TimTem telemedicine workstation pilot on Tilos model for remote island tele-consultation

Tilos 02 August 2002The ongoing TimTem initiative, managed by the Department of Surgery at the University of Pisa and set up in 1997 to implement a permanent telemedicine workstation on the Greek island of Tilos, has left the project phase to become a real model for European islands and remote areas, according to Dr. Enrico Cavina who is Head of the Telemedicine Project TimTem. The synergy and collaboration with similar project experiences is only taking up slowly but things seem to be moving nevertheless. After the visit of the Health Department Officers, located on Rhodos, at the end of July 2002, the bureaucratic procedures for the connection between Tilos and the "Sismanoglio Telemedicine Center" in Athens were started, but doubts about the efficiency of this 24/7 Teleconsult Center remain. However, the interest of the Greek Authorities for Telemedicine in Tilos offers nice perspectives for TimTem.


In 2001, the International Cooperation of the Italian University Ministry (MIUR) positively assessed the project. TimTem was awarded with a finance of about $70.000 supported by MIUR, the University of Pisa, Telemed s.r.l., and some sub-partners for instrumentation and equipment supply including Ethicon S.p.A, Ebit@sanità, and the Italian Diagnostic Center. In March 2002, the operative phase of the project started, based on the already acquired experience. The deadline is October 2002, as stated by Dr. Cavina in his latest report.

The Italian private companies in the international Cooperation Programme supplied the TimTem project team with a Videoconference Vega 2 Aethra system, provided by Ethicon S.p.A.; a US Sonosite device provided by Esaote; and telesonography software provided by Ebit@sanità. In addition, the Municipality of Tilos signed an official contract to recruit a doctor-technician, devoted to the Tilos Telemedicine Station management.

In his report, Dr. Cavina describes how in the period March-April 2002, some computers and technical instrumentations were brought to Tilos. Four dedicated ISDN lines were set up at the Livadia village ambulatory room, re-arranging, when possible, all the spaces useful for either technical devices and clinical check-ups. Three computers, together with some others belonging to the Tilos Municipality and never used, were installed and prepared for data "storage" and informatics telecommunication.

During the months of May and June 2002, an Italian informatics expert has been working in order to upgrade the whole system building a specific data-registry for use and research. For the holiday perdiod June-September, he has been substituted by a Greek informatics expert who is now trying to make the system easy to use in Greek language, which is very difficult as written language, and can give problems of computer compatibility.

At the same time, five Italian physicians have been working on Tilos during different periods, making clinical check-ups, updating the data-registry, listing the pathologies, and giving suggestions for single cases' diagnosis and care to the only island physician. The July 2002 data-registry comprises 430 clinical files with ECG and ultra-sonography images of the patients' neck, abdomen, breast, etc. The most relevant ones involving about 200 patients, have been stored in a data-base.

Dr. Cavina explains in his report that ultra-sonography mapping was performed by trained personnel on the spot with the expert long-distance support in terms of remote ultrasound tele-consultation. A Greek health care provider was taught how to use the ultrasound probe, how to transmit images in dynamic connection through tele-sonography, and how to perform dynamic images useful for the diagnosis from a distance. The final result constitutes an excellent working tele-ultrasound service with no remote area expert.

Ultrasound images interpretation is a main concern in Greece because, according to the Greek law, only a radiologist can perform this, as stated by the Health Department Officers from Rhodos who visited Tilos. They believe that the TimTem experience could be the key solution for the Greek tele-sonography problems. The tele-consultation was performed with the support of the video-conferencing system Vega 2 Aethra which is compatible with other video-conferencing systems. Specialist and multi-specialist teleconsultations were performed, together with didactic conferences in collaboration with Italian universities and hospitals in Athens.

Dr. Cavina describes how digital images transmission relating to specialities such as tele-dermatology, tele-ophtalmology, and tele-otho-rino-laryngology, was easy to use for local operators also trying to send pieces of compressed dynamic images with a video-camera. Ultrasound images were sent using a proprietary software but at the same time, the ultrasound live transmission was performed with the usual video-conferencing system checking its quality in comparison with the proprietary software to achieve the most reliable diagnosis. Results of previous and current experiences were presented in a series of reports at the International Telemedicine Congress (TICD), held in Pisa, Italy, in June 2002.

The clinical mapping of the islanders came to an end in July 2002 with the above-mentioned 430 files representing about 92 percent of the present population, which is twice as much as in 1998. In the same period, the project team faced some serious emergencies requiring heli-rescue, and problems of local management deficiencies and operative risks which must be deeply analysed in order to plan proper protocols, as Dr. Cavina states in his report. All these lacks are related to "human factors" such as not sufficiently prepared personnel and absence of willingness to fill the gaps.

There is no real availability on the part of the reference hospital although the local population was enthusiast about the project and the major-physician of the island supported the team. The video-conferencing equipment was freely supplied. Waiting for the announced Telemedicine National Greek System, the TimTem model continues to fully work performing tele-consultation connections outside and inside Greece. Dr. Cavina has received offers for free-of-charge co-operation from two private hospitals in Athens.

The Telemedicine Station in Tilos is now run by Greek operators specifically trained throughout the TimTem experience. They will be tutored until the end of September. Later, a system for validation will be installed to deeply analyse specific pathologies in September with the support of specialists. During the same month, some students from Pisa University will have the chance to directly see the Tilos "lab" after their registration to an official university telemedicine postgraduate training course. In August, a special computer training seminar already was organised by the Educational Department of the Aegean University.

Dr. Cavina also notes that the scientific analysis of results for the island diseases is in progress and will be available for the local authorities and health care providers. These results will also be published in international journals. The TimTem system is able to work autonomously. The pilot work and methodology are ready to be used by the island physician. As such, the Tilos TimTem project will be useful for the forthcoming Greek National Telemedicine Plan.

Furthermore, some preliminary clinical data concerning epidemiology and prevention can be underlined, namely that 40 percent of the resident population suffers from light, median or serious arterial hypertension, and globally 35 percent of the people is at risk. Some 20 percent of the population suffers from different thyroid pathologies as reported by the tele-sonography ultrasound screening. These data need a continuous updating.

The pilot work's deadline is the 25th of September when the Telemedicine Station at the Livadia ambulatory room will be likely to manage the local health situation without any external support. Dr. Cavina expects that his team will be able to improve both the system and its use for next September. More news on the TimTem project is available in the VMW July 2001 article Cost-effective telemedicine for efficient health care management on smaller Greek islands still ignored.

Leslie Versweyveld

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