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Apr 27, 2006 - Stephen Cone, MD,. 1. Edgar Rodas ... the patients to major hospital facilities impractical for all but the most dire ... electronic health record to a telemedicine platform to evaluate ..... mental and clinical applications. Surg Clin ...

 2006 by the Socie´te´ Internationale de Chirurgie Published Online: 27 April 2006

World J Surg (2006) 30: 1–7 DOI: 10.1007/s00268-005-0204-9

Telemedicine and Electronic Health Information for Clinical Continuity in a Mobile Surgery Program Francisco Mora, MD,1 Stephen Cone, MD,1 Edgar Rodas, MD,2 Ronald C. Merrell, MD1 1

Medical Informatics and Technology Applications Consortium, Department of Surgery, Virginia Commonwealth University, PO Box 980480, Richmond, Virginia 23298, USA 2 Fundacio´n Cinterandes, University of Azuay, Medical School, Av. 24 de Mayo 7-77 y Herma´n Malo, Cuenca, Ecuador

Abstract Introduction: An intermittent surgical services program in rural Ecuador was able to benefit from close collaboration between surgeons and primary care physicians through the use of telemedicine technologies. Methods: Inexpensive telemedicine workstations capable of patient documentation, imaging, and video-conferencing at extremely low bandwidth were established in collaborative primary care sites in rural Ecuador. Patients were screened for intermittent surgical services by primary caregivers according to the surgeons’ guidelines. Real-time and store-and-forward telemedicine allowed appropriate collaborative, informed decision-making. Surgery was performed, and postoperative care was similarly handled by on-site, familiar primary caregivers. Results: To date, this system has been used in more than 124 patient encounters (74 preoperative and 50 postoperative visits). The system allowed advance screening of patients on the part of the surgeons, leading to cancellations for 9 patients. Postoperatively, the system allowed 100% concurrence in postoperative diagnoses between the primary caregivers and the surgeons. Conclusions: Inexpensive, low-bandwidth telemedicine solutions can support intermittent surgical services by providing patients to have contact with specialist care through their familiar, local primary caregivers.


n rural areas of developing nations, a large percentage of the population is poor and marginally educated, and it faces great barriers to health care. These characteristics translate into poor health outcomes. For example, in Ecuador, a developing country, the average life expectancy at birth is 70.7 years, and the child mortality rate is 32 per 1000 live births.1 Telemedicine is a promising adjunct to care in developing areas through the application of electronic information and communication technologies to achieve efficiency, broader access, and Correspondence to: Ronald C. Merrell, MD, Medical Informatics and Technology Applications Consortium, Department of Surgery, Virginia Commonwealth University, PO Box 980480, Richmond, Virginia 23298, USA, e-mail: [email protected]

consensus standards. Considerable experience has been gained in telemedicine for the developing world.2–11 Patient management in remote areas is challenging because of sparse distribution of limited resources in geographically isolated regions. Telecommunication (advanced technology for information management and telemedicine program infrastructures) offers practical solutions to the problem of distance and can manage resources with accuracy. Telemedicine provides context and continuity to network care despite geographic isolation and sparse resources. Historically, telemedicine has been associated with expensive equipment and an infrastructure based in technically sophisticated medical institutions. Many


projects failed, mostly owing to their inability to show costbenefit advantages.3–5 In an attempt to make telemedicine more applicable in rural regions with minimal resources in technology and communication infrastructures, recent efforts have validated the use of inexpensive personal computers, open platform software, and low bandwidth (£56 Kbps) for the capture, management, and transmission of patient data.6–11 Medical systems can be made contiguous by electronics despite large distances between points of care and central management centers. The application of telemedicine to surgery has advanced substantially. Surgery has integrated technologies such as robotics, other minimally invasive tools, and telecommunication for sharing surgical information in an asynchronous and synchronous fashion for surgical mentoring and education.12–18 Moreover, the association between telemedicine and a mobile surgical facility to serve rural communities has proven effective in several studies.6–11 One such surgical program is currently managed by Cinterandes Foundation, a nonprofit organization that brings intermittent surgical care to remote areas of Ecuador through a mobile operating room (OR) facility.19–23 Ecuador is a developing country with a health system that operates on a severely restricted budget [per capita gross domestic product (GDP) $3905; per capita total expenditure on health $76; total expenditure on health as a percentage of the GDP 4.5%1] that cannot cover the widely dispersed population. Although the remote areas of the country lack specialty care, there is an extensive program of primary care. Poor roads, difficult travel conditions, and poor economic conditions make transfer of the patients to major hospital facilities impractical for all but the most dire conditions. Travel requirements for elective care place substantial financial and social burdens on the entire family of the patient. The mobile surgical program supplements primary care in rural communities with coordinated intermittent surgical services.24 To maintain continuity of care, the intermittent surgical practice format has applied a simple electronic health record to a telemedicine platform to evaluate patients proposed for surgery, maintain access to information resources during surgery, and provide consistent follow-up. The surgical program has been fully integrated into the primary care model by training the primary care site to use the software and present surgical consults by means of telemedicine. This study reports the preoperative screening and postoperative care provided by primary

Mora et al.: Telemedicine in a Mobile Surgery Program

care physicians in collaboration with, and under the direction of, surgical specialists operating an intermittent surgical services vehicle. The utility, feasibility, accuracy, and efficiency of patient screening are evaluated in this study. Patient evaluation by telemedicine in the mobile surgical program has evolved over several years. Initial efforts validated patient evaluation and telementoring between the United States and the mobile surgical unit located in the jungle using low-bandwidth connections.6 Then telemedicine advance teams connected remote/ rural service areas and fixed medical facilities using two communications protocols (H.323 and H.324) for preoperative and postoperative evaluation.7 Later, surgical cases were monitored via satellite connection (128 Kbps) between Ecuador and the United States.11 The reliability of the data and image transmission over distance was compared with that obtained by personal examination for preoperative and postoperative consultation.12 The current study validates the use of an electronic health record (EHR) for collaborative management of surgical patients in rural communities, integrating information from remote primary care centers with the intermittent mobile surgical program.

MATERIALS AND METHODS Three fixed telemedicine stations were established for this study. Two were instituted in primary care clinics in remote areas of Ecuador, each equipped with an IBM Think Centre computer (Pentium 4: 2.4 GHz, 512 MB RAM, 56 Kbps modem), monitor (View Sonics 15 inches), video-conference camera (E-Zonics EZ 305 Internet Camera), and digital camera (Olympus C-3000: 3.1 mega pixel) with a 64 MB memory card. The other station was set up in the Cinterandes Foundation (Cuenca, Ecuador), with a Pentium 4 computer (2.4 GHz, 512 MB RAM, 56 Kbps modem), 15-inch LCD monitor, and video-conference camera (Genius 014-109 D20VCGU, QC/OK B3) (Fig. 1). Each computer was also equipped with a video-conference program (NetMeeting; Microsoft, Redmond, WA, USA) and an EHR software package developed by collaborators in Richmond, VA. The EHR was developed in a Microsoft Access database platform designed specifically for use in Ecuador. The EHR included a complete medical record utilizing electronic forms identical to the paper forms used by the Cinterandes Foundation. Medical records could be shared between sites by means of electronic mail, with simple exporting and importing of

Mora et al.: Telemedicine in a Mobile Surgery Program


Figure 1. Telemedicine network in Ecuador.

XML formatted files. Digital images were linked to appropriate records in the database though stored in separate files for better database management. A telemedicine network teaching module for the primary care physician (PCP) was also designed. The PCP received 2 days of training on site followed up by weekly telementoring sessions until the PCP was competent and certified. Periodic video-conferences provided technical support and reinforcement. The PCP at the remote clinics interviewed the patients, entering clinical data and diagnostic digital images. Using low-bandwidth (22 Kbps) transmission, the data were shared by e-mail (store-and-forward telemedicine) with consulting surgeons at the program center. The surgeons

at Cinterandes reviewed the EHR, developed a treatment plan, and ordered supplementary diagnostic tests when necessary. Strict criteria for co-morbidity and surgical procedure were well known to the PCP. An elective surgical schedule was prepared, and supplies were allocated. The EHR data, containing comments by consulting surgeons, were returned by e-mail to the remote clinic. Follow-up by video-conference between the patient and PCP in the remote clinic and the surgeon at Cinterandes was conducted as deemed necessary by the surgeon. Appropriate patients were scheduled for surgery, and preoperative orders were given electronically. The surgeons and the mobile unit arrived at the health service area late the day before surgery and performed confir-


Mora et al.: Telemedicine in a Mobile Surgery Program

Table 1. Diagnoses enrolled in the program and networking: telemedicine consultation Diagnosis Inguinal hernia Cholelithiasis Uterine leiomyoma Umbilical hernia Cryptorchidism Phimosis Lipoma Cystocele Miscellaneous Total

No. preoperatively No. postoperatively 26 18 2 5 4 4 2 2 11 50

20 13 1 3 1 1 1 10 50

matory diagnostic examinations. Patients knew of their appointments and gathered at the primary care center. With average distances of 200 miles between the primary clinics and the Cinterandes offices, travel by car over improved roadways generally required an average of 8 hours. The mobile unit personnel were on site for 2 days, which included the immediate postoperative period. Thereafter, the PCP was again in charge of patient care. Postoperative sessions by telemedicine were performed at regular intervals (1 week, 1 month, 6 months) and as needed following surgery. Utilizing dial-up connectivity (POTS 22 Kbps), the EHR, with digital images, was sent to the Cinterandes Foundation for postoperative evaluation. Pending any complications, the evaluating surgeon could formulate a treatment plan and videoconference consultation, as needed, to be scheduled and implemented by the PCP. The initial experience with this system is reported.

RESULTS Altogether, 74 patients were evaluated during 124 consultations: 74 preoperative evaluations and 50 postoperative follow-up consultations. The diagnoses and distribution are listed in Table 1. The high scheduling rate reflects the close working relationship of the PCP, the surgeon, and the program. Before using an integrated electronic system, the intermittent service team would hold large surgical clinics with potentially hundreds of consults, huge logistical problems for the PCP, and substantial patient disappointment. Furthermore, the team was obligated to oversupply each session because it was never known what procedures might be done. After instituting the system, of the nine patients rejected, only four were found not to need an

Table 2. Triage: surgical logistics Parameter Operative telemedicine scheduled Required subspecialty surgery Surgery not indicated Required further unavailable laboratory testing Total Patients not scheduled for operation On-site surgical evaluations Intercurrent infections Transportation problems Taking aspirin Diagnoses changed Total Evaluations not performed Operations performed Inguinal herniorrhaphy Cholecy stectomy Umbilical herniorrhaphy Lipoma resection Myomectomy Orchiopexy Circumcision Miscellaneous Total

No. 65 3 4 2 74 9/74 (12%) 54 2 6 1 2 65 11/65 (17%) 21 14 4 2 1 1 1 10 54

operation, three needed a specialty surgeon not available on a particular day, and two were sent for further testing. Of the 65 patients scheduled, 54 had their operations. The cancellation rate of 14% is low and was due to only two instances of diagnostic dissonance between the telemedicine evaluation and the preoperative clearance on site. Most of the cancellations were due to transportation problems for patients who encountered travel barriers even in their own regions where floods, landslides, broken vehicles, and treacherous footpaths often separated patients from the service site (Table 2). Low-bandwidth transmission proved effective for sharing patient information. No data were lost, and image quality was preserved during transmission (Figs. 2–4). Audio and video quality was maintained during video-conferencing, although, as expected, episodes of pixelation did occur during movement. The diagnostic accuracy was 97% (57/59) for preoperative evaluation between the telemedicine evaluation and the confirmatory examination in person of those patients who arrived for surgery. Two patients had a change in diagnosis after personal evaluation by the surgeon. For the postoperative evaluation, there was 100% diagnostic agreement between the telemedicine evaluation by the surgeon and personal evaluation by the PCP. In other words, with maturation of the program, the PCP

Mora et al.: Telemedicine in a Mobile Surgery Program


Figure 2. Digital image of gallstones obtained by ultrasonography in a remote clinic sent in telemedicine format.

Figure 3. Digital image of an umbilical hernia sent in telemedicine format to a remote clinic for consultation.

was in complete agreement with the surgeon’s assessment of wound healing, infection potential, and other factors. A previous study showed 77% accuracy for preoperative evaluation and 97% for postoperative evaluation.9 Therefore, substituting trained PCPs for the surgery advance teams led to greater accuracy (97% compared to 77% for preoperative evaluations and 100% compared to 97% for postoperative evaluations). This is likely due to a more comprehensive EHR, improved image quality, and improved interaction between the PCP and the surgeon to clarify information and images.

The time spent by the PCP for the preoperative consultation, which included completing the EMR, capturing digital images, and e-mailing the information, was 15 to 20 minutes. The time spent by the surgeon to review patients’ records and reply by e-mail with the treatment plan was about 5 minutes. Approximately 30 patients were evaluated by video-conference, averaging 5 minutes per patient. Video-conferencing was a beneficial supplement to clarify patient information and ask specific questions of the patient and the PCP. Video-conferencing did not have a quantitative impact on patient care. The value was more qualitative and highly reassuring. Pre-


Mora et al.: Telemedicine in a Mobile Surgery Program

Figure 4. Postoperative image following open cholecystectomy transmitted in telemedicine format for evaluation.

operative clinics, with the benefits of the information obtained by telemedicine screening, required less than half the time previously required per patient scheduled. Additionally, the surgical team saved significant time by eliminating extensive screening clinics, as this work had been performed by the PCP, who screened appropriate patients for the services available. Routine follow-up by telemedicine was 93% (50/54) in this study, compared with an absence of follow-up previously. This rate of follow-up is extraordinary given the patients’ transportation problems and the heavy work schedule of the PCP. Previously, complications were reported only when patients returned to the PCP for treatment. The cooperation of the newly trained PCP deserves mention. Recruitment of patients for research is at an alltime high, and the efficiency of telemedicine is the explanation. It is easier for the PCP to manage the surgical complaint in this manner than by disjointed paper referrals or holding open-ended surgical clinics when intermittent surgical services are available.

DISCUSSION Telehealth extends competence to remote communities with an electronic continuum of quality care. Telemedicine in this study applies an easy-to-use, technically integrated patient management system that is patientcentric and cost-effective. This project has important societal as well as health benefits, which are attributed to

improved efficiency without compromising the quality of patient care. The study shows that telemedicine is feasible for routine preoperative and postoperative care, permitting better resource utilization by eliminating redundant examinations and superfluous travel. Telemedicine applications, as evaluated in this study, augment specialty medical care in remote areas, improving patient care at the primary care sites. Overall, the number of unnecessary trips by the patients was reduced while maintaining the ability to obtain an accurate diagnosis in their communities. Technical capabilities are not a limitation for using telemedicine technologies in surgical case management in remote areas. Areas of the world restricted by lowbandwidth connectivity may still benefit by appropriately directed efforts in telemedicine. This study shows a practical application that can be expanded, with low costs, to improve medical care for remote populations. In this project, a well established mobile surgery program was offered a telemedicine program that the volunteer faculty refined and implemented. Highly motivated primary care facilities long affiliated with the mobile surgery program joined the effort and actively participated in the design. Hence the utility and utilization of the telemedicine tools was strongly referenced by enthusiastic participants. Implementation of such a program more widely depends on the enthusiasm and commitment of the participants. This need for commitment can be applied to any telemedicine innovation in surgery. Telemedicine activities

Mora et al.: Telemedicine in a Mobile Surgery Program

described herein offer great advantages, but success can only be expected when participants are actively seeking ways to interact more efficiently with some technical innovations that require at least a basic course and instruction for competence. Telemedicine associated with mobile health care systems could be the answer for a fair distribution of health care and better utilization of resources and personnel in developing countries. Communications technology overcomes frontiers, permitting remote areas to benefit from current and new practices.

ACKNOWLEDGMENTS The authors thank all members of the staffs of Hospital Pio XII in Sucu´ a, Ecuador, and the Santa Maria de Fiat Foundation in Manglaralto, Ecuador for their assistance with this project. Specifically, we thank Drs. Isabel Freire and Monika Steffel for their dedication to this project. We also thank Ms. Chasity Roberts for her editorial assistance. This work was funded in part by a grant from NASA.

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