The programs described in this section represent only a sample of established or developing international telemedicine humanitarian initiatives. These programs use a spectrum of ICT, telehealth platforms, and models, applying possible collaborations with nonprofit and for-profit entities, nongovernmental organizations (NGOs), and governmental agencies, along with panels of health care provider volunteers and experts. These programs may provide consultation, case reviews, education, and knowledge sharing, as well as augment in-person provision of health services. These services can be synchronous (real time), asynchronous, or a combination of both. The platforms may use wireless systems connected to the Internet; be web-based; include text and images; utilize mobile devices such as smart phones or tablets; or use specialized equipment, carts, and peripheral devices to support consultation.
The Swinfen Charitable Trust (http://www.swinfencharitabletrust.org/) based in the United Kingdom was started in 1998 by Lord and Lady Swinfen as a nonprofit organization to provide asynchronous consultation to health care providers in developing countries. It uses a secure web-based platform that operates 24 hours, 7 days a week throughout the year and allows an authorized health care provider in a participating developing country to request a consult about a specific patient using text and attaching images as needed. A large panel of specialty volunteers has been recruited and continues to be recruited. These individual volunteer specialists are contacted via email based upon the type of consultation requested. When a consult is requested, the appropriate specialist is asked to log into the website and respond within 48 hours, providing possible diagnoses and management options. On average each case is answered within 12 hours. Health care providers can also request additional information from the referring provider and ask other specialty consultants to participate as needed. These consults may reinforce current diagnosis and treatment; suggest other possible diagnoses, additional testing, procedures, or treatments within the context of the local resources available; or, if feasible, suggest transfer of the patient to a higher-level facility for further evaluation, management, or procedures such as surgery that cannot be done locally. Swinfen Charitable Trust has 335 hospital links in 76 countries involving nearly 600 referring providers and over 700 consultants in over 120 specialties. They have examined nearly 5,000 cases since 1998 and use four medically trained system operators: three in the UK (two voluntary) and one in New Zealand.
The following is a compelling case example managed through the Swinfen Charitable Trust and one of their certified pediatric specialists that led to a positive outcome without which this child would likely not have received the care that was needed. A 4-month-old infant was referred to the Swinfen Charitable Trust by a team staffing an orphanage for children with medical needs for evaluation of growth failure and cyanosis. Her birth weight was 2.0 kg, and at 4 months she weighed 3.7 kg. Her vital signs were pulse (P) 150, respiratory rate (RR) 40, and oxygen saturation 80% in room air. Cardiac examination showed a grade III/VI continuous murmur at the upper-right sternal border. Peripheral pulses were normal. Chest X-ray showed levocardia, cardiomegaly, decreased pulmonary vascularity, and a right-sided stomach bubble. A limited echocardiogram showed a complete atrioventricular (AV) canal defect. After discussion with colleagues at a children's hospital more than 750 miles away, at 6 months of age, she was transferred and found to have asplenia syndrome, pulmonary atresia, imbalanced complete AV canal, double outlet right ventricle, right-sided patent ductus arteriosus, aorticopulmonary collaterals, and a diaphragmatic hernia. The infant was begun on amoxicillin prophylaxis. She underwent repair of the hernia, followed by a bidirectional Glenn procedure. Postoperatively, she did very well and returned to her orphanage receiving antibiotics, baby aspirin, and diuretics. She was adopted soon thereafter, and has since undergone a Fontan procedure with an excellent hemodynamic result. She is developmentally normal at age 4.
Medecins Sans Frontieres (MSF), Doctors Without Borders, has been providing humanitarian health care in many developing countries, particularly after natural disasters or during wars and conflicts resulting in manmade disasters. Recently they have developed a web-based platform, similar to the Swinfen Charitable Trust, for asynchronous consults for providers in those countries being served and provided by a panel of specialty volunteers.
The ECHO (Extension for Community Health Outcomes) Project founded by Dr. Sanjeev Arora at the University of New Mexico in 2003 (http://echo.unm.edu/about-echo/) uses telehealth ICT to provide primary care providers with education and case reviews of patients with common complex diseases that started with the need for care of patients with hepatitis C. 10,11 Demonstrating success, ECHO has rapidly expanded to other diseases and health issues. 12–29 This model is being replicated throughout the United States and other regions, such as Canada, India, Vietnam, Ireland, Mexico, South American countries, parts of the Caribbean, Australia, Egypt, and countries in Africa, with the hope of touching 1 billion lives worldwide by 2025. 30,31 As stated on their web page, “The ECHO model™ does not actually ‘provide’ care to patients. Instead, it dramatically increases access to specialty treatment in rural and underserved areas by providing front-line clinicians with the knowledge and support they need to manage patients with complex conditions.” These ECHO sessions often include multiple providers at different locations and create “learning loops” for group education and knowledge sharing through case discussions and reviews. See also https://www.statnews.com/2016/09/12/doctors-primary-care-specialists-project-echo/ and https://www.stepsforward.org/modules/project-echo.
Shriners provides free orthopedics, cleft lip palate repair, burn care and reconstruction, orthotics, prosthetics, plastic surgery, and spinal cord surgery for children (http://www.shrinershospitalsforchildren.org/). They are committed to providing the best care for children in their specialty areas regardless of a family's ability to pay. Telemedicine provides screening and follow-up care for children being served from around the world at Shriners facilities (http://www.shrinershospitalsforchildren.org/search?q=telemedicine). For example, the telemedicine burn clinic at Shriners Hospital for Children – Mexico City is now in operation to provide follow-up care for the burn patients that were treated at Shriners Hospitals for Children in Galveston. The goal of the telemedicine clinic is to follow up with these patients by optimizing resources and avoiding the stress of travel for patients and relatives. The Shriners’ coordinators have noted in orthopedics, telemedicine is used routinely. For many patients, being able to connect with telemedicine services has actually made their treatment possible. For example, a growing child with an orthopedic problem is often at risk for recurrent deformity. As a bone grows, it may not grow correctly, even after surgery to correct the alignment. Health care providers often need to follow their patients closely until they are done growing to treat any recurrent deformity before it becomes more severe.
Children's Hospital Colorado's telehealth program supports the University of Colorado (CU) Center for Global Health, with their primary telehealth usage occurring at a clinic in Guatemala. 32 They support a weekly tele-education conference between experts at CU and the community health nurses in Guatemala, and the topics are designed to increase the nurses’ capacity to provide evidence-based care in their community. One of the most successful projects has been breastfeeding education with the nurses now feeling more confident in their abilities to support breastfeeding moms locally. They also have residents rotating at this site who present cases on a monthly basis during morning report or noon conference in Denver via videoconferencing. This helps them stay connected to their home program while working internationally and brings global health education to the other residents who don’t go to the Guatemala clinic. They’ve also been trialing a Helping Babies Breathe (HBB) course taught via telehealth at this clinic. It is still a pilot project, but preliminary data suggest that passing rates and knowledge/skills teaching are quite good. The model uses a lead instructor in Denver who teaches the didactic sessions, monitors skills practice, and tests the students via teleconferencing, and local staff and residents rotate in Guatemala and help with the course execution. They’ve taught two telehealth courses with plans to retest the students later this year to assess skill retention.
Telehealth is also being used to facilitate global health research at the University of Colorado. Thus telehealth can be used to facilitate large-scale global research projects that otherwise tend to be expensive and difficult from a logistic perspective. For example, discussions with the American Academy of Pediatrics (AAP) have the goal of generalizing the HBB teaching model to other locations once it's established enough to move beyond the pilot stage. In addition, one of their global health researchers is exploring use of the telehealth system to facilitate his projects with less travel time and costs. One of these projects would be assessing efficacy of the pneumococcal vaccine in the Philippines, and the telehealth component would capture tympanic membrane exams with digital otoscopes/tympanograms using local research assistants; then pediatric ear/nose/throat (ENT) specialists would interpret the results in the United States. They use their system to do mortality case review for a hospital in India.
The Children's National Health System at George Washington University School of Medicine and Craig Sable, MD, Director, Echocardiography and Telemedicine, have been providing pediatric cardiology telehealth services to countries, such as Morocco, United Arab Emirates (UAE), Uganda, and Brazil. 33,34 These have included evaluation of patients with rheumatic heart disease, and as the participants have noted: “The global burden of rheumatic heart disease is nearly 33 million people. Telemedicine, using cloud-server technology, provides an ideal solution for sharing images performed by non-physicians with cardiologists who are experts in rheumatic heart disease.” The program coordinators have described their experience in using telemedicine to support a large rheumatic heart disease outreach screening program in the Brazilian state of Minas Gerais. The program uses cloud-based sharing of echocardiographic images with expert support between the sites in Brazil with Washington, DC. Secondary goals included (a) developing and sharing online training modules for nonphysicians in echocardiography performance and interpretation and (b) utilizing a secure web-based system to share clinical and research data. Their efforts included 4,615 studies that were performed by nonexperts at 21 schools and shared via cloud technology. Latent rheumatic heart disease was found in 251 subjects (4.2% of subjects: 3.7% borderline and 0.5% definite disease). Of the studies, 50% were performed on fully functional echocardiograph machines and transmitted via Digital Imaging and Communications in Medicine (DICOM) and 50% were performed on handheld echocardiograph machines and transferred via a secure Dropbox connection. The average time between study performance date and interpretation was 10 days. There was 100% success in initial image transfer. Less than 1% of studies performed by nonexperts could not be interpreted. As the project coordinators stated: “A sustainable, low-cost telehealth model, using task-shifting with non-medical personnel in low and middle income countries can improve access to echocardiography for rheumatic heart disease.”
Another project from the Children's National Medical Center has used telemedicine for neurologic disorders. 35 The authors state: “A telemedicine program was developed between the Children's National Medical Center (CNMC) in Washington, DC, and the Sheikh Khalifa Bin Zayed Foundation in the United Arab Emirates (UAE).” A needs assessment and a curriculum of onsite training conferences were devised preparatory to an ongoing telemedicine consultation program for children with neurodevelopmental disabilities in the underserved eastern region of the UAE. Weekly telemedicine consultations are provided by a multidisciplinary faculty. Patients were presented in the UAE with their therapists and families. Real-time (video over Internet Protocol; average connection, 768 kilobits/s) telemedicine conferences were held weekly following previews of medical records. A full consultation report followed each telemedicine session. They report that between February 29, 2012, and June 26, 2013, 48 weekly one-hour live interactive telemedicine consultations were conducted on 48 patients (28 males, 20 females; age range, 8 months to 22 years; median age, 5.4 years). The primary diagnoses were cerebral palsy, neurogenetic disorders, autism, neuromuscular disorders, congenital anomalies, global developmental delay, systemic disease, and epilepsy. Common comorbidities were cognitive impairment, communication disorders, and behavioral disorders. Specific recommendations included imaging and DNA studies; antiseizure management; spasticity management (including botulinum toxin protocols); and specific therapy modalities including taping techniques, customized body vests, and speech/language and behavioral therapy. Improved outcomes were reported in terms of clinician satisfaction, achievement of therapy goals for patients, and requests for ongoing sessions. The project coordinators concluded that weekly telemedicine sessions coupled with triannual training conferences were successfully implemented in a clinical program dedicated to patients with neurodevelopmental disabilities by the Center for Neuroscience at CNMC and the UAE government. International consultations in neurodevelopmental disabilities utilizing telemedicine services offer a reliable and productive method for joint clinical programs.
The Harvard Global Mental Health Program and Program in Refugee Trauma and their director of telemedicine, Eugene F. Augusterfer, and colleagues have been using telemedicine to provide support to victims of disaster in Haiti and refugees in Syria in collaboration with Yale University School of Medicine. 36,37 As the author states: “Telemental health (TMH) is an important component in meeting critical mental health needs of the global population. Mental health is an issue of global importance; an estimated 450 million people worldwide have mental or behavioural disorders, accounting for 12% of the World Health Organization's (WHO) global burden of disease. However, it is reported that 75% of people suffering from mental disorders in the Developing World receive no treatment or care. In this paper, the authors review global mental health needs with a focus on the use of TMH to meet mental health needs in international and post-disaster settings. Telemedicine and TMH have the capacity to bring evidence-based best practices in medicine and mental health to the under-served and difficult to reach areas of the world, including post-disaster settings.” The authors reported on the mental health impact of the Haiti 2010 earthquake and on the limited use of telemedicine in postdisaster Haiti. They underscore the point that published papers on the use of TMH in postdisaster settings are lacking and reviewed considerations before working in TMH in international and postdisaster settings. As they also note, given the scarcity of mental health resources available for refugees in areas of conflict, it is imperative to investigate interventions that would be accepted by the refugees. In this study they surveyed 354 Syrian refugees using the HADStress screening tool and asked about their openness to referral to psychiatry and telepsychiatry. Of the surveyed sample, 41.8% had scores on HADStress that correlate to posttraumatic stress disorder. However, only 34% of the entire sample reported a perceived need to see a psychiatrist, and of those only 45% were open to telepsychiatry.
The NIH Fogarty program includes the Global Health Research and Research Training eCapacity Initiative (R25) with the purpose to develop innovative educational approaches that enhance research capacity at LMIC institutions by expanding the use of ICT in global health research and research training (https://www.fic.nih.gov/Programs/Pages/ecapacity.aspx). In addition, participants in the programs should develop into adaptable users of ICT who are able to sustain such activities as changes arise in technology. This program aims to leverage the research capacity established by current or former Fogarty International Center research and training grants through direct links with these awards (https://www.fic.nih.gov/Pages/Default.aspx).
The American Telemedicine Association (ATA) (http://www.americantelemed.org/home) has several members involved in international telemedicine activities, including the International Special Interest Group (SIG) and the ATA Latin American and Caribbean Chapter (ATALACC) and the Pacific Islands Chapter of ATA (PICATA). ATA has developed memoranda of agreement with many partner countries and their telemedicine initiatives and/or associations, including Armenia, Australia, Canada, China, Nepal, Netherlands, India, France, Iran, Korea, Pakistan, and the United Kingdom. This is enabling the exchange of ideas, experience, and expertise related to telehealth in the global community. For example, a two-day symposium on electronic hospitals and telemedicine held at the Tehran University of Medical Sciences (TUMS) occurred on October 12, 2010. The symposium was attended by academics from Iran and some guests from the United States. The event brought about a memorandum of understanding (MOU) which was signed between the university and the ATA. This MOU will serve to establish cooperation between the two institutions and will include educational, research, and scholarly activities along with operational plans in telemedicine, as well as holding joint symposia. Both the TUMS chancellor and the president of the association hope this agreement will help improve the health system and act as a starting point for sharing information and experience in this field.
The International Society for Telemedicine and eHealth (ISfTEH) also has several international partners represented in 93 countries and territories, and their mission is to facilitate the international dissemination of knowledge and experience in telemedicine and e-health, providing access to recognized experts in the field worldwide (https://www.isfteh.org/).
Company Donation Collaborative Programs
Other initiatives have worked with companies to foster telehealth programs in other countries, such as in Guatemala, Guam, Mexico, Philippines, Pakistan, Bhutan, and Jordan.
Telemedicine has the potential to bring medical expertise to patients located anywhere in the world. Unfortunately, history suggests that telemedicine systems are often abandoned after the completion of a demonstration or pilot project and are never fully adopted for long-term use—often because standard procedures and workflows within the health care organization are never examined and modified to support the routine use of telemedicine. A telemedicine implementation in Jordan was supported by Cisco Systems. 38 The principal participant developers addressed the organizational adoption of telemedicine technologies based on an example case study drawn from an implementation in two hospitals in Jordan. Three types of specialty consults were offered: dermatology, cardiology, and nephrology based upon high-priority needs identified by health care individuals in Jordan. The Cisco systems equipment could support delivery of images and data needed by these specialists, including high-resolution skin images and heart and lung sounds. Each participating specialist was able to provide one hour per week of teleconsultations. There were two participating cardiologists, two nephrologists, and one dermatologist, for a total of five hours of consultations per week. A fixed schedule was created, with each consultation hour for a specialist occurring at the same time each week. They identified the organizational challenges and the potential benefits. Cisco Systems and the project coordinators state that they hope their efforts will encourage anyone who develops or donates telemedicine systems to consider not only how challenging organizational barriers to use can be, but also how easily they can be overcome.
AMD Global Medicine has provided humanitarian support in Guatemala, where 40% of the Guatemalan population faces a future without adequate health care.39 For many indigenous families, Mayan Families is their only access point for affordable and quality health care. The Charlie Gomez Medical Clinic provides preventive and primary health care, education, and follow-up to the families they work with. The telemedicine equipment allows them to deliver these services to patients in their local communities with specialists from various partner organizations in the region, including WINGS Guatemala, Opal House Guatemala, and Wuqu’ Kawoq – Maya Health Alliance.
Another recently launched AMD-supported telemedicine program works with the underserved patient population on the island of Guam, with cost-effective, real-time access to secure medical consultation services from specialists an ocean away. 40 The Department of Public Health and Social Services and Good Samaritan Hospital have partnered to connect patients in Guam with medical staff in Los Angeles. There is also collaboration between Hospital Infantil De Las Californias and Tiopa Santuario de Luz and a community health clinic in the village of Autlan de Navarro. The Hospital Infantil De Las Californias is the only pediatric specialty hospital in the Tijuana region of Mexico, with 25 specialties in a 56,000-square-foot facility. Sixty percent of the staff serve in a volunteer capacity. No child is ever turned away because of the family's inability to pay. The Tiopa Santuario de Luz was created by music legend Carlos Santana and Dr. Martin Sandoval. Since 2005 Santana and his family's Milagro Foundation have provided the operating funds. The Santana Telehealth Project was formed to connect Hospital Infantil De Las Californias and Tiopa Santuario de Luz. The project will include primary care and specialist referrals over live video, as well as remote patient monitoring. Once established, the program will be a telehealth model that can be used for expansion into other underserved communities.
Disaster logistics relief focused on bringing humanitarian health care to patients in the Philippines after the destruction of Typhoon Haiyan. Telemedicine was used to perform onsite examinations of patients while communicating live back to physicians and specialists in the United States for consult.
The Paul Chester Children's Hope Foundation provides vital assistance to improve the lives and well-being of families in developing countries such as in rural Kenya. Their medical outreach programs bring critical health resources and treatments to remote communities, harnessing the expertise of their volunteer medical professionals. In order to treat patients, they leveraged telemedicine technology to set up video consults with U.S. doctors from the middle of Narok or from the coast of Malindi.
Medical Mission for Children uses telemedicine to help critically ill children all over the world. Medical Mission for Children's Telemedicine Outreach Program (TOP) is a cost-efficient way for health care professionals to consult on unique cases where one doctor may have more specialized training and can discuss a case more thoroughly than a general practitioner. The telemedicine equipment takes a medical consultation from speculation to diagnosis and treatment. Remote diagnostic instruments such as a telephonic stethoscope allow a doctor in the United States to accurately assess the auscultation of a child's heart even though they are thousands of miles apart.
Comsats is a telecommunications provider in Pakistan that offers health care services to rural citizens via telemedicine in the areas of Gokina, Mehra Behri, Dagai, Swabi, Quetta, Maraka, Muzaffarabad, Chak Faiz, Sangu, Shadoband in Gwadar, and Ubhri. They have set up 14 rural clinics in these small towns, providing 100% free service to patients. To date, they have completed 40,000 telemedicine consults. This telehealth initiative was necessary to help people save the cost of transportation and paid visits to the doctors.
Bhutan Ministry of Health brings health care access to communities more than 14 hours away from major medical facilities. For example, the ministry set up a telemedicine clinic in a remote mountainous community to connect the members with health care services provided by the Royal University of Bhutan.