Ninth Conference of Spouses of Heads of State and Government of the Americas

Health-care practice is currently undergoing a massive and irreversible transformation and change in the Americas. The motor behind this change is the growing availability and affordability of telecommunications-based technologies, which are rapidly entering the mainstream of health practice. These technologies make it possible to extend access to and improve the quality of health services for a larger number of individuals than at any other time in history. Vast medical resources, normally locked inside major health-care institutions, are becoming readily accessible to the Americas health-care community.

The Pan American Health Organization (PAHO) succeeded in putting health technology on the agenda of the Summit of the Americas, held in Santiago, Chile, in April 1998, noting in a proposal that the Health Technology Linking the Americas initiative has enormous potential to reduce today�s social inequities, and that it will help governments to achieve through partnerships what they cannot achieve alone. By sharing technologies and information networks, countries can better prepare themselves for disease outbreaks or natural disasters; they can share ground-breaking news on emerging health issues and discoveries in vaccine research and development; and they can empower public health workers at all levels to make timely, well-informed decisions by providing them with access to the crucial data and knowledge that they require.

PAHO and other organizations are engaged in initiatives to tap into the advantages of the current information revolution. Telehealth is the result. It is the use of communications and information technology to deliver health and health-care services and information over large and small distances. Telecommunications support to the health sector is improving health-service delivery, health promotion, consumer education, environmental protection, and the pursuit of equity, quality and efficiency in health-care throughout the Americas. The active use of telehealth practices will result in a truly universal standard of medical practice for both urban and rural areas.

Telehealth is a broad term used to describe the provision of health services over distance through the use of electronic networks. Telehealth, as a branch of health informatics, includes the exchange of highly detailed medical data between health professionals, the education of health personnel and the public, health-promotion activities, epidemiological surveillance, and health-services management. Although frequently used interchangeably with telehealth, telemedicine refers to direct patient care.

TELEHEALTH IN ACTION

One of the most important trends in the telehealth industry today is the integration of various applications over one network, or in a series of interconnecting networks, designed to span a range of health-care applications to meet different needs using a variety of technological combinations. Along with telemedicine, this allows telehealth to be used for a variety of health-care services:

� Tele-education, where information is provided that assists health-care providers in keeping up-to-date on the latest health-care innovations;

� Teleconsulting, where doctors and nurses can exchange important diagnostic information on the health status of patients and decide on the appropriate treatment;

� Telemonitoring (Tele-homecare), where patients and nurses can forward information about health status without patients having to leave their homes;

� Health Information Networking, which allows members of the community to become better informed on their health status and to learn how to manage personal health; and

� Advocacy and Support Networks that link individuals and organizations with similar health issues and concerns. This form of communication is becoming an essential ingredient in effective decision making as communications technologies help to create "virtual" communities that encourage and support dialogue on important societal issues.

Telehealth is a way of linking the countries of the Americas together to work collaboratively to improve the health of all. Examples of this form of collaboration include:

� The Hospital de Pediatria Juan P. Garrahan Children�s Hospital in Buenos Aires, Argentina is linked to the Hospital for Sick Children in Toronto through video conferencing. Patient records are discussed, data are transmitted and advice is solicited on the appropriate treatment.

� The University of Dalhousie Medical School in Halifax, Nova Scotia, is the first Medical School in Canada to export telemedicine services to the Caribbean region in partnership with St. Kitts - Nevis. Radiologists in Halifax receive X-ray information via telephone lines, and can send reports back within 24 hours. Physicians in St. Kitts can access video-conferencing to consult their colleagues in Halifax, and can transmit information on heart sounds, blood pressure and EKGs.

� The Telemedicine Center of Memorial University in St. John�s, Newfoundland, has been exploring collaborations with colleagues in Chile and Brazil on how to best provide affordable solutions to their need for distance education and telehealth.

Telehealth can be of benefit to all countries in the Americas, regardless of their level of technological infrastructure. Many telehealth users prefer low-cost technology, such as plain old telephone systems (POTS), but many remote regions lack even this basic infrastructure. In such situations innovative approaches have used wireless solutions involving portable computers and mobile electrical generators to send messages and data via satellite communication systems. As demands for telehealth services increase, further innovations will undoubtedly make networking connections easier and more affordable, in most circumstances.

In Canada, telehealth is particularly important for rural and Aboriginal populations. Canada has a vast geographic land mass that presents many problems to delivering health care to remote areas. Most of the population is grouped in urban centers. Canada�s large Aboriginal population has its own distinct culture and unique health needs. Telehealth is one way to make health services more equitable and accessible for First Nation communities.

It is known that certain segments of the population are particularly affected by health decisions made by institutions and governments, and telehealth can be a powerful tool in empowering groups and individuals to be better-informed and to take action on their health. This is especially true in the case of women�s health. The Canadian Women�s Health Network has been established to aid Canadian women in making important, informed health decisions by linking concerned individuals and organizations.

In some countries, telehealth mostly benefits health-care providers who have access to technology, by allowing them to receive up-to-date health information and education and to network with other health professionals around the world. In many Latin American countries, there is currently an emphasis on distance education, whereby countries are investing in remote access sites in communities to give greater numbers of people access to education. These initiatives are a bridge to telehealth activities.

RELEVANCE TO WOMEN

Improving women�s access to health-care services and health information benefits everyone because women are the guardian of their family�s health. In addition, since women comprise the majority of health-care providers, both paid and unpaid, communities will benefit greatly from their ability to link to educational resources and to network with other individuals and organizations with similar concerns.

A number of social and economic aspects of women�s lives must be considered to ensure that women fully benefit from telehealth initiatives. Women have more limited resources, both in terms of time and money; as a result, special attention must be paid to facilitating women�s participation. The following issues should also be addressed to make women�s access to telehealth services meaningful:

� gender-specific learning approaches;

� the role and impact of economic and social health determinants as they relate separately to women and men; and

� the quality and use of information.

The promotion and support of appropriate telehealth activities can empower women to improve their own health and the health of their communities.

Dr. Mo Watanabe, Professor Emeritus of Medicine, University of Calgary, Alberta, was an important member of the Minister of Health�s Advisory Council on Health Infostructure. The Advisory Council pointed out that we are nowhere near to realizing the full potential of a health infostructure to improve our health and our health-care system in Canada. A health infostructure refers to the use of information and communications technologies in the health field, and to the health information generated by these technologies. It also refers to the policies that govern the use of such information, and to the people and organizations that use the information and participate in its development.

In an address on August 17, 1999 to the First International Congress on Telehealth and Multimedia Technologies, Lillian Bayne, Regional Director General of Health Canada, stated:

"Telehealth can play a major role in both strengthening and integrating health- care services. In a country as large as ours, people living in remote and rural areas have found it difficult to gain access to health-care services. Thanks to telehealth applications, we foresee new possibilities for providing services � diagnosis, treatment, monitoring, and health information, close to where people live, be it in rural or urban settings. We can support providers with tools for continuing education and maintenance of competencies. Telehealth applications will enable health-care providers to remain in close communication with each other, and to exchange information quickly, even when they are separated by large distances."

The National Aeronautics and Space Administration (NASA) played an important role in the early development of telemedicine. In the early 1960s during the first manned space flights, physiological parameters were telemetered from both the spacecraft and the space suits during missions. NASA provided much of the technology and funding for early telemedicine demonstrations, such as the Alaska ATS-6 Satellite Biomedical Demonstration, which began in 1971 to investigate the use of satellite video consultation to improve the quality of rural health care in Alaska.

Telehealth projects have been in existence in Canada for three decades. The Memorial University of Newfoundland (MUN) was an early participant in the Canadian Space Program. The joint Canadian/U.S. Hermes satellite provided Canadians with an opportunity to use satellite technology in distance education and medical care. Since 1977, the Telemedicine Center at MUN has worked toward developing interactive audio networks for educational programs and the transmission of medical data. The guidelines followed include: use the simplest and least-expensive technology, be flexible, involve the users from the beginning of the project, seek administrative support in hospitals, clinics and other agencies, and include evaluation.

The MUN Teleconferencing System, a province-wide network consisting of five dedicated circuits, began in 1977. MUN�s Health Sciences Centre is connected to 200 sites in 120 communities, including installations in all provincial hospitals, community colleges, university campuses, high schools, town halls and education agencies. MUN has been active in international teleconferencing, and has played a significant role in the School of Medicine at the University of Nairobi, Kenya. In 1985, MUN became involved in the International Satellite Organization (Intelsat) linking to Nairobi and Kampala, which later was extended to six Caribbean countries. Newfoundland is a leader in the field of telehealth, with over 25 years� experience. Data for nuclear medicine, cardiology, psychiatry, radiology, and health education are transmitted. Funding is in place to link five sites in Labrador with St. John�s.

In 1998, Nova Scotia became the first jurisdiction in Canada � and in the world � to establish a province-wide computer-based telemedicine network linking every hospital in the province (43 sites in total) through telemedicine workstations capable of capturing and transmitting important medical data and real-time audio and video. Specialists are able to review and interpret examinations, such as ultrasound and echocardiology, as they are being performed. They are also able to speak to thetechnicians conducting the exams while they are taking place. The Nova Scotia Tele Health Network can deliver regularly scheduled educational sessions to doctors and other health-care workers in their communities, thus improving the quality of care throughout the province. It has potential cost advantages to reduce follow-up visits and treatment by 65 percent.

� Baffin Island�s outlying communities of Pond Inlet and Lake Harbour are equipped with telehealth systems connected to Iqaluit, which is itself linked to the Ottawa Health Institute by satellite and phone lines. Nine other communities are also connected. Savings on medical care � especially the high cost of transporting patients to urban hospitals ($10 million plus in 1998) more than offsets the cost of $120,000 for the installation of a medical workstation.

� Keeweetinok Lakes Regional Health Authority #15, located approximately 300 kilometres northwest of Edmonton, Alberta, is the first health region in Canada to be linked together by a Satellite Telehealth Network. Launched in April 1998, six sites within the region are hooked into EFW Radiology in Calgary and the Telehealth Technology Research Institute at the University of Alberta in Edmonton. Instead of a six-hour drive in an ambulance, telehealth provides area residents with teleconsultations, teleradiology, tele-education, telenetworking, tele-opthamology an teleresearch.

� In August 1999, Alberta hosted the First International Congress on Telehealth and Multimedia Technologies. Alberta today is implementing a province-wide telehealth system � Alberta we // net.

� The University of Ottawa Heart Institute is in the second year of a two-year, $4.5-million test program called HEARRT (Heath Care and Education Access for Remote Residents by Telecommunications). Telemedicine platforms have been installed at five rural and regional Ontario locations. It is funded by Ontario�s Telecommunications Access Partnerships, Telesat Canada, Northern Telecom Ltd., Bell Canada, and Computing Devices Canada, a manufacturer of telemedicine platforms.

� On March 10, 1999, Bell Canada launched the Bell Canada Telemedicine Centre at Centenary Health Centre. This education theatre and teleconference studio will allow health professionals to provide education and service to over 200 000 children.

� In September 1996, Bell Canada with other partners (Canvas Visual Communications, T�l�bec, Cifra Medical Inc. and Theratechnologies) began an 18-month trial with tele-education when the H�tel-Dieu, Montreal�s foremost French-language hospital, began holding biweekly joint consultations and teaching seminars with regional hospitals at Trois Rivi�res, Joliette and Rouyn-Noranda. Doctors review difficult cases and current developments in neurology, hematology, gynecology and other specialities. The second phase will enable doctors to go on-line for emergency telemedicine consultations, thanks to fast, high-quality digital image transmission of patient records and images used in diagnosis, and full-duplex (two-way) colour telecommunications links that reduce the intrusiveness of the machine as intermediary between physician and patient.

� In Costa Rica, the Ministry of Health, the Costa Rican Social Security Agency and other partners are implementing a nation-wide telemedicine network linking hospitals, clinics and research and learning centres.

� In Peru, the Red Cien�fica Peruana (Peruvian Scientific Network) joins together a vast and growing network of researchers and the Red Cientifica Peruana has found a new way to bring the Internet to low-income users in underdeveloped areas, at low cost. Cabinas p�licas, or public computer centres, are now installed in 27 locations throughout Peru. They typically contain 20 computers with dedicated Internet lines, which users rent for as little as US$1 per hour. The centres also provide training, personal e-mail accounts, Web page development, and other services. They are popula with people who don�t have a phone line or computer at home, which is the case with more than 95 percent of Peruvians. Plans are under way to finance 1000 more centres in Peru, with help from the Inter-American Development Bank. The Peruvian network has direct links to clinics and hospitals, conference proceedings, and information on such topics as children�s health and mental health, so that anyone in Peru, for a modest fee, can access information globally.

� In Brazil, the Oswaldo Cruz Foundation and many other organizations serve to disseminate technical information.

� In Argentina, the University of Buenos Aires has connected its academic units to the national and international Internet community and has integrated that network with 33 national universities and foreign institutions. The increase of computer communications and the development of health infomatics in the last few years has been significant, with a greater number of physicians and paramedics using computers for self-teaching.

� In Mexico in 1997, the Instituto de Siguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) introduced a teleradiology program that uses satellite links. ISSSTE finances the health care of public-sector workers. Since the project began, there has been a 50 percent reduction in the number of patients visiting the 20 de Noviebre medical centres in Mexico City for treatment and consultation. As a result, savings of 30 percent should be made on ISSSTE�s annual budget by the end of 1999. In addition to consultations, ISSSTE also uses the satellite link for educational purposes, and it is exploring the possibility of conducting telesurgery.

� In 1998, the Universidad Nacional Aut�noma de Mexico(UNAM) , one of Mexico�s premier medical schools, purchased a $250,000 Internet server to launch "a virtual hospital project" linking 48 participating hospitals. It advises those who link on paediatrics, obstetrics, gynaecology, surgery, internal medicine and poison control. Obstetrics is a particular priority because nearly 40 percent of all hospitalizations in Mexico in 1994 were for complications in childbirth. UNAM envisages a team of specialists available on-line to answer the questions of any medical student, doctor, or even patient.

� On April 21, 1999, Cuba officially launched the Telemedicine Network at the Hermanos Ameijeiras Hospital. A key element of the program is the Proyecto de Telemedicina para el Diagn�stico (the Telemedicine Diagnosis Project). Its aims are to improve services to patients and to reduce material costs.

� In 1998, Varig Airlines of Brazil became one of a growing number of commercial air carriers to purchase onboard equipment, including defibrallators and monitoring devices that allow crew members to deal with serious medical emergencies in flight under the direction of doctors receiving electronic data on the patient via airphone.

Health-care providers are striving to enhance their ability to share information across electronic networks. Telehealth applications are becoming increasingly important in the cost-effective provision of quality health care. Telehealth�s vision to provide timely, appropriate access to essential health care and health information regardless of location is the way of the future. It is an agent of change; an enabler of health reform. Telehealth systems facilitate redistribution of health-care services, cutting down on duplication, potentially helping to reduce the number of drug interactions and inappropriate prescriptions, reducing patient and professional travel, and generally contributing to better productivity and reduced unit cost.

Professor Ricky Richardson of WorldCare UK, one of the pioneers in the field of telemedicine, predicts, "The traditional ways of practising medicine, which have evolved over 3000 years, involving a pyramidal structure, will be overturned in the course of the next 10 to 20 years. The �entry port� will be a PC based at home or a �health kiosk� in a shopping mall. The process will be beneficial, with the consequence that the global deployment and active use of telemedicine will result in a truly universal standard of medical practice becoming available around the world."