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Introduction

The Khmer empire was once the largest and most powerful in South-East Asia. The descendant country of Cambodia is now home to over 14 million people. The Vietnam War and the violent reign of the Khmer Rouge in the 1970s left millions dead or traumatized. The collapsed health system was left with an enormous burden of infectious diseases, malnutrition and psychological trauma. In 1979, there were thought to be fewer than 50 doctors left in the entire country.¹

The average annual rate of 0.3 medical contacts per person remains the lowest in the region. This may be primarily due to a lack of access, as Cambodia has the lowest ratio of physicians to population in the region.² Despite the fact that 85% of Cambodians live in rural areas, only 13% of government health workers work there.² The problems associated with the lack of access are compounded by frequent misuse of prescription drugs and indigenous health practices that are at times dangerous.³ For example, animist healers may sometimes treat open fractures with a splint and a topical application called ‘ma’lou’. This compound is made from chewed betel nut and lime paste, and has been known to result in serious infection or even death.

Poor health system performance has led to poor health outcomes. One out of 12 children never lives to reach the age of five years,⁴ and among antenatal clinic attendees, HIV is estimated at 2.2%, the highest reported for any country in Asia.⁵ The tuberculosis case rate (508 per 100 000 persons) is approximately 100 times that of the USA and is the highest rate in Asia.⁶ Malaria remains endemic, and has a prevalence of 5 per 1000 persons.⁷ Meanwhile, there is a growing prevalence of chronic non-communicable disease, and traumatic injuries and deaths from landmines and road traffic accidents continue steadily.

Cambodia ranks among the lowest countries on the United Nations Human Development Index (it was ranked 129 of 177 countries in 2006)⁸ and among the highest in poverty. Forty percent of Cambodians live on less than US$10 per month, and some 45% of the population has to borrow money to pay for health care services, which in turn has become the main cause of indebtedness and loss of land ownership.⁹ Table 13.1 compares Cambodia’s health indicators and resources with those of the USA.

Telecommunications

During the 1990s, the advent of the Internet and the growth of mobile phone technology dramatically changed the way that people communicate and share information on a global scale. Disparities in access to these networks inadvertently left Cambodia and many other regions isolated by a ‘digital divide’. None the less, broad public access to the Internet within Cambodia was boosted by foreign investment in the late 1990s from countries such as Canada and Australia via a link through Singapore.¹⁰ Like many developing countries, diffusion has been slow, with only 2 of every 1000 citizens becoming Internet users by 2002.¹¹

Early investment in mobile phone networks gave Cambodia the distinction of being the first country in the world where mobile phone subscribers outnumbered fixed line subscribers. By 2000, four out of five telephone subscribers were using a mobile phone – the highest ratio in the world.¹⁰ Various information and communication technology (ICT) indicators in Cambodia and the USA are compared in Table 13.2.

Humanitarian non-profit organizations and social entrepreneurs have begun to recognize the opportunity to use these growing communications networks for social change. The non-profit organization American Assistance for Cambodia (AAfC) and its founder provide one example. Bernard Krisher formed the AAfC in 1993 with the aim of rehabilitating Cambodia. Since that time, the AAfC has built over 300 elementary schools throughout rural Cambodia and has provided approximately one-third of them with access to the Internet.¹² This growing Internet infrastructure established by AAfC has become the backbone for a cross-cultural, multi-organizational telemedicine project that allows physicians at the Harvard Medical School in Boston and clinicians at the Sihanouk Hospital Centre of HOPE in Phnom Penh to support patient care in under-served regions of Cambodia.

Telemedicine programme

The telemedicine programme is a collaboration between the AAfC, Operation Village Health (a project of the Center for Connected Health of the Partners HealthCare system in Boston) and the Sihanouk Hospital Centre of HOPE in Phnom Penh. The aim is to provide remote consultation and supporting tools to build capacity and improve local care for those living in rural Cambodia.

The local health care providers (Cambodian nurses and doctors) play a central role in the work. After assessing the patient (i.e. history and physical and diagnostic tests), they transcribe a document of their findings into English and transmit this, together with attached images, via email to the consulting clinicians in Boston and Phnom Penh for review. Coordinators at each facility direct the cases to the appropriate medical specialist. After reviewing the medical cases, the offsite clinicians return their recommendations. The supportive guidance delivered in this way not only enhances the quality of care, but also provides a unique educational opportunity.

Figure 13.1 Sites of operation of the telemedicine clinics in Cambodia

The programme currently operates at two sites in northern Cambodia (Figure 13.1). In the first seven years, approximately 1000 telemedicine-supported patient encounters were completed at the two sites.

Site 1: Rovieng Health Centre

The Rovieng district is located in the Preah Vihear province, and is home to 6493 families (approximately 32 000 people). The region is served by two health centres, which are located 15 km apart. The region is primarily an agricultural community, and the estimated average annual income is less than US$50. Indigenous medical practices are still commonly used, and include techniques that involve direct skin contact (i.e. cupping, pinching and coining), animistic healing practices and the use of various herbal remedies.¹³ Most visitors to the health centre have never met a Western-trained physician in person.

The pilot telemedicine programme began in February 2001 at one of the health centres in Rovieng. Each month, 25–40 people gather there to have their medical conditions assessed and, if appropriate, triaged for telemedicine consultation. Typically, 15–20 of these cases are documented in English and sent via email to Western-trained clinicians located in Phnom Penh and Boston. To date, telemedicine patients have come from 35 of the 57 villages in the district. On many occasions, those living near the health centre provide accommodation for people who have travelled longer distances by allowing them to stay for several days in their homes.

This site is 235 km and about 6 hours by road from the major hospitals in the capital city of Phnom Penh. It is also about 4 hours from the nearest referral hospital. Despite the existence of these more sophisticated facilities, cost, uncertainty and time constraints prevent most village inhabitants from seeking care outside the village.

To facilitate improved local care, a nurse from Sihanouk Hospital Centre of HOPE travels by road from Phnom Penh to Rovieng each month. Those patients who cannot be easily diagnosed and treated by the nurse have their cases sent by email to consulting physicians using the satellite Internet connection at the adjacent elementary school. The local nurse must assess each patient and transcribe the details of the encounter before these recommendations are provided. Once received by the relevant consultant, recommendations for patient management are generally returned to the nurse within 12 hours.

The telemedicine clinic operates as follows:

To enhance local diagnostic capacity, five point-of-care laboratory tests were introduced in October 2004. The availability of these tests has decreased the need for more expensive off-site laboratory testing, allowing quicker and more accurate diagnosis. The five tests were:

The choice of these tests was based on several factors, including the prevalence of local disease, ease of use, storage requirements, low cost, and the ability to use them without reliance on running water or electricity. Simple algorithms for using these tests were also created so that the nurse could use them independently. Several manufacturers kindly donated test kits to launch the service.

Site 2: Rattanakiri Referral Hospital

Based on the success of telemedicine in Rovieng, a second site opened in April 2003 at the Rattanakiri Referral Hospital (RRH) in Banlung, the capital of the Rattanakiri province. This province is home to a mixture of 13 ethnic and tribal groups, and is generally considered to be the poorest of the provinces. Non-Western indigenous health practices are widely practised. Unlike the cases from Rovieng, these referrals are initiated by Cambodian physicians working at the RRH, who have greater access to local resources, including ECG measurement, laboratory tests and basic X-ray imaging. Accordingly, the cases tend to be more complex, although there is usually more information for consulting physicians to consider in formulating their recommendations. As with the Rovieng site, the cases are sent each month as email messages using a satellite connection to the Internet. Turnaround time for receipt of consultant recommendations is also less than 12 hours. The telemedicine clinic operates as follows:

This site received its initial financial support from the Markle Foundation and is now largely supported by private individual donations, most notably from Edward and Laurie Bacharach.

Effects on local care

Retrospective reviews of the telemedicine work have been completed by staff at the Center for Connected Health and the Harvard Medical School. These studies have examined the types of patients participating in the telemedicine programme, the clinical impact on the community, and the utility and cost savings associated with the portable point-of-care laboratory. To date, the majority of these formal evaluations and reviews have focused on operations at the Rovieng site. The results are summarized below.

Demographics and case mix

A retrospective review evaluated all cases completed at the Rovieng site from January 2005 to May 2006.¹³ There were 196 teleconsultations for 106 patients. The majority of patients were female, and two-thirds of all patients sought telemedicine care on more than one occasion (Table 13.3). Most visits for new patients were for non-communicable chronic diseases (Table 13.4). The most frequent diagnosis among all patients was dyspepsia (Table 13.5).

Clinical impact

In a previous study, the first 214 cases of the programme were reviewed.¹⁴ The mean duration of the chief complaint among first-time clinic visitors was 37 months for the first 6 months of the study period. By the last six months of the study period, this had dropped to 8 months (Figure 13.2). The proportion of patients referred for care at offsite facilities decreased by 51% per year of clinic operation (95% confidence interval 27–75%; p < 0.001) (Figure 13.3). These data suggest that longstanding chronic conditions among villagers are now being addressed and that appropriate care can be delivered locally.

Figure 13.2 Duration of patients’ primary chief complaint at initial visit, during three phases of the study period. (Reproduced with permission from Telemed J E Health 2005; 11(1), published by Mary Ann Liebert, Inc.)

Figure 13.3 Proportion of patients referred off-site for care during the study period. (Reproduced with permission from Telemed J E Health 2005; 11(1), published by Mary Ann Liebert, Inc.)

Point-of-care testing

Comparisons were made between the 57 patient encounters occurring after the introduction of the laboratory tests and 119 encounters occurring in the year before, which served as historical controls. Overall, the proportion of patient cases receiving laboratory testing did not increase (Fisher’s exact test, p = 0.71). Meanwhile, the proportion of cases requiring off-site referral for the completion of laboratory testing decreased significantly from an average of 69% to 35% (p < 0.001). The costs associated with laboratory testing also decreased, from an estimated average of US$41 to US$17 per month.¹⁵

Lessons learned

Several valuable lessons have been learned during seven years of operation. The project has demonstrated the feasibility of using store-and-forward telemedicine across time zones, socioeconomic strata and cultures. More specific observations have also been made, and can be categorized as human, economic or technology factors (Table 13.6).

Human factors

Human factors are arguably the most important for success. This requires not only commitment at the organization level, but also adoption by the users: the patients, local care providers and consulting physicians.

Patients

Demand by patients for telemedicine services at the Rovieng Health Centre has remained high, particularly among women aged 15–64 years. The sustained patient volume and rate of return visits suggest that cross-cultural telemedicine can compete successfully with conventional and local indigenous practices. This is probably due to several factors.

The willingness of families to accommodate one another during the monthly tele-medicine clinics signals a high degree of ‘social capital’ within this community. The monthly schedule of the clinics encourages adherence among patients through frequent opportunities to educate, inform and reinforce the benefits of the prescribed medication. The social nature of these monthly gatherings brings community members together, and may also play a role in adherence – much like that of a support group or ‘group visit’ (a model of chronic care management gaining popularity among US primary care physicians). The significance of this is most evident in instances where patients are asked to begin long-term medication regimens that may have little effect on their sense of wellbeing – or even produce undesirable side effects. For example, antihypertensive medications are now frequently prescribed to treat the surprisingly high prevalence of high blood pressure in this community. The high return rate among villagers and the apparent adherence to modern drug regimens suggests that the concept of chronic disease management is being incorporated into the local culture.

It is important to note that, at present, there is no direct cost to patients for telemedicine visits or for the prescribed medications recommended in the consultations, which undoubtedly encourages a high return rate. To better understand patient expectations, their satisfaction and willingness-to-pay were assessed in 2003 using a verbally administered survey.⁷ All patients surveyed (n = 63) were either ‘satisfied’ or ‘very satisfied’ with the use of telemedicine as an alternative to the seeking of care within the traditional Cambodian health system. Of those surveyed, 78% were willing to pay for these services. Of those willing to pay, the mean amount was US$0.63 per visit.

Local providers

Initially the dialogue between local and consulting clinicians was a fairly unstructured exchange, akin to an instant messaging Internet ‘chat’. However, as the telemedicine programme has matured, this has evolved into a structured format using a standardized template for history and physical examination (Box 13.1).

The visiting telemedicine nurse in Rovieng is part of the SHCH staff, and participation is mandated in the job description. In contrast, telemedicine at the RRH depends on the interest and willingness of the local physicians to participate. Patients that are managed using telemedicine require more local physician time, although there is no additional physician remuneration. It could be argued that the inherent opportunity cost to physicians who participate under this arrangement might ultimately become a barrier to sustainability. Possible methods of maintaining the participation of local Cambodian physicians include reducing lengthy translation/transcription times and improving cultural competence among US consultants to ensure that their recommendations are relevant to the local context and available resources.

Consulting physicians

Informal inquiries of consulting clinicians in the USA and Phnom Penh have revealed several potential areas for quality improvement. To maximize the value of the consulting physician’s recommendations and avoid a ‘garbage-in–garbage-out’ situation, measures should be taken to ensure the completeness of the initial clinical data collected and documented by the local provider. Convenient and reliable web access to patient medical records could enhance continuity of care for those with recurring or chronic conditions.

Overall, a high degree of cultural competence among consulting and local clinicians has been important to the successful introduction of Western-based medical concepts such as chronic disease (i.e. diabetes and hypertension) and prevention.

Economic factors

Grants, foundations and private donations from organizations such as the Asia Development Bank and Japanese corporate sponsors have funded the efforts of AAfC. Satellite services (estimated cost US$285 per site per month) have been secured as corporate gift-in-kind donations from a Thai telecommunications company. By ‘piggy-backing’ the telemedicine programme onto this existing Internet infrastructure, large capital investments have been avoided.

None the less, certain problems remain, such as the cost implications of telemedicine. As mentioned above, the local physician time required per patient is greater than for traditional care in cases originating at the RRH. Furthermore, strict adherence by local clinicians to the recommendations of US consulting physicians who are uninformed about local resource constraints could result in increased utilization and, therefore, cost.

At present, the programme continues to rely on volunteers and donations from charitable organizations. As a result, alternative economic schemes (i.e. fee-for-service or a pooled payment model) may eventually need to be introduced if this model of care is to be transferred to other regions or implemented on a broader scale. Some revenue has been generated via the online sales of locally produced products such as coffee, scarves and other handicrafts, but, to date, this has contributed little to the overall operating budget.

Technological factors

Reliable electrical power and Internet connectivity are central to the operation of the programme. The use of solar panels supplemented by portable generators has proven to be feasible for the operation of computers and satellite communications equipment. Telecommunication employs a low-to-moderate range of bandwidth and uses a store-and-forward, asynchronous email mode of communication. These characteristics contribute to the potential for scalability, especially as the use of email and familiarity with computers among Cambodians grow. Expansion of Internet connectivity, however, has been restricted by poverty, the lack of a rigorous academic community to nurture networking, the complexity of using the Khmer language with computing and application development, a shortage of dial-up telephone lines and restrictive government regulations.¹⁰

In terms of laboratory technologies to support remote consultations, the point-of-care laboratory tests appear to be feasible, clinically useful and likely to reduce the need for slower, more expensive offsite testing.

Future directions

The data from the retrospective reviews and lessons learned have helped to plan a strategy for the future.

Human factors

As there is a high level of demand for management of chronic illnesses such as diabetes and hypertension, an increased emphasis on continuity of care is planned for patients at the Rovieng site.

Recently, the non-governmental organization HealthNet International has been contracted by the Cambodia Ministry of Health to reform health care delivery in several provinces, including Rattanakiri. As a result, the telemedicine component at the RRH is also being restructured. Expected benefits include greater local ownership and accountability of the programme through stronger administrative oversight and physician participation. This change is expected to integrate telemedicine more formally into the hospital’s service and enable a greater measure of evaluation and quality control. In addition, it is hoped that this new arrangement will facilitate a stronger relationship with the Ministry of Health and potentially enable broader use of tele-medicine to support government-sponsored public health initiatives.

To build local capacity, an increased emphasis on clinician education is anticipated. Linking educational content directly to patient care recommendations is being considered as one way to enhance the experiential learning that already occurs. Skills training in the use of computers, project management and administration would also enable greater local ownership of the programme.

Economic factors

To date, the programme has successfully enlisted the voluntary participation of highly skilled medical specialists and clinicians whose time would otherwise not be affordable. This approach will continue to be crucial for the future sustainability of the programme, as will philanthropic and gift-in-kind contributions from socially minded individuals and corporations.

Technology factors

A more sophisticated clinical information management system is required. This would facilitate continuity of care through web access to patient records and enable more robust data analysis for population tracking and research. Several web-based platforms or electronic medical records are being explored. Examples include the system created by the Swinfen Charitable Trust (see Chapter 19) and open-source formats (i.e. OpenMRS and OpenVista).

To improve the efficiency and completeness of local clinician assessment and transcription, digital pen technology combined with standardized clinical forms is being explored. This may be an improvement over keyboard data entry.

Conclusion

Cambodia’s health system faces a significant disease burden, as well as provider shortages and limited resources. The low-bandwidth, store-and-forward telemedicine programme that began in 2001 has expanded to a second site. Experience suggests that this model of care is not only feasible, but also acceptable to patients and care providers, and has positive clinical effects. Continued challenges to its operational efficiency and effectiveness remain, as do methods of data collection to assess the clinical effects. With stakeholders in the USA and Cambodia, this collaborative project seeks to become a sustainable, scalable and transferable model of cross-cultural telemedicine for low-resource settings.

From a broad perspective, the process of globalization will undoubtedly have an impact on the health of populations in both the industrialized and the developing world.¹⁶ Telemedicine and telehealth applications are likely to emerge as future tools to transform the way care is delivered across cultures, geography and time zones. It is clear that utilizing communication technologies to decrease health disparities is possible in places such as rural Cambodia, but large-scale deployment of telehealth in the developing world will depend on the positive convergence of human, economic and technological factors.¹⁷

Acknowledgements

We thank Kathy Fiamma, Dr Kavitha Reddy, Dr Sherene Idriss, Heather Bello, Nedialka Douptcheva and Marco Senelly.

Further reading

King H, Keuky L, Seng S et al. Diabetes and associated disorders in Cambodia: two epidemiological surveys. Lancet 2005; 366: 1633–9.

Telemedicine in Low Resource Settings (Discussion Group). Available at: www.dgroups.org/groups/telemedicine/index.cfm.

References

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² Kvedar J, Heinzelmann PJ, Jacques G. Cancer diagnosis and telemedicine: a case study from Cambodia. Ann Oncol 2006; 17(Suppl 8): 37–42.

³ Kemp C. Cambodian refugee health beliefs and practices. J Community Health Nurs 1985; 2: 41–52

⁴ World Health Organization. The World Health Report 2000 – Health Systems: Improving Performance. Geneva: WHO, 2000. Available at: www.who.int/whr/2000/en/index.html.

⁵ Centers for Disease Control. Screening HIV-infected persons for tuberculosis – Cambodia, January 2004–February 2005. MMWR Morb Mortal Wkly Rep 2005; 54(46): 1177–1180.

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⁹ World Health Organization. Country Cooperation Strategy: Cambodia. Available at: who.int/countries/en/cooperation_strategy_khm_en.pdf.

¹⁰ Wright D. The International Telecommunication Union’s report on Telemedicine and Developing Countries. J Telemed Telecare 1998; 4(Suppl 1): 75–9.

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¹³ Reddy KK, Idriss SZ, Chau R et al. Cross-cultural telemedicine approach to epidemic diabetes: model for developing nations. Telemed J E Health 2007, 13: 198 (Abst T5C1).

¹⁴ Brandling-Bennett HA, Kedar I, Pallin DJ et al. Delivering health care in rural Cambodia via store-and-forward telemedicine: a pilot study. Telemed J E Health 2005; 11: 56–62.

¹⁵ Heinzelmann PJ, Jacques G, Kvedar J. Telemedicine by email in remote Cambodia. J Telemed Telecare 2005; 11(Suppl 2): 44–7.

¹⁶ Huynen MM, Martens P, Hilderink HB. The health impacts of globalization: a conceptual framework. Global Health 2005; 1: 14.

¹⁷ Graham LE, Zimmerman M, Vassallo DJ et al. Telemedicine – the way ahead for medicine in the developing world. Trop Doct 2003; 33: 36–8.

¹⁸ Heinzelmann PJ, Lugn NE, Kvedar JC. Telemedicine in the future. J Telemed Telecare 2005; 11: 384–90.

¹⁹ World Health Organization. WHO Statistical Information System (WHOSIS). Available at: www.who.int/whosis.

²⁰ World Health Organization. The Digital Divide: ICT Development Indices 2004. New York and Geneva: United Nations, 2005.

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