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TELEMEDICINE
AND TELEHEALTH IN THE PACIFIC ISLAND REGION: A SURVEY OF APPLICATIONS,
EXPERIMENTS, AND ISSUES
Primary Author: Lori Mukaida
Telecommunications can assist local physicians, health care givers, policy and decision makers to: (a) reach out to their communities (b) acquire a better understanding of basic primary health care goals, and (c) discuss and analyze appropriate interventions. In essence, the term "telehealth" connotes the use of telecommunications technologies for the enhancement of the health of a population, and does not limit that use to medicine alone. 3. TELEMEDICINE AND TELEHEALTH IN REMOTE AREAS Telemedicine and telehealth applications have advanced rapidly during the past five years and may have a significant, practical impact on improving the delivery of medical and health care in remote areas that suffer from isolation, small size, sparse and dispersed populations, a limited resource base, and great distances. As noted by Dena Puskin (1995: 54) of the Office of Rural Health, U.S. Department of Health and Human Services, telemedicine and telehealth "have the potential to reduce the isolation of rural practitioners and patients, and facilitate integration of services across communities that individually cannot sustain a full range of health services." Significant portions of the Pacific Islands Region populations are underserved by their health care system due to geographic and socio-economic constraints. Some of the areas in which health care systems may lack sufficient support are: (a) in the number of or the lack of physicians and/or specialists necessary to serve the population; (b) continuing education for existing health care providers; and, (c) appropriate facilities and technologies to serve their populations. Telemedicine and telehealth applications can improve Pacific Island health care systems by providing affordable, quality health care to patients, where and when they need it. Telemedicine and telehealth may also help to lessen the cost of services. For example, the current practice of the U.S. affiliated countries is to evacuate patients in the Pacific Islands once a determination for critical or acute care is made. Family members are often allowed to accompany the patient. The cost of evacuation is extremely excessive and represents a large proportion of health and medical expenditures in the Pacific region. Telemedicine could conceivably help to lessen the number of evacuations and the attendant costs by assisting in diagnosing the need for evacuation and by providing remote consultation. Further, and just as significant, are the travel costs for follow-up care. Family members are often allowed to travel with the patient even for follow-up care. By delivering health and medical services through telecommunications, the cost of follow-up care could be lessened, thereby enabling resources not spent for evacuations to be reallocated to other areas of health and medical program needs. Certainly, there are indications that the economic condition of the '90's may require health care systems to discriminate among priorities in critical and acute care based upon available funding and resources. Delinquent hospital and medical bills in Fiji, Guam, Hawaii and elsewhere might not be tolerated. The use of telemedicine and telehealth applications should be examined as a means to improve medical and health care while reducing costs in the Pacific Islands Region. 4. TELEMEDICINE EXPERIMENTS IN THE PACIFIC ISLANDS REGION There are several current and planned telemedicine and telehealth experiments in the Pacific Islands Region. These experiments are intended to develop a base of experience and knowledge that will help to determine the usefulness of these telecommunications applications. Since these trials are still in the initial stages of development and experimentation, it is far too early to determine their long-term programmatic value and costs. These trials are further important to: (a) assess the needs within communities, which vary significantly across the region; (b) identify cultural and other issues with the introduction of such services; and, (c) identify other barriers and problems that might affect the usefulness of these applications in the region. These experiments in telemedicine and telehealth applications may provide the base of experiences that will lead to substantive, appropriate services and programs to promote health, increase medical responsiveness, and lessen the costs of providing these services and programs in remote island environments. 4.1 TRIPLER ARMY MEDICAL HOSPITAL AND KWAJALEIN MISSILE RANGE HOSPITAL One of the first experiments in the Pacific Islands Region was initiated by the Tripler Army Medical Center (TAMC) located in Honolulu, Hawaii. The TAMC Telemedicine Program was originally developed to support the hospital services at Kwajalein Missile Range (KMR) Hospital in the Republic of the Marshall Islands. The TAMC uses a Department of Defense T-1 link between TAMC and Kwajalein for video-based teleconsultation twice a month between doctors and patients. Results of experiments demonstrate that TAMC has had a significant impact on the number of medical referrals by the KMR Hospital. Adjacent to Kwajalein is Ebeye which supports a dense population of 14,000 on an atoll comprising less than two square miles. Since medical conditions are unsatisfactory on Ebeye, patients on Ebeye are also seen through teleconsultation under TAMC's mandate to provide specialty care to the Republic of the Marshall Islands. Over the past two years, more than 200 teleconsultations in 23 specialties have been conducted. The TAMC telemedicine program provides the means for intervention before the condition of the patient deteriorates to the point of requiring costly referral and evacuation. The initial goals of the TAMC telemedicine program are to provide: (a) primary care services; (b) specialty consultations; (c) continuing health education programs; (d) patient and community health education; and (e) communications links among providers in the region. In order to achieve these goals, TAMC is collaborating with the Pacific Basin Medical Officers Training Program (PBMOTP), in Pohnpei, Federated States of Micronesia (FSM), and PEACESAT. Both PBMOTP and PEACESAT are University of Hawaii programs. 4.2 PACIFIC BASIN MEDICAL OFFICERS TRAINING PROGRAM The Pacific Basin Medical Officers Training Program, located in Kolonia, Pohnpei, was introduced to the Telemedicine Program at Tripler Army Medical Center (TAMC) in early 1994. Through experimentation with the AT&T Picasso Still-Image Phone, TAMC began to expand its telemedicine program to specific sites in the U.S. affiliated Pacific Islands in the Western Pacific. The Picasso Still-Image Phone is a still-frame, video phone system which, when used with a video camera and a TV monitor, can digitize and transmit freeze frame color pictures of high quality over regular telephone lines. The Picasso Phone unit, which is the size of a desk top executive telephone, is a computer capable of storing, sending, and receiving high quality, freeze-frame color video pictures with simultaneous voice communications. The Picasso Phone unit costs under $5,000 and certain models have battery storage capacity to insure against loss of picture memory due to power failures. Connected to a camcorder, a TV monitor, and a dedicated telephone line, the unit is user friendly and operates much like a VCR. 4.2.1 PACIFIC BASIN MEDICAL OFFICER TRAINING PROGRAM EXPERIMENTS
Since 1994, the Pacific Basin Medical Officers Training Program has participated
in and has documented the following telemedicine experiments:
Facilitated by TAMC, AT&T donated four Picasso Still-Image Phones
to the region. PBMOTP (Pohnpei) received 2, Kosrae State Hospital (Kosrae)
received 1, and PEACESAT (Headquarters, Hawaii) received 1. Since then,
other demonstration activities have been documented using the Picasso
Still-Image Phone for teleconsultation and distance learning.
4.2.2 CURRENT STATUS OF PBMOTP TELEMEDICINE EXPERIMENTS Efforts are underway to link the Picasso Still-Frame Phone system through the PEACESAT satellite system to introduce this technology to remote Pacific Island countries supported by PEACESAT earth stations. Experimentation may then focus on the regular use of Picasso-based telemedicine applications among remote island countries and become the experimental base for the documentation and evaluation of its potential, audio conferencing and still-frame video, to benefit Pacific Island health care. The major expense in the PBMOTP experiments has been the international transmission costs incurred. When the still-frame video phone technology is adapted to the PEACESAT Public Service Telecommunications Network, transmission cost will no longer be a deterrent in the growth of this telemedicine network. Utilization of PEACESAT's 44 earth stations in 22 countries will create a virtual geographical extension of the experiments with very few new funding dollars. The use of the Picasso Still-Frame Phone System as a telemedicine application is an example of a relatively low cost, user-friendly, narrowband system. The system requires purchase of the phone system, access to the public switched telephone network, and/or use of PEACESAT for the remote link. Additional equipment for remote sites could be added as budgets permit. The PBMOTP experiments in telemedicine applications have shown the utility of the system in many arenas: (a) international telecommunications between developed and developing country urban centers (Hawaii to Pohnpei, Hawaii to Kosrae), (b) telecommunications among developing countries (Pohnpei to Kosrae, Pohnpei to Palau), and (c) domestic telemedicine applications from developing urban centers to remote dispensaries (Nett, Pohnpei to Pohnlangas, Pohnpei). 4.3 TELEMEDICINE AND FIJI: THE FIJI SCHOOL OF MEDICINE The Fiji School of Medicine (FIJI-SM) has trained well over one thousand medical officers.(2) More than one-third of the graduates are nationals of American Samoa, Western Samoa, Tonga, Cook Islands, Tokelau, Niue, Tuvalu, Kiribati, the Solomon Islands, Vanuatu, Nauru, the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau. The FIJI-SM recently implemented a unique layer to its undergraduate medical training program. Fourth year FIJI-SM students are attached to rural health care facilities in their own communities. As an apprentice, the student receives practical, on-the-job training, and is required to undertake an applied health research project in primary health care. For this phase of training, the students come under the supervision of practicing medical officers from within their own communities who have been specifically selected and trained to be supervisors and Public Health Care tutors. These medical officers are also appointed as Honorary Clinical Instructors to FIJI-SM and, in this way, become non-salaried members of the faculty. In this context, the FIJI-SM is effectively decentralized throughout the region by the actual physical presence of students in the region and the Honorary Supervisors in those communities. The FIJI-SM and the Fiji government have endorsed the School of Medicine as an institution of Post-graduate Training and Continuing Medical Education. The FIJI-SM is currently developing a strategic plan for the implementation of postgraduate training and continuing medical education within the region. The decentralization of FIJI-SM resources throughout the Pacific Islands in support of the undergraduate medical training program has strengthened the regional nature of the institution. Consequently, the FIJI-SM has established an enhanced human network among Pacific Island health care centers through its tutors and students which could support other cooperative and collaborative endeavors to improve medical and health services throughout the region. The FIJI-SM is also strengthened through its affiliation with the Colonial War Memorial Hospital (CWMH), which has recently expanded and upgraded its technology and services in support of diagnosis and management of secondary and tertiary care problems. Currently, remote Pacific Island countries can not access these resources or facilities remotely. At this time, a cost-effective telecommunications capability does not exist to support real-time, interactive voice, data, or video applications between and among the FIJI-SM and the participating Pacific Health Care Centers. In order for the FIJI-SM to successfully implement its undergraduate medical training, postgraduate training, and continuing medical education programs, the FIJI-SM must have access to public health care constituents in the Pacific Islands region on a real-time, interactive, and daily basis. The FIJI-SM followed the PBMOTP experiments very closely, and will adapt these experiments and applications under its new Office of Postgraduate Training and Continuing Medical Education. 4.4 PACIFIC ISLAND HEALTH OFFICERS ASSOCIATION The Pacific Island Health Officers Association (PIHOA) is a non-profit organization with members in the six Pacific countries and territories affiliated with the United States: American Samoa; the Commonwealth of the Northern Mariana Islands; the Federated States of Micronesia; the Territory of Guam; the Republic of the Marshall Islands; and, the Republic of Palau. The members of PIHOA are the principal health officials from each island jurisdiction. PIHOA is committed to improving health within the region, and focuses on health issues and special projects of regional significance. In 1995, the U.S. Public Health Service funded a PIHOA training project to work collaboratively with PEACESAT to ensure that health personnel in the region would be able to use remote dial-in services for access to Internet electronic mail and file transfer services. PIHOA and PEACESAT have implemented this network and are examining other alternatives for improving information access and electronic mail communications in the region. 5. THE TELECOMMUNICATIONS BARRIER One of the major barriers to extending telemedicine and telehealth applications throughout the Pacific Islands Region is the state and cost of the telecommunications and information infrastructure. In this regard, the international telecommunications and information infrastructure is viewed as an important and significant barrier in the development of telemedicine and telehealth applications. If the region is to benefit from the sharing of resources and the emerging telemedicine and telehealth experiments, the international telecommunications infrastructure must be able to support these applications. The problem of the state and cost of the telecommunications infrastructure is not limited to the Pacific, but extends to rural communities in the United States and other developed countries as well. The barrier of the telecommunications infrastructure to telemedicine and telehealth applications is clearly stated by Dena S. Puskin of the U.S. Department of Health and Human Services. In an article describing barriers to the development of rural telemedicine systems in the U.S., Puskin notes that: "[t]he best designed systems still face barriers to implementation. While much has been said about building the nation's electronic highway, we in rural America are often dealing with the equivalent of the dirt road. The lack of an adequate telecommunications infrastructure is a key barrier to development of telemedicine systems in rural communities." (1995:55) Puskin is not only concerned with the nature of the infrastructure, she is also concerned with costs. She states that: "Clearly, transmission costs must be lowered if telemedicine is to become economically feasible for many rural communities." The statements of Puskin regarding the telecommunications infrastructure and costs are appropriate not only to rural areas in the United States, but also applies to the Pacific Islands Region as well. Unfortunately, for reasons beyond this paper, the cost of international telecommunications is prohibitive and is a deterrent to more experimentation. For example, a direct dial telephone call from Honolulu to the Pacific Islands region varies from U.S. $1.20 per minute to over U.S. $2.00 per minute. The cost of a call from the FSM to Fiji is close to $3.00 per minute. These costs severely restrict the ability of health and medical organizations from sharing resources and expertise, and prohibits other countries in the region from participating in the trials. Fortunately, in the Pacific Islands Region, there are two public service telecommunications test-beds for telemedicine and telehealth application experiments. One is Japan's PARTNERS network. Another is PEACESAT. 5.1 PARTNERS The Japan Ministry of Posts and Telecommunications (MPT), following technical experiments on the Engineering Test Satellite-V or "ETS-V," made the satellite available for application experiments in 1989. The project was named the Pan-Pacific Regional Telecommunications Network Experiment and Research by Satellite or "PARTNERS" Project. There are two types of network systems supported by the PARTNERS Project. Network I was designed by the Communications Research Laboratory (CRL) of MPT as a 64-Kbps digital satellite link to support video conferencing for distance learning. The PARTNERS Network I distance education program includes the King Mongkut's Institute of Technology Ladkrabang (KMITL) in Thailand, the Institute of Technology Bandung (ITB) and LAPAN in Indonesia, the University of Technology (UNITEC) in Papua New Guinea, the University of the South Pacific (USP) in Fiji, the University of Hawaii (PEACESAT) in the U.S.A., the Communications Research Laboratory (CRL) of the Ministry of Posts and Telecommunications in Japan, the National Institute of Multi-Media Education (NIME) of the Ministry of Education in Japan, and the University of Electro-Communications in Japan. Network II was developed by Tokai University, Japan, for the transmission of precise still pictures via an FM satellite link, making it useful for telemedicine experiments in teleconsultation and diagnoses. Network II includes seventeen hospitals in Thailand, Papua New Guinea, Fiji, and Cambodia. After five years of experimentation, the ETS-V PARTNERS Project plans to migrate to another satellite system in 1996. 5.2 PEACESAT PEACESAT is a Pacific region satellite telecommunication network supporting application experiments in narrowband satellite communications and international public service telecommunications.(3) Public service telecommunications is defined as non-commercial, international communication services used by educational institutions, government, medical, and other non-profit organizations to support distance education and learning, emergency management, medical and health, research, technical assistance, economic development, and community service programs. PEACESAT uses the Geostationary Observation Environmental Satellite (GOES-2) on a dedicated basis for use by the Pacific Islands Region. This is an obsolete weather satellite with a functional, although limited, communication transponder. The network may not be used for personal or commercial communications. PEACESAT currently has 44 earth stations in 22 countries within the Pacific Basin. PEACESAT offers voice and data services, but also provides access to Internet in both on-line and batch transfer modes. The earth stations are 3m in size, have a 50W HPA, audio processor, phone patch, and analog data modem. There are two major limitations of the network. First, the earth stations can only perform one function at a time. For example, the PEACESAT 3m earth station can be used for voice teleconferencing over a simplex circuit, voice teleconferencing over a full duplex circuit, or data communications over a full duplex circuit. However, it is not possible to perform more than one of these functions at the same time. A second limitation is that there are only 3 full duplex circuits. This essentially means that the users must schedule data transmission time for use of these circuits. PEACESAT has developed plans for a digital "Hub Site" network using the residual bandwidth and power of the GOES satellite which will significantly improve services.(4) Each of the Hub Sites will support multiple concurrent voice circuits, a dedicated data (28.8 Kbps) circuit, and shared use of compressed digital video circuits. These Hub Sites will use a 6m antenna, 75W HPA, and other digital compression and switching capabilities to provide a medium for the Pacific Island countries to offer and to connect to public service telecommunications programs and services throughout the region and the world.
The digital network will further enable a significant extension of the
TAMC, Kwajalein, FIJI-SM, PARTNERS, PEACESAT experiments and other telemedicine/telehealth
initiatives. Some of the planned health and medical users and uses of
the PEACESAT Hub Site network are briefly described below:
This network should be in place in 1996, providing that appropriate funding for the Hub Site technology is obtained. The Hub Sites will include American Samoa, the Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, Fiji, Guam, the Republic of the Marshall Islands, the Republic of Palau, and the Solomon Islands. The initiation of the trials in telemedicine and telehealth in the Pacific Islands Region are valuable in helping to raise questions and identify issues. Although the experiments are only in its infancy, the trials have already raised many issues and questions. The following is a brief discussion of a few of these issues and questions. 6.1 ISSUES
The following describes some of the application specific issues that have
emerged during these trials.
There are many other issues that should be examined, including, but not to be limited to: professional and/or educational level of medical organizations and individual physicians providing services through telecommunications; ethics and standards; reimbursement; liability; application of insurance benefits; and inter-cultural and inter-personal perspectives. These issues suggest a need for a parallel research effort into the many social, economic, and policy issues raised in telemedicine and telehealth. Unfortunately, the extent of these studies will be constrained by many of the same barriers of funding, distance, cost of telecommunications, and so on. 6.2 QUESTIONS
As with many application experiments in telecommunications, the initiation
of a trial often raises more questions than answers. Some of the questions
that have been raised are:
These are only a few of the questions that have arisen. There is a need to codify and begin to analyze the experiments in relationship to the promises of the technology. However, as stated earlier, it is too soon to undertake such an evaluation since the trials have just begun. Telemedicine and telehealth applications are important emerging applications for the Pacific Islands Region. Experiments are being proposed and/or conducted in the Pacific Islands Region under many venues, such as PARTNERS, PEACESAT, Tripler Army Medical Center, the Pacific Basin Medical Officers Training Program (PBMOTP), and the Fiji School of Medicine (FIJI-SM). Although it is far too early for an in-depth evaluation of these programs, the efforts so far have been useful in identifying many important issues and questions. International cooperation and collaboration in the development of telehealth and telemedicine programs in the Pacific Islands Region could expedite experiments exponentially. The basis of cooperation and collaboration among and within the region appear to be developing. A dialogue on telemedicine and telehealth experiments should be initiated among the service providers, experimenters, end users, and beneficiaries. Such a dialogue could begin to discuss the need to document, evaluate, analyze, and report on the telemedicine technologies, services, applications, methodologies, and evaluation techniques; and will aid greatly in developing an understanding of appropriate applications of these technologies in the Region.
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