TELEHEALTH CORE TO WHO’S MISSIONS
World Health Organization (WHO) is playing a growing role in helping developing nations use telehealth in rural and underserved areas. WHO is currently assessing projects in Thailand and South Africa, and is overseeing successful programs in several Latin American countries, according to Salah Mandil, PhD, director of informatics and telematics for WHO in Geneva, Switzerland. The projects are owned and managed at the country level, with WHO largely playing an advisory and facilitation role.
WHO has been assisting informally with information technology needs of member states for years, but an increase in demand led to the decision in 1991 to create a separate informatics and telematics department specifically for member needs. Formerly, experts from WHO’s internal IS division were taking on the outside project work.
In late 1997, WHO’s former director-general, Dr. Hiroshi Nakajima, announced that the organization would make telehealth a global strategy for the 21st century by improving collaboration with international organizations like the World Bank and the International Telecommunications Union, local ministries of health and universities, and creating an advisory committee on health telematics. WHO’s mission is to promote telehealth for use in disease surveillance, prevention, health education and training, "giving priority to the poorest countries," according to a WHO document on the telehealth policy.
Mandil travels frequently to visit with health ministers implementing telehealth programs, and says that most cultures are open to using technology for healthcare delivery. "From our own contacts so far, we do not know of any acceptance problems by patients." Any concerns typically come from the medical community in regard to confidentiality and accuracy--also leading issues in the industrial world.
EDUCATING CHIAPAS
One of the most successful projects today is a telehealth satellite link between 10 hospitals in the mountainous, underdeveloped region of Chiapas in southeastern Mexico with the modern "20 November" hospital in Mexico City. The network is used for radiology and pathology consultations with specialists at 20 November, and is preventing expensive trips for patients and their families to the capital.
Mandil says 20 November has reported a drop of 60 percent to 70 percent in unnecessary referrals to the hospital since the program began roughly one year ago. What Mandil refers to as a "quiet built-in training process" also is helping justify the costs of the network. Chiapas physicians learn from each consultation, and over time, can handle diagnosis and treatment for specialized cases on their own. While WHO does not fund the projects, it provides gratis consulting services, and helps coordinate funding and implementation with non-governmental organizations, local governments and the commercial vendor community.
THIRD WORLD CONSTRAINTS
Despite the potential of telehealth in the Third World, Mandil emphasizes that WHO’s priority is to ensure that basic health needs are met first. "The WHO and health authorities in all countries we are working with do not put telehealth or telemedicine as priority over meeting basic requirements like sanitation, supply of clean drinking water, waste disposal and so on." Many countries that could benefit from the technology still are overwhelmed by fundamental quality of life issues. Ethiopia is a perfect example.
While an unlikely candidate for advanced technology given the country’s dire economic and public health needs, Ethiopia could benefit from telehealth, which could drastically increase clinicians’ productivity, according to a WHO study. The country has only five radiologists who must travel between 22 different radiology labs, or wait for exams to come in the mail. If a remote imaging network was installed instead, the study found, the radiologists could triple or even quadruple their output. While more basic needs will prevent the immediate deployment of such a network, Mandil is convinced that one day telemedicine will have a tremendous impact in Ethiopia too.
Another international organization, SatelLife, a Boston-based nonprofit also working in Ethiopia, is helping healthcare workers in Africa communicate electronically. SatelLife has developed a service called HealthNet, currently installed in a medical school library in Ethiopia. The Ethiopians are sending some 500 email messages a day; the messages are routed to SatelLife, which provides the Internet gateway. SatelLife’s technology also can embed text from Web pages requested by users into a reply message. HealthNet is provided free to users, and is an important tool in Africa where Internet access is still too expensive for most people, according to Frank Elbers, programs officer with SatelLife. SatelLife also provides information training, and is opening a training center in Nairobi for health professionals. SatelLife is working in roughly 20 sub-Saharan African nations. (http://www.healthnet.org)
Polly Schneider is senior editor at Healthcare Informatics.
U.K.’S NHS UNVEILS IT STRATEGY
Britain’s National Health Service is about to launch a new information systems strategy. The product of a year’s work by one man, its all-consuming aim is creating electronic patient records for all citizens, nationally accessible by any NHS organization.
Development partners for the project have not been announced, but the NHS will incorporate some of the systems developed under the prior program, including: a nationwide private TCP/IP intranet, NHS Net; a clearing service for distributing electronic payment claims across the NHS, based on the international messaging protocol X.400; a unique health identifier for every U.K. citizen; a standard clinical coding vocabulary; and systems for patient documentation and prescription writing, installed in 90 percent of primary care physician offices.
Still, the program failed to provide any clinical benefits. Its experiments with advanced hospital information systems were especially catastrophic--costing more than $170 million with few measurable results, according to a 1996 report from the U.K.’s National Audit Office.
In June 1997, Frank Burns, formerly chief executive of a large hospital in northern England and a pioneer of clinical computing, landed the task of developing a successor to the NHS’s first five-year IT plan. Burns wants to push NHS hospitals and physician offices away from the old tradition where each organization keeps its own separate records of patient encounters. Instead, they will all contribute to a single, integrated lifetime record, available 24 hours a day to every NHS body, most likely over the NHS Net.
"We have to move on from the idea that the electronic patient record is just a couple of pilot projects, that it’s the cherry on the cake. It’s not: it’s the whole cake," Burns said in a recent briefing on the strategy.
The challenge for Burns, however, will be adequately balancing broad access with the need for privacy, according to Fleur Fisher, MD, independent consultant and former head of ethics at the British Medical Association: "I enthusiastically support this attempt to improve the quality of clinical services through IT. But I hope that Burns will apply the same determination for quality to the issues that really worry the medical profession--namely, the confidentiality and security of patient information."
Burns says his switch of policy emphasis to clinical rather than administrative processes has general NHS support. Nevertheless, some policies will be enforced, rather than just encouraged, by government: "Ministers are determined to modernize the NHS, and we need to have clear, and if necessary, mandated objectives to be delivered by everyone. We have got to be prepared to make use of the infrastructures, particularly the NHS Net and the NHS (patient ID) number." For example, he says all family doctors will have to access their lab results from the NHS Net by the year 2000. Burns has also solidly backed the British-developed "Read Codes"--a clinical vocabulary similar in concept to the U.S.-based language SNOMED.
Burns admits that his program will be more expensive than its predecessor, and the Treasury has already told him that he will have to help fund it by axing some existing IT projects. Currently, the NHS spends about $350 million a year on IT--out of the total budget of roughly $55 billion. A timeline for implementing the new IT strategy has not been set.
Given the disappointment with the old strategy, how effectively a new government-run strategy will work in the long run is unclear. Tim Benson, an architect of the Read Codes and chief of health informatics consulting firm Abies, questions Burns’ top-down approach: "What the government should do is adopt an absolutely hands-off policy, leaving hospitals to do what they like, subject to financial accountability."
Britain’s IT Goals
National Health Service
- Streamline procurement processes. Hospitals spend years trying to get approval to buy new computer systems.
- Collect information on clinicians’ individual performance and deliver to professional audit groups.
- Create an online electronic reference service for best practices.
- Develop telemedicine and remote monitoring technology for home healthcare.
- Collect and track performance indicators on clinical quality and efficiency.
- Focus on a more responsible, confidential use of computerized patient
information. - Create health information services for the public. The first of these, NHS Direct--a national nurse-staffed call center for medical advice currently available in three regions--will cost the NHS about $90 million.
Pete Mitchell is a London-based writer specializing in healthcare and information technology.
