Document(s) 18 de 31

Introduction

In 2002, the Italian Ministry of Health began a project to support Italian hospitals around the world. This was driven by an ad hoc governing body, the Alliance of Italian Hospitals Worldwide. The IPOCM (Integration and Promotion of Italian Hospitals and Health Care Centres Worldwide) project originated from a census of Italian hospitals abroad conducted by the Ministry of Foreign Affairs. By using an elastic definition of the term ‘Italian’, hospitals were identified in most developing countries. The hospitals included those with Italian ownership, Italian management or Italian physicians and health staff, and also those managed or owned by Catholic religious orders.

In the initial census, there were 41 Italian hospitals or other health care centres. Almost immediately, another hospital was added to the list (Table 16.1), and after the First Conference on Italian Hospitals Worldwide, which was held in Rome, other Italian health care centres applied to be included. At present, there are 79, and the number is expected to increase in the future.

The project’s vision was of a new kind of international health cooperation that was able to keep results locally, for use by health providers who are committed to improving the health status of the population. In other words, the intention was not to adopt a spot approach to health cooperation, which might alleviate the specific health needs of certain population groups, but rather to share with local staff the most appropriate methodologies for attaining ambitious and sustainable targets.

Within this framework, telemedicine was considered as one strategic factor in the structure and organization of the health care network. Since telemedicine facilitates diagnosis, medical consultation and assistance using the resources of centres of excellence, it could therefore improve both medical and administrative support for Italian hospitals abroad. A model based on the use of the Internet^1–9 which is autonomous and cooperative at the same time would conform with the principle of subsidiarity, i.e. decisions would be taken at the nearest level of responsibility.

At the 2003 conference in Rome, Italian hospitals abroad made the request to be part of a democratic organization. The Alliance of Italian Hospitals Worldwide was then formally established. The founding partners were a number of government ministries. Immediately afterwards, certain centres of excellence in Italy were invited to join the Alliance. It was agreed that all partner hospitals in Italy and abroad would cooperate on health by supporting the network. The strategic objective was to contribute expertise from Italy to increase the quality of health care in Italian hospitals abroad.

Policy-making process

Under normal circumstances, a distinction can be made between the different phases in the policy-making process.¹⁰ Accordingly, the Italian Ministry of Health began a public policy cycle. The phases were agenda setting, policy formulation, policy implementation and policy evaluation, i.e. those of classical public policy research.

The agenda setting was established on the basis of the wishes of the Italian hospitals abroad, which expressed a need for diagnostic support and organizational assistance. Within the Ministry of Health, a group of experts who later on would be working for the IPOCM project started studying the problem, using systematic methodologies and tools. Five objectives resulted:

1. To connect the Italian hospitals abroad with centres of excellence in Italy and the Secretariat for Technical Assistance (STA) in Rome
   
   
2. To reduce diagnostic and organizational shortcomings among doctors working in Italian hospitals abroad, through a teleconsultation service
   
   
3. To increase the individual and collective skills of the health personnel through an e-learning service
   
   
4. To facilitate twinning arrangements between hospitals and facilitate government agreements with the countries hosting Italian hospitals abroad
   
   
5. To find out more about the health needs of Italian hospitals abroad in order to provide better cooperation and sustain the acquisition of medical equipment.

Task environment

Since the IPOCM participants and activities were functionally interconnected, actions of any one could potentially affect the others.¹¹ Given this complex framework for action, an assessment of stakeholders and their relevance was undertaken. The relevant internal stakeholders were the founding ministries and the associated hospitals in Italy and abroad. The relevant external stakeholders were the hospitals in the developing countries, the scientific community, citizens’ associations and the press.

Figure 16.1 The Alliance’s power-interest grid

Observation of the policy arena requires accurate management of all stakeholders. They can be prioritized using the power versus interest grid.¹² Figure 16.1 shows the power–interest grid of the project stakeholders.

The task environment of the Alliance describes the ideal area occupied by its stake-holders, such as clients, providers, competitors, unions, employees, financiers, institutions and scientific organizations. It is also a place in which the Alliance operates intense and continuous relationships.¹³

In order to pursue the project’s objectives, telemedicine instruments and political levers were identified, all of them designed to empower health professionals abroad. Medical teleconsultation and e-learning services were designed. In addition, an inventory of health equipment was set up in order to allow hospitals abroad to benefit from health equipment donated by institutions in Italy. (A complete description of the Alliance’s services and user manuals is available at the Ministry of Labour’s website.¹⁴)

Teleconsultation

Various telemedicine approaches have been used over the last few years.^15–17 In particular, those of medium or low cost that use customized computer applications have been found to be best for developing countries. This is confirmed by the extensive use of the Internet^18,19 and email in low-resource settings,²⁰ on the basis of cost–benefit considerations, high availability of connection services and common knowledge about their use.

The methodology adopted for the network was to assess first the technological need expressed by each Italian hospital abroad. As a consequence of this, all information from the different countries was collected and studied by the Secretariat in order to identify those that were viable. The availability of local Internet connectivity was examined, and standard contracts to be signed by hospitals with Internet service providers (ISPs) were developed. All this work was designed to allow all hospitals to have similar connectivity. The best approach for about 30% of the hospitals, most of them in the sub-Saharan area, was a satellite connection through individual contracts with a non-profit-making provider. To improve interoperability, the hospitals were equipped with similar workstations. Finally, software specifications were produced.

The Alliance’s network is based on access to the Internet via ADSL, HDSL (high-bit-rate digital subscriber line) or full-duplex 256 kbit/s Ku-band satellite communication. The satellite connections are mainly used by hospitals in sub-Saharan Africa. Workstations are PCs equipped with peripheral devices such as a digital cameras, printers and A4 scanners. The teleconsultation architecture is based on a Management Centre (MC) located at the Secretariat in Rome. The client software allows either an asynchronous telemedicine interaction or a real-time videoconference.

Two different types of users are involved. The referring doctors are located in 45 hospitals abroad and the specialists are located in 34 hospitals in Italy. The choice of specialist for a given teleconsultation is not made at the referring site. Instead, the teleconsultation allocation is performed by the MC. This guarantees the same quality to all referring doctors. The MC allocates the request to the most appropriate specialist based on a routing matrix. The MC can monitor the process until the teleconsultation is completed (the target is to complete consultations within 72 hours). The Alliance’s database contains 86 disease code groups, according to the International Classification of Diseases, 9th revision, Clinical Modification (ICD9-CM),²¹ which expand into 8500 single disease codes. Each specialist centre is responsible for negotiated code groups, and organizes itself to satisfy the service workload within the established targets for reply time and performance quality. Most specialist centres decided to concentrate the incoming referral traffic on a single workstation.

The referring doctor uses the client software to generate an email message containing clinical case data, or to access a videoconsultation if necessary. When compiling the fields on the electronic form, structured XML messages are created. Since both enquiry and reply are managed by the same client software, any health centre is able to act as a referral or a specialist site. The referring doctor, in addition, can invite a close examination of a clinical case by sending a videoconsultation invitation to the specialist.

International standard medical terminology is supported by the system, as well as five different languages (Italian, English, French, Portuguese and Spanish). Diseases are codified according to ICD9-CM and drug names are taken from a standard reference work.²² The interface collects all relevant data for the teleconsultation request or reply into encoded fields, in order to allow later textual retrieval and statistical analysis. ICD9-CM codes and the patient’s gender and age are the relevant pieces of information for the routing function performed at the MC, and they are put into the form by the referring doctor through multi-option lists. Most attached files are captured by digital cameras, and are usually sent after compression (i.e. with a .zip extension). Some attached files are taken directly from diagnostic equipment where feasible.

The database does not store any patient identity information, and therefore the system complies with Italian privacy law. The message reaching the MC contains a teleconsultation identification number, which is automatically generated by the software, as well as the hospital and workstation identifiers. Request and reply data are stored in a teleconsultation record in the database (Microsoft Access), which also holds diagnostic attachments and other information, such as the time of the request delivery at the MC and the time of the reply being forwarded to the referring doctor. Attachments are classified by content (e.g. patient pictures, reports, images or chart recordings). The attachment extension is automatically captured by the system, allowing the MC to detect possible mismatches between the number of attachments that are sent and those actually received. Transfer protocols between the PC and mail server are SMTP and POP.

In addition, a videoconsultation can be requested by a referring doctor in relation to a clinical case where a reply has already been delivered. It can also be requested by a specialist when sending the reply. The MC manages the videoconsultation requests until the referring doctor and the specialist reach an agreement about the date and time. The MC’s main functions allow clinicians to contact hospitals in different time zones while they are not online and allow clinicians to handle requests for videoconsultation. Once the meeting has been agreed, the MC notifies the caller, and those involved are sent an invitation message that contains a link to the web portal. Finally the system sends an alert message some minutes before the scheduled time to ensure that both doctors are available in front of their PCs. Doctors can therefore launch the session from any workstation with a browser that accepts ActiveX controls and discuss the case with the help of the relevant documentation.

E-learning

Global support to health personnel includes the provision of an e-learning service oriented to the needs of doctors and health staff abroad. This facility is provided in addition to training events on specific topics of common interest.

Assessment of training needs

One main problem was to understand as accurately as possible the scale and quality of the training required. The Secretariat reviewed various information sources. The first was the declaration given by the hospital at the time of application to the Alliance. They are required to complete a health personnel training requirement form for each of their health staff. This information is then stored in a database ready for analysis.

A second source was the registration of doctors and health staff with the Alliance e-learning platform. Potential users are asked to give information about their professional and training profile, curriculum and career expectations. They are also requested to state their training need in terms of medical disciplines. This information is also stored in the database and used for subsequent analysis.

A third source, although an indirect one, is the medical teleconsultation service itself, with a database that provides statistics about the most commonly used ICD9-CM codes. The teleconsultation data therefore identifies disease areas that deserve particular attention and thus training support.

Other aspects that are taken into consideration are the hospital resources and the sociopolitical framework. Developing countries, especially the least developed countries, have their own agenda on health topics.

Production of learning content

Most of the learning materials that have been produced are the result of an assessment of the training needs expressed by the hospitals. Each centre of excellence selected its own production materials and made them available to the Secretariat. These materials were optimized for uploading and organized by training area and by an assigned ICD9-CM code.

Other important data accessible via the platform come from the medical teleconsultation reports. In fact all teleconsultations result in reports that are classified by ICD9-CM code, and therefore a referring doctor can consult this archive before making a new teleconsultation request. The teleconsultation service therefore has substantial training benefits.

In addition to all this, the Secretariat has produced 18 new learning courses in response to identified training needs:

1. Oral urgent treatment protocol
   
   
2. Infectious disease prevention
   
   
3. Disorders of growth
   
   
4. Periodic fevers in the child
   
   
5. Chronic diarrhoeas
   
   
6. HIV/TB comorbidity
   
   
7. Clinical and biochemical ART monitoring
   
   
8. Hypertension in pregnancy
   
   
9. Post-partum haemorrhage and puerperal infections
   
   
10. Ectopic pregnancy
    
    
11. Ovarian tumours and their complications
    
    
12. Menorrhagia
    
    
13. Lung TB radiological diagnosis
    
    
14. Hospital infections
    
    
15. Biological risk and vaccine prevention for health personnel
    
    
16. Low economic impact reconstructive prosthesis techniques
    
    
17. Pharmacological and surgical therapy in acute oral infections
    
    
18. Infectious diseases in pregnancy.

The courses were produced by teams that are facilitated and monitored by the Secretariat for Technical Assistance. The MC looks after the whole production process with an expert who manages relations with the external producer company. The role of the MC’s expert is essential in monitoring the timing, given the complexity of the multiple production processes.

Health equipment inventory

In response to requests for new equipment coming from doctors working abroad, the Secretariat produced a web-based inventory for health equipment that was being donated. In 2005, Italian law provided the legal framework for public health centres to give notice to the inventory of the planned disposal of functioning health equipment. Thus, the inventory allows a centre to make the equipment available for an interested hospital abroad. Hospitals can see all equipment on the inventory and reserve items according to their need. This system, which matches offer and demand, improves the efficiency of the donation process and provides a picture of the entire donation cycle, which is useful for a better cooperation policy.

An ontology for the Alliance

Classification of diagnoses and other statistical data is fundamental to the work of the Alliance. This led to an ontological definition of the Alliance’s services.^23,24 ICD9-CM codes are ontology agents of the teleconsultation routing matrix. Doctors can scroll through the list of training materials and cross-link the interservice ontology agent, taking advantage of different databases. The same thing is possible when using the web-based inventory of donated medical equipment (which is the third service of the Alliance), where the agent is hospital structure, as well as when talking of teleconsultation, where both ICD9-CM and hospital structure are considered (Figure 16.2).

Quality control

Customer satisfaction

In 2005, a survey of service satisfaction was carried out among teleconsultation users. The areas investigated were technology, communication and organization. The results of the survey showed that 89% of specialists expressed positive judgements, and 86% of referring doctors. There were only a small number of negative judgements (about 9%). Criticisms were discussed subsequently with specialist and referring centres in order to improve service quality.

The Secretariat urged the MC to intervene on a few points related to technological and organizational matters. In about 10% of the hospitals, the MC detected trans-coding actions on teleconsultation messages operated by some Microsoft Exchange mail servers, as well as difficulties related to internal security policies. These problems were overcome by helping the hospital IT departments to properly configure their internal mail servers and security systems. The automatic alarm facilities at the MC helped to identify the problem of lost attachments and to solve it.

Figure 16.2 The first implementation of the Alliance’s reference ontology. (Adapted from Top Level Concepts of the Reference Ontology of Medicine. Laboratory of Applied Ontology of Rome, National Research Council.)

As far as the service organization at the health centres is concerned, after experiencing some mismanagement of time and allocation of requests, hospitals were advised by the Secretariat to install the teleconsultation workstation in the health directorate in order to manage the incoming flow of enquiries centrally. Some teleconsultation forms were not properly filled in by the referring centres in terms of completeness of medical data for diagnosis, so the Secretariat intervened in order to improve the request quality and speed up the processing. This represents a global process of optimization.

In 2006, a second survey on satisfaction was carried out. The results were positive in relation to the national health centres and to the Italian hospitals worldwide. For the latter, a slight decrease of service satisfaction was recorded in comparison with the previous survey. The reasons are essentially due to the ‘distance’ of some physicians who in Italy are far from the day-to-day problems of hospitals in other countries. As far as the specialists are concerned, communication can sometimes be difficult (mostly because of the use of the English and Spanish languages on the form, rather than Italian, and the lack of clinical data).

Manual of procedures

The total quality management approach adopted by the Alliance includes a manual of procedures. Procedures are planned for each of the Alliance’s services with the help of the relevant people in the operational management. This is an attempt to standardize actions in a conceptualized framework. It helps operators to manage routine and unexpected events. Procedures are revised either periodically or when needed.

Insights

Common difficulties experienced during the first years of the project included a shortage of local infrastructure and a lack of financial resources. War conditions in some of the countries hosting the Alliance’s hospitals provided additional problems. Planning and implementation activities were therefore very important, and the Secretariat accomplished these tasks successfully. We concentrated on finding technical solutions tailored to the micro dimension of each problem, since it was impossible to act with a country-level approach. The motivation and cohesion of the hospitals were continuously supported by the Secretariat, and there was public–private sponsorship for some technical solutions. After four years of experience, it is clear that success is mainly due to the strong organizational framework provided by the Secretariat, in terms of methodologies and procedures. This has made it possible to produce better results than are common with telemedicine projects in developing countries, where simple email is the usual medium of communication. Key factors in our success were a telecommunication network, specialized software for teleconsultation, an organized database and ad hoc ontologies.

There were other components that were also essential for the success of the initiative. The hospitals in Italy provided valuable expertise, both in teleconsultation and in distance learning. In addition, it should be mentioned that free-of-charge participation of hundreds of specialists would be simply inconceivable if done outside the public health system.

Finally, all doctors of Italian hospitals worldwide have left their own mark in strengthening the mission of the Alliance, which is both ethical and cooperative. The mixture of all these things has made the programme effective, and now partnership appears to be a main asset.

Conclusion

The IPOCM programme is rather different from other telemedicine work recorded in the literature. Although it shares some elements with other telemedicine initiatives in developing countries, it has relied on a solid organizational element as well as standardized procedures. Institutional support, in terms of resources and know-how, was crucial in ensuring sustainability and high service quality. Furthermore, good governance was required to keep all these elements together. Appropriate resources and good governance are therefore important components for a public policy focused on health partnership in developing countries.

Further reading

Aas IH. The future of telemedicine – take the organizational challenge! J Telemed Telecare 2007; 13: 379–81.

Geissbuhler A, Bagayoko CO, Ly O. The RAFT network: 5 years of distance continuing medical education and tele-consultations over the Internet in French-speaking Africa. Int J Med Inform 2007; 76: 351–6.

References

¹ Vassallo DJ, Buxton PJ, Kilbey JH, Trasler M. The first telemedicine link for the British Forces. J R Army Med Corps 1998; 144: 125–30.

² Vassallo DJ. Twelve months’ experience with telemedicine for the British armed forces. J Telemed Telecare 1999; 5(Suppl 1): 117–18

³ Edejer TT. Disseminating health information in developing countries: the role of the Internet. BMJ 2000; 321: 797–800.

⁴ Fraser HS, McGrath SJ. Information technology and telemedicine in sub-Saharan Africa. BMJ 2000; 321: 465–6.

⁵ 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.

⁶ Vassallo DJ, Hoque F, Roberts MF et al. An evaluation of the first year’s experience with a low-cost tele-medicine link in Bangladesh. J Telemed Telecare 2001; 7: 125–38.

⁷ Graham LE, Zimmerman M, Vassallo DJ et al. Telemedicine – the way ahead for medicine in the developing world. Trop Doct 2003; 33: 36–8.

⁸ Wootton R. Design and implementation of an automatic message-routing system for low-cost telemedicine. J Telemed Telecare 2003; 9(Suppl 1): 44–7.

⁹ Cone SW, Carucci LR, Yu J et al. Acquisition and evaluation of radiography images by digital camera. Telemed J E Health 2005; 11: 130–6.

¹⁰ Anderson JE. Public Policy-Making. New York: Praeger, 1972.

¹¹ Kirsh D. Adapting the environment instead of oneself. Adaptive Behavior 1996; 4: 415–52.

¹² Eden C, Ackermann F. Making Strategy: the Journey of Strategic Management. London: Sage, 1998.

¹³ Johnson G, Scholes K. Exploring Corporate Strategy. Englewood Cliffs, NJ: Prentice-Hall, 1993: 75–114.

¹⁴ Ministero del Lavoro, della Salute e della Politiche Sociale: Settore Salute. Available (in Italian) at: www.ministerosalute.it.

¹⁵ Mitka M. Developing countries find telemedicine forges links to more care and research. JAMA 1998; 280: 1295–6.

¹⁶ Strode SW, Gustke S, Allen A. Technical and clinical progress in telemedicine. JAMA 1999; 281: 1066–8.

¹⁷ Rodas EB, Latifi R, Cone S et al. Telesurgical presence and consultation for open surgery. Arch Surg 2002; 137: 1360–3.

¹⁸ Fisk NM, Vaughan JI, Wootton R, Harrison MR. Intercontinental fetal surgical consultation with image transmission via Internet. Lancet 1993; 341: 1601–2.

¹⁹ Kuntalp M, Akar O. A simple and low-cost Internet-based teleconsultation system that could effectively solve the health care access problems in underserved areas of developing countries. Comput Methods Programs Biomed 2004; 75: 117–26.

²⁰ Zolfo M, Lynen L, Dierckx J, Colebunders R. Remote consultations and HIV/AIDS continuing education in low-resource settings. Int J Med Inform 2006; 75: 633–7.

²¹ National Center for Health Statistics, US Centers for Disease Control and Prevention. International Classification of Diseases, 9th revision, Clinical Modification (ICD9-CM). Available at: www.cdc.gov/nchs/icd9.htm.

²² Martindale: The Complete Drug Reference, 35th edn, London: Pharmaceutical Press, 2007.

²³ Gruber TR. Toward principles for the design of ontologies used for knowledge sharing. Int J Hum Comput Stud 1995; 43: 907–8.

²⁴ Eccher C, Purin B, Pisanelli DM et al. Ontologies supporting continuity of care: the case of heart failure. Comput Biol Med 2006; 36: 789–801.

Document(s) 18 de 31