enhancing interoperability among the various telemedicine systems being set up in the country.⁶ This document aims to streamline the establishment of telemedicine centres and to standardize services available from different telemedicine centres. In addition to suggesting standards for various equipments needed for setting up telemedicine centre, it also provides guidelines for conducting telemedicine interactions.

The Ministry of Health and Family Welfare has recently launched two national projects. The first is oncoNET India, which will connect 25 regional cancer centres with four peripheral medical colleges/hospitals each, creating a network of about 100 telemedicine nodes exclusively for cancer care. The second is the Integrated Disease Surveillance Project, in which all the district hospitals in India will be networked with regional medical colleges. The object is to improve surveillance of diseases of public health importance and to deliver continuous professional education of peripheral health care staff. A national task force on telemedicine has been working under this ministry for over two years in formulating policies to facilitate the growth and integration of telemedicine into health care.⁷ During the government’s next five-year plan, it is expected that new telemedicine projects will be introduced based on an evaluation of existing telemedicine projects.

SGPGIMS infrastructure

In 1999, the Department of Endocrine Surgery at the SGPGIMS started experimenting with the use of videoconferencing to deliver education to a remote medical college. This followed a successful trial of multisite videoconferencing of a four-day postgraduate course in endocrine surgery and a workshop on minimally invasive endocrine surgery. Endocrine surgery, as a subspecialty of surgery, is not well developed in India. To facilitate knowledge exchange across the country, the department carried out a technical trial. Gradually, the educational interest expanded to include remote health care delivery. More projects began, and the telemedicine infrastructure grew. Currently, the infrastructure at the SGPGIMS telemedicine centre consists of several telemedicine workstations, equipped with teleradiology, pathology and videoconferencing units with large display devices. It can carry out medical data transfer and videoconferencing with six remote locations simultaneously.

The equipment used for telemedicine includes multimedia PCs with 43 cm monitors, as well as studio-type videoconference systems with flat-panel 74 cm television screens. Peripherals include an X-ray digitizer and a trinocular microscope with digital camera attachment. Initially, the connectivity was through a 128 kbit/s ISDN line. Subsequently, satellite-based connectivity with a 384 kbit/s bandwidth was obtained from ISRO. There is one Ku-band demand assigned multiple access (DAMA) and an extended C-band very small aperture terminal (VSAT).

The telemedicine centre at the SGPGIMS uses various modules in telemedicine care (teleconsultation, tele-follow-up, pre-referral screening, treatment planning and telementoring), distant medical education and remote assistance in skill development of health care professionals, as well as research and development in the field of tele-medicine.⁸ All telemedicine sessions are real-time.

Partners

The SGPGIMS telemedicine network partners are both national and international. National partners are listed in Table 11.1.

The international partners are Ranguil University, Toulouse, France and the Holy Family Hospital, Rawalpindi, Pakistan. Both of the overseas centres are connected with 384 kbit/s ISDN.

The technical partners are ISRO, the Centre for Development of Advanced Computing (CDAC), Pune and Mohali, and the Online Telemedicine Research Institute (OTRI), Ahmedabad.

Currently, the Orissa Telemedicine Network project is operational and the Uttaranchal network is in the implementation phase. A network involving eight medical colleges in Uttar Pradesh is being designed.

Telementoring and tele-education at the SGPGIMS

The first successful telementoring session was conducted in 2004, when a parathyroid tumour removal was performed at the Amrita Institute of Medical Sciences under expert guidance from the SGPGIMS. There had been two previous unsuccessful attempts at tumour removal by the same surgeon in 2001. This experiment was the first of its kind reported from India.^5,9 The patient benefited, since he had the operation performed locally, without having to travel to a distant specialist centre. In fact, the general condition of this patient was so poor that he could not have travelled to the specialist endocrine surgical unit. For the telementoring session, both institutions were provided with dedicated 512 kbit/s VSAT connectivity. Video and audio quality was good enough for the expert at the SGPGIMS to guide the remote team satisfactorily.

We have also used telementoring as a tool in subspecialty growth in general⁴ and in reinforcing endocrine surgical training.⁵ This has been done to meet local requirements, since there is a lack of specialist endocrine surgical centres in India. As far as structured endocrine surgical training is concerned, only two centres in India provide the MCh (Master of Surgery) degree. They have an annual intake of three candidates. In addition to the MCh training, short-course training (1–3 months) is also provided by the department at the SGPGIMS. The short-course training is reinforced by the use of telemedicine. During a short training post of three months, the trainees rotate through clinical and laboratory services and attend all the academic sessions conducted by the department. Following their return to their parent institute, telementoring is used to monitor their endocrine surgical practice and to guide them in solving diagnostic problems, in treatment planning and postoperative care.⁵ The trainees also receive mentoring from experts in associated specialties such as nuclear medicine, endocrine pathology and interventional radiology.⁵

The tele-CME (continuing medical education) programmes conducted by the Department of Endocrine Surgery at the SGPGIMS are regularly transmitted to these trainee locations so that they receive updates on recent developments.¹⁰ Table 11.2 shows the details of the tele-CME transmitted to the medical college in Cuttack, where two of the short-term trainees are currently located.

The trainees also consult their mentors at the SGPGIMS in discussing complex endocrine surgical problems, treatment planning, intraoperative and postoperative consultation, and follow-up plan. Figure 11.1 shows the numbers of such sessions held from 2001 to 2007. Figure 11.2 shows a tele-CME and a tele-education session in progress.

The benefit of telementoring and tele-education is that the trainees are able to manage many of the common endocrine surgical diseases without referring them to the SGPGIMS.⁵ The added confidence due to the continuous presence of the mentor increases their output in terms of the range of endocrine surgical procedures performed and reduces the complication rates.⁵

Figure 11.1 Number of telemedicine sessions held per year for reinforcement of training

Figure 11.2 (a) Tele-CME session in progress

Figure 11.2 (b) Tele-education session in progress

Although our initial experience has been successful, there is a need to develop standards and an accreditation system to facilitate general adoption of the techniques. The government has now set up a national task force for telemedicine that is going to address these matters.

Other telementoring and tele-education in India

There are few reports of telementoring in medicine from other centres in India. However, some institutions, such as the All India Institute of Medical Sciences and the Apollo Telemedicine Centre, are involved in telementoring experiments (personal communications). The 50-bed hospital at Aragonda, Andhra Pradesh (in the southern part of India) receives guidance for managing its patients from the specialists at the Apollo hospitals in Chennai or Hyderabad. Under expert guidance from specialists at Chennai, the Apollo Telemedicine Centre at Aragonda has also helped primary care physicians in making decisions about complex neurosurgical cases and treating certain minor problems locally without referring them to the tertiary centre at Chennai.¹¹

Telementoring and tele-education in other
developing countries

Telemedicine has increasingly been used to solve certain health care problems faced by the developing world, but there is a paucity of published reports. This is especially true regarding telementoring. Until the number of publications increases, it will be difficult to judge the true extent of telemedicine applications being carried out in the developing world.¹²

Publications in the field of telementoring in endocrine surgery from the developing world are very few in number. Even though there is paucity of telementoring applications in the field of endocrine surgery in developing countries, there are reports in other specialties. Lee et al¹³ reported telementored laparoscopic varicocelectomy and nephrectomy in Bangkok, Thailand, which was 17 500 km from the mentoring location at the Johns Hopkins Hospital in Baltimore, USA. This experiment was conducted using ISDN lines at a bandwidth of 384 kbit/s. The authors concluded that transfer of knowledge and teaching–learning were achieved and that the video pictures transmitted had acceptable resolution and clarity. Similarly, transcontinental telementored procedures (laparoscopic bilateral varicocelectomy and a percutaneous renal access for a percutaneous nephrolithotomy) were carried out in collaboration between surgeons in Baltimore and Sao Paulo and Recife in Brazil.¹⁴

Telementoring has been conducted using low-bandwidth mobile telemedicine applications to support a mobile surgery programme in rural Ecuador.¹⁵ This involved a mobile operating room, which was taken to a remote region of Ecuador (see Chapter 18). Using a laptop computer equipped with telemedicine software, a videoconferencing system and a digital camera, surgical patients were evaluated and operative decisions were made via ordinary telephone lines. The surgeons in the mobile unit in Ecuador were telementored by an experienced surgeon located at Yale University in the USA. Apart from five preoperative evaluations, a laparoscopic cholecystectomy was successfully telementored from the Department of Surgery at Yale University School of Medicine to the mobile surgery unit in Ecuador. The use of real-time surgical telementoring to teach complex ophthalmological procedures was successfully performed in real time via an ISDN line at a bandwidth of 128 kbit/s from the Saint Francis Medical Centre in Honolulu, Hawaii, to ophthalmologists at the Makati Medical Center in Manila, Philippines, more than 8000 km away.¹⁶

Telemedicine has also been used asynchronously (store-and-forward) for consultations and patient management by practitioners at remote location. Vassallo et al¹⁷ reported the establishment of a telemedicine link by the Swinfen Charitable Trust in July 1999, to support a lone orthopaedic surgeon practising in Savar, near Dhaka, Bangladesh. Evaluation of the telemedicine-based advice for 27 referrals revealed it to be useful and cost-effective (see Chapter 19).

A trial telemedicine system to facilitate consultation between medical students pursuing elective study at a remote location in the developing world and specialists at a central location was established between Gizo Hospital in the Solomon Islands and Emory University Hospital in Atlanta, USA. A visiting medical student used this facility to relay images and investigation reports to specialists in Atlanta. This was used for telemedicine-aided learning, thus providing expert support to medical students in remote locations.¹⁸ A pilot study at the Patan Hospital, Kathmandu, Nepal by the Swinfen Charitable Trust has shown that a low-cost telemedicine link is technically feasible and can be of significant benefit for diagnosis, management and telemedicine based education in a developing world setting.¹⁹ Remote monitoring of paediatric patients at the Children’s Field Hospital in Gudermes, Chechnya, not only allowed significant number of patients to be treated locally but also enabled the doctors at the peripheral location to receive advice about operative techniques²⁰ (see Chapter 25).

Problems concerning telementoring and tele-education
in developing countries

Common health care delivery problems faced by developing countries are infrastructural and organizational in nature. Infrastructural problems include unreliable electricity supplies, poor telephone services, lack of transport and lack of medical supplies. Organizational problems include a lack of CME for health staff, poor training and supervision of health care workers, shortage of doctors and health care workers, and too many patients. Telemedicine may be useful in assisting with many of these difficulties. The major challenges with telemedicine in developing countries are unrealistic expectations, unsustainable funding models, lack of trials and evaluation data, and lack of published results and sharing of expertise.

During the audit of the telemedicine programmes at the SGPGIMS (2001–2005), it was found that only 61% of the scheduled sessions were held successfully, i.e. 39% of sessions could not be conducted owing to technical or human resource problems. Technical problems (23%) included power failure at the remote end, disconnection of the VSAT link and shifting of the VSAT service (Indian National Satellite System) to a new transponder. Human resource problems (77%) included non-availability of doctors at the expert end (36%) or at the remote end (35%), non-availability of technical staff at the remote end (7%) and others.²¹

The legal and ethical barriers that are commonly cited in telemedicine generally are also relevant in developing countries. These include questions about medicolegal liability and recommendations for good clinical practice, for which guidelines and protocols are still evolving. This is especially true for cross-border practice.²² Other concerns include standards, interoperability, product liability, intellectual property rights and sharing of health information. Ethical and political matters need to be addressed.²³

At present, professional boundaries are definitely barriers to the practice of telementoring both within and between countries. This may be assisted by national health care regulatory bodies or by international agencies such as the World Health Organization, which in consultation with its member countries has the potential to develop a global regulatory framework. In the meantime, accreditation of telementoring-based programmes needs to be carried out by appropriate agencies in each country or at a global level. Standardization of equipment, networks, technique, professional competence and process needs to be worked out. Legal questions regarding the sharing of responsibility as a result of the consequences of actions taken during telementoring must be addressed. There are as yet no guidelines on these matters. The health care regulatory body within each country needs to develop legislation for safe practice via telemedicine.

Conclusion

Telemedicine has the potential to improve the utilization of available resources for health care in developing countries. Our experience in the specialty of endocrine surgery in India has demonstrated the effectiveness of telemedicine applications in training, education and skills development. We have successfully used telementoring for continuous reinforcement of endocrine surgical training and also in the operating theatre for guided tumour removal. Even though telemedicine-enabled applications are being explored in India and other developing countries, few published reports have yet appeared. Deploying and sustaining telemedicine and telementoring requires the commitment and support of all those involved if success is to be achieved.

Further reading

Anvari M, Durst L. Development of a new telementoring program. Healthcare Q 2000; 3(3): 26–30. Available at: www.longwoods.com/product.php?productid=16718.

NASA. NEEMO 9 Mission Journal. Available at: www.nasa.gov/mission_pages/NEEMO/NEEMO9/mission_journal_4.html.SGPGIMS. Telemedindia.

References

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² Bruschi M, Micali S, Porpiglia F et al. Laparoscopic telementored adrenalectomy: the Italian experience. Surg Endosc 2005; 19: 836–40.

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