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Introduction

A surgery project for the isolated and under-served in Ecuador, which began more than 25 years ago, has matured into a fixed element of service delivery. Telemedicine was first applied to support the surgery programme in 1995.¹ Ecuador has characteristics that make it highly suitable for telemedicine.

Ecuador (more properly called the Republic of Ecuador) has a population of 13 million.² They are a mixture of European heritage and indigenous peoples, and occupy three distinct geographical zones.³ The westernmost zone is the coastal region. The central zone is the highlands (the Sierra). The easternmost region (the Oriente) marks the beginning of the Amazonian rainforest.

The majority of the population work in the service industry, many being employed in eco-tourism.³ However, the unemployment rate is 10.6%, with poverty affecting 39% of the population.³ The gross national product (GNP) for Ecuador is US$4070 per capita.² The average per capita expenditure for health care is US$127.² Total health care spending for the country is 5.5% of the gross domestic product (GDP).²

Health concerns in Ecuador

Ecuador has certain medical problems that are common to much of the rest of the world, some that are common to tropical regions and some that are common to developing countries. These three categories are important in considering illness in Ecuador. Like the world in general, Ecuador is facing changing illness patterns that reflect the emergence of chronic conditions, rather than the acute, infectious diseases more common in earlier times. There is also increasing interpersonal violence and trauma (mainly due to increased motor vehicle activity) and tropical disease. As a developing country, Ecuador has the common problems of sanitation, nutrition and access to health care.

Despite these challenges, life expectancy in Ecuador is similar to that in industrialized countries, with recent data predicting 70 years for males and 75 years for females.² Infant and child mortality are high, at 22 and 25 per 1000 live births, respectively.² Compared with 10 years ago, non-communicable diseases have increased in importance (up to 42% of deaths), as have injuries (21% of deaths), while communicable diseases have declined as a measure of the burden for mortality (down to 37% of deaths).⁴

Medical system in Ecuador

Ecuador has developed a health care system based on a combination of public, private and volunteer support. In 2000, the total health workforce (physicians, nurses, midwives and dentists) numbered 41 000.² There were 18 000 physicians (or 1.5 per 1000 people).² These numbers do not include the traditional tribal healers, once an important part of the culture of the indigenous peoples. With 39% of the people living in rural areas, and up to 30% of the population classified as Amerindian,³ the role of the ‘curanderos’ in health care is still significant.

The more common, Western-style practitioners study in a traditional style of medical education, modelled on the European system. The national government supports the education of doctors (six years of medical school followed by a one-year internship), in return for which the doctors are expected to provide a year of service, typically in rural/under-served areas.

The national government is also responsible for 41% of total health spending, of which about 15% is from social security funds, the rest coming from the Ministerio de Salud Publica (MSP), the public health ministry.² In many cases, the patient’s family is responsible for providing meals, medicines and some materials during the course of care. Despite the efforts of private payers, and government support for health care, about 25% of the population do not have access to health care.²

For people in rural areas and the poorest sections of urban areas, care may be nonexistent or may come from volunteer providers. Many providers in the country are philanthropic organizations, such as the Fundación Cinterandes (Cuenca, Ecuador). Many health care workers are volunteers from the USA and elsewhere. Interplast and Operation Smile are two examples of plastic surgery missions well established in many developing countries, including Ecuador.

Intermittent surgical services

Volunteer organizations, such as those mentioned, provide intermittent surgical services to meet the surgical needs of under-served populations. This has previously been decried as poor-quality care, since the surgeon does not follow the care of the patient directly throughout the process of healing. However, intermittent surgical services are becoming recognized as part of a comprehensive system of health care delivery.⁵ With the use of telemedicine, the distance between patient and surgeon becomes less of a problem and, with a system of integrated providers (primary care and specialist), the patient need never be without expert opinion.

The original intention of the mobile surgery programme of the Cinterandes Foundation was to use Ecuadorian and international volunteers to provide intermittent surgical services to under-served populations. The system has subsequently expanded to become a more inclusive, integrated part of a continuum of care.¹ Since 1994, the Cinterandes Foundation has been providing surgical care to remote populations, decreasing the need for patient/family travel (and travel-related expenses), reducing delays in treatment, and the associated mortality and morbidity.¹

The mobile surgery programme is based on a truck with an operating room built on it (Figures 18.1 and 18.2). There is a small permanent staff, which is supplemented with volunteers and students. However, even from the beginning, it was apparent that the role of local providers would be essential. The local primary providers supply initial contact with the population in need, and act as the continuing contact for follow-up care. In many ways, the mobile surgery programme operates like the typical specialist practice, depending on primary care for patient referrals, and then proceeding through preoperative care, the operation and the immediate postoperative care. Local surgeons lend support and participate when the mobile programme is in their community. Thus, the programme is properly integrated into a model of continuous care.

Prescreening evaluation is extremely important in the mobile surgery programme. It is during this period that the primary care providers in the region, working under strict protocols, recruit patients with surgical problems for further evaluation. Cinterandes personnel then travel to the area to evaluate the patients, decide which patients are appropriate for the mobile surgery programme, which of them have priority needs, which patients have disqualifying comorbidities and which patients need medical treatment before surgical consideration.^1,6–8 This careful prescreening has been important to the success of the programme. Patients with additional illnesses or infections may be referred to definitive facilities or may be excluded, to avoid unnecessary complications. Those who are accepted into the programme must be followed using existing local resources after surgery.

Figure 18.1 Operating room on the truck with tents for patient preparation and recovery

Figure 18.2 Interior view of the operating room, showing the induction of a patient. Note the laparoscopic equipment in the background

Prior to the day for surgery, the truck arrives on location, and parks outside the local health care facility. On the day of surgery, patients are re-examined in the local facility or in a Cinterandes tent (when local facilities are lacking).^1,7,8 After surgery, while the patient is recovering from anaesthesia, he or she is transferred to the recovery area, either in the local facility or in a recovery tent. During this time, postoperative care is arranged and ambulatory patients are discharged to home.

Cinterandes personnel provide the initial postoperative care.^1,7,8 Generally, doctors and students/residents see any patients still in the facility on the morning of the first postoperative day, returning to base in the afternoon. For those ambulatory patients sent home on the day of surgery, the postoperative plan has already been discussed with the patient and local provider. For those patients spending the night in the facility, postoperative plans are decided upon and communicated prior to discharge.

Although the initial postoperative evaluation is performed by the Cinterandes personnel, continuing care requires the support of the local caregivers. Continued postoperative care generally consists of visits at one week, one month and six months after surgery – or more frequently in the case of complications or suture removal. While these visits are performed by the local providers, the Cinterandes personnel remain available for consultation by telephone, advising about wound care and providing guidance about transferring patients in need of more advanced care.⁷

Understandably, this interdependence has made the interaction with local providers an important part of the success of the intermittent surgical service in Ecuador. Local providers and patients need the additional services provided by the intermittent surgical service to avoid costly alternatives or increased morbidity/mortality. The mobile surgery programme depends on the local providers to find suitable patients, arrange preoperative evaluations, assist with surgical scheduling and provide postoperative care to the patients.

In addition, the mobile surgery programme has come to develop an interaction with local and international medical education. The local schools in the Cuenca region provide students and residents to help with the surgery programme, in turn gaining a unique educational experience.¹ With this success, the Cinterandes Foundation has expanded the educational role to include students from foreign medical schools, who also gain valuable experience in learning about a new culture and medical system.

Programme activity

The Cinterandes Foundation has been operating the mobile surgery programme in various areas of Ecuador since 1994.¹ In that time, the programme has visited 15 of the 22 provinces in the country, performing approximately 40–50 surgical trips per year, i.e. each location generally receives more than one visit per year.⁵ Thus, the surgical truck is in operation almost every week.

The programme has performed over 4500 operations in general surgery and specialties such as gynaecological and paediatric surgery.^1,5 Even with this patient volume in a small, mobile operating room, there has been no recorded mortality, and only four major complications (bleeding, cardiac arrest, pulmonary embolism and gastrointestinal injury).⁵ A complication rate of less than 1% is similar to that of sophisticated US surgical centres. At this workload, the average cost of an operation performed by the mobile surgery programme is less than US$100.⁵ These costs are met by the programme, so the service is free to patients.

Telemedicine to support surgery

Telemedicine has made a strong contribution to the intermittent surgical service. The first step was to apply digital records and review the management of the programme. Next, the primary care, Foundation and international consulting sites were connected by dial-up Internet connections for email (Figure 18.3). Then the needs of the programme were assessed. The telemedicine stations were installed, personnel were trained in their use, and all participants were encouraged to practice protocols and use the Spanish-language electronic health record (EHR) before programme implementation. Both store-and-forward and real-time telemedicine were used.

Telemedicine support is, of course, limited by the telecommunications available. The rate that data (bits) can be transferred between sites is known as bandwidth. Table 18.1 shows the bandwidths of some of the different means of connectivity. All around the world, telecommunications continue to improve. However, in remote areas of the developing world, slower-speed connections remain the most robust medium for telemedicine.

Figure 18.3 Cinterandes Foundation headquarters in Cuenca, during review of patient postoperative records. The images shown on the computer screen were collected during the postoperative care of a patient following a laparoscopic cholecystectomy In developing a telemedicine system in such areas, it is often necessary to use connections of limited bandwidth.^6,9 Satellite transmission could certainly be employed, but the high cost usually makes this impractical. The ordinary telephone network (PSTN) is available in most of Ecuador, so that dial-up modems permit connection to an Internet service provider (ISP).^6,8,10 A technician may operate the equipment for the clinician, while attempting to familiarize the local providers with the use of such technology.⁶

The procedure for telemedicine to support mobile surgery begins with patient registration and the creation of an EHR. The data can be text, pictures (e.g. JPEG images), video or voice recordings. Registration includes the medical history and demographics, and can be longitudinal for primary care management. When surgical consultation is needed, there are, by protocol, strict criteria for acceptable patient risk for comorbidity and scope of surgery. The record is forwarded to the Foundation in an email attachment with a question. Staff at the Foundation assess the problem, recommend further diagnostic tests if necessary, order preoperative measures and, if appropriate, schedule the surgical procedure. Videoconferencing between the Foundation and patient is an option. This has been done using Microsoft NetMeeting. By this screening mechanism, the requests for surgical care are managed promptly and efficiently. Prior to telemedicine, large surgery consulting clinics took up enormous amounts of time, with little patient care offered. After operation, the same EHR keeps the surgeons apprised of the patient’s progress and any complications, for care continuity. This postoperative phase can also use videoconferencing.

The telephone network can also be used during the operation to allow distant surgeons to advise (telementoring) or to educate (distance education).¹⁰ Better-quality video and audio during surgery has been achieved with higher-bandwidth connections, for example using a satellite link from time to time. While an intraoperative videoconference is certainly improved with increased bandwidth, the pre- and postoperative visits are also better with the use of improved video. Low-bandwidth video transmission results in lower-resolution images or slower frame rates, or both, which may be unacceptable.¹¹ However, in increasing the bandwidth, the biggest problem is the cost. None the less, clinically acceptable transmission has been consistently achieved at 56 kbit/s using the ordinary telephone network.^6–10

Videoconference consultations can run as smoothly as in-person examinations. Telemedicine establishes a sense of continuity in the care of the patient, and a link between the patient, primary provider and surgeon, despite the distances and intermittent services. The cost of telemedicine in Ecuador has been low once computers (US$1500) and digital camera (US$250) have been supplied. Training is provided by volunteers, and the only ongoing cost is for telecommunication. The cost of a local ISP is quite affordable in Ecuador.

The cost of telemedicine should be compared with that of on-site screening and consultation. In general, telemedicine allows time savings in a three-day surgical mission. For the cost of the ISP, there is a 25% increase in efficiency. The impact on patient safety is difficult to quantify, but the rarity of transfers suggests that telemedicine is at least as good as conventional management.

Experience in Ecuador

The role of the primary caregiver in the use of intermittent surgical care cannot be overemphasized. Likewise, the role of the primary caregiver in supporting the use of telemedicine should not be underplayed. The equipment used in primary care centres must be familiar to the providers, with utility beyond the support of intermittent surgical services. The equipment should be used daily and computer skills should be encouraged on a regular basis. This daily practice, along with curiosity and an interest in providing better care for their patients, prompts primary caregivers to seek additional skills with computers. Databases can provide a good means of storing patient data, allowing both archiving and retrieval. Spreadsheets simplify the process of calculating statistics. The addition of a digital camera to the equipment available in the clinic allows for digital image documentation of lesions, radiographs and the general appearance of patients. Digital cameras are now reasonably easy to use. One primary care doctor in the eastern rainforest region of Ecuador computerized his entire clinic, networking five computers (Figure 18.4) in different treatment areas, sharing the same database, and integrating images from a handheld digital camera, a video camera, a microscope eyepiece camera and an ultrasound scanner.¹² He has even employed the equipment in remote areas.

Figure 18.4 Primary care site in Macas. Computers are connected via a local area network (LAN). The unit shown is stationed in the clinic’s laboratory, and can import microscopic images into the EHR, via an eyepiece camera

Early on, the surgeons in the Cinterandes Foundation recognized the importance of the role of primary care providers in supporting the continued intermittent mobile surgery programme. Using existing communications systems in rural areas of Ecuador, the surgeons have been able to integrate the primary providers into the prescreening process of surgical care. Store-and-forward telemedicine, i.e. asynchronous transmission of information, provides the basis for this support. As in work done in Kenya,⁹ primary care providers can send information via email to the surgeons for review prior to a surgical trip.^6–8,10 With this advance information, surgeons are able to make better decisions about appropriateness for surgery. Equally important, the surgeons may use this opportunity to address the problems that made the patient inappropriate for surgery, and may direct further care for the patient. In Ecuador, the programme has sent students and junior surgeons to the field areas to set up and perform the remote clinics. Local providers have been enlisted to conduct the prescreening clinics, and have networked with permanent telemedicine stations in primary care clinics in three areas of Ecuador.⁷ These connections employ computers with telephone dial-up modems that deliver, at best, 26 kbit/s bandwidth. Yet the system has prospered and continues to function (see Figure 18.3). The ISP may not have a fixed Internet Protocol (IP) address for the subscriber, and this can be very frustrating. Furthermore, the ISP’s servers have limited capacity, and there is a consistent decline in quality and reliability during business (high-traffic) hours.

Prescreening of patients only needs store-and-forward telemedicine. However, video interaction by NetMeeting is possible. For the prescreening work, the videoconferencing may elicit further information and support informed consent. Low bandwidth may be used intraoperatively, sometimes with the additional transmission of high-quality still images.¹³ As considerable image compression is required at these low bandwidths, higher-bandwidth transmission is certainly easier and faster for video-intensive applications.¹¹ A hand-carried, portable satellite communications system provides 64 kbit/s connectivity, while larger models and vehicle-mounted models provide even greater bandwidths. Using two 64 kbit/s satellite channels in parallel (i.e. a total of 128 kbit/s), transmission of live surgical images from the mobile surgery equipment can be performed at 30 frames per second with little image degradation.¹⁴ Using a computer, rather than a videophone, allows sharing of email messages and forwarding of still images and other data. A full record of the surgical procedure is possible with video recording into a computerized database complete with patient and procedure information.¹⁴

Anaesthesia may also make use of telemedicine. In addition to using store-and-forward technology to share a patient’s data and develop an anaesthetic plan, higher bandwidth allows transmission of live anaesthetic images and data. A single 64 kbit/s satellite connection provides enough bandwidth to transmit images, including endotracheal intubation via a fibre-optic intubation system, along with physiological data during the surgical procedure.¹⁶

Following surgery, the patient recovers in a familiar locality with familiar care-givers. It is important in this setting to provide a means for the concerns of the patient and the health providers to reach the intermittent surgery team. The telemedicine systems in place can provide support for postoperative care. Wound images and data may be sent in a store-and-forward manner, unless the surgeon decides that real-time videoconferencing is required. Again, the relationship with the local providers is important to the success of the intermittent surgical service.

The mobile surgery programme in Ecuador has enjoyed clinical success. This has been accompanied by great success in maintaining social support for patients in their communities and solidarity with primary care providers. Telemedicine has made this programme more efficient, and therefore available to more patients. The interactions with consultants outside Ecuador have matured into sound professional friendships.

Further reading

American College of Surgeons. Operation Giving Back. Available at: www.opera-tiongivingback.facs.org.

Istepanian R, Laxminarayan S, Pattichis CS. M-Health. Emerging Mobile Health Systems. New York: Springer, 2006.

Latifi R, ed. Establishing Telemedicine in Developing Countries: From Inception to Implementation. Amsterdam: IOS Press, 2004.

References

¹ The Cinterandes Foundation. Available at: www.cinterandes.org.

² World Health Organization. Ecuador. Available at: www.who.int/countries/ecu/en.

³ Central Intelligence Agency. The World Factbook: Ecuador. Available at: www.cia.gov/library/publications/the-world-factbook/geos/ec.html.

⁴ Pan American Health Organization. Country Health Profile: Ecuador. Available at: www.paho.org/English/SHA/prflECU.htm.

⁵ Rodas E, Vicuna A, Merrell RC. Intermittent and mobile surgical services: logistics and outcomes. World J Surg 2005; 29: 1335–9.

⁶ Doarn CR, Fitzgerald S, Rodas E et al. Telemedicine to integrate intermittent surgical services into primary care. Telemed J E Health 2002; 8: 131–7.

⁷ Mora F, Cone S, Rodas E, Merrell RC. Telemedicine and electronic health information for clinical continuity in a mobile surgery program. World J Surg 2006; 30: 1128–34.

⁸ Rodas E, Mora F, Tamariz F et al. Low-bandwidth telemedicine for pre- and postoperative evaluation in mobile surgical services. J Telemed Telecare 2005; 11: 191–3.

⁹ Lee S, Broderick TJ, Haynes J et al. The role of low-bandwidth telemedicine in surgical prescreening. J Pediatr Surg 2003; 38: 1281–3.

¹⁰ Rosser JC, Bell RL, Harnett B et al. Use of mobile low-bandwith telemedical techniques for extreme telemedicine applications. J Am Coll Surg 1999; 189: 397–404.

¹¹ Broderick TJ, Harnett BM, Merriam NR et al. Impact of varying transmission bandwidth on image quality. Telemed J E Health 2001; 7: 47–53.

¹² Cone SW, Hummel R, Leon J, Merrell RC. Implementation and evaluation of a low-cost telemedicine station in the remote Ecuadorian rainforest. J Telemed Telecare 2007; 13: 31–4.

¹³ Broderick TJ, Harnett BM, Doarn CR et al. Real-time Internet connections: implications for surgical decision making in laparoscopy. Ann Surg 2001; 234: 165–71.

¹⁴ Rodas EB, Latifi R, Cone S et al. Telesurgical presence and consultation for open surgery. Arch Surg 2002; 137: 1360–3.

¹⁵ Cone SW, Leung A, Mora F et al. Multimedia data capture and management for surgical events: evaluation of a system. Telemed J E Health 2006; 12: 351–8.

¹⁶ Cone SW, Gehr L, Hummel R, Merrell RC. Remote anesthetic monitoring using satellite telecommunications and the Internet. Anesth Analg 2006; 102: 1463–7.

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