Objective human factors' analysis prevails over abstract methodology in telemedicine project on Greek island

Pisa 16 November 1998 Professor Enrico Cavina of the Post-graduate School of Emergency Surgery within the Department of Surgery at the University of Pisa has made available the first results of the "Tilos Medicine & Tele-medicine" initiative. The Tim-Tem project, running from October 1997 till June 1999, aims to develop a concrete telemedicine case study on a little Greek island, called Tilos, to create an exportable model for telemedicine services in rural areas, such as islands and isolated regions. The preliminary results clearly show that treatment of acutely ill patients in remote areas implies more than the implementation of advanced technologies and abstract protocols. Careful observation of the daily routine in the two medical ambulatory rooms on the island and a lively interest in the specific human and cultural factors, which play a vital role in the minds of the local people, call for a simple, practical no-nonsense approach, characterized by useful training facilities and basic technologies.

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Professor Enrico Cavina of the Post-graduate School of Emergency Surgery within the Department of Surgery at the University of Pisa has made available the first results of the "Tilos Medicine & Tele-medicine" initiative. The Tim-Tem project, running from October 1997 till June 1999, aims to develop a concrete telemedicine case study on a little Greek island, called Tilos, to create an exportable model for telemedicine services in rural areas, such as islands and isolated regions. The preliminary results clearly show that treatment of acutely ill patients in remote areas implies more than the implementation of advanced technologies and abstract protocols. Careful observation of the daily routine in the two medical ambulatory rooms on the island and a lively interest in the specific human and cultural factors, which play a vital role in the minds of the local people, call for a simple, practical no-nonsense approach, characterized by useful training facilities and basic technologies.

The Mediterranean island of Tilos is part of the Dodecanneso. It has two main villages, Livadia Harbour and Megalochorio, which are 7 km apart from one another, both hosting military garrisons of about 50 soldiers. The local population consists of nearly 300 people but the number triples in the tourist season. The other islands and the mainland can be reached via ferry boat and hydrofoil services or by helicopter. Rodos and Cos host the nearest available hospital centres whereas Athens provides all high quality medical specialities. One physician and two nurses are responsible for the health care delivery and drug distribution on Tilos. The resident doctor has been living on the island for 15 years, of which the past three years, he has been the Mayor. This political and social function makes some 10% of the people trust in the doctor only reluctantly, since politics are a fundamental issue, lending cause to conflicts of interest among the islanders.

In conjunction with the local authorities of Tilos, the University of Pisa has set up the Tim-Tem project to improve the level of medical care on the island by means of telematic support in three phases. In May 1998, the team of Professor Cavina performed a clinical and ecographic mapping of the local population. In this period, 280 inhabitants were living on the island, out of which 268 or 96% participated to the initiative. The Pisa researchers have just evaluated this first phase's results. The implementation of a dispatch centre and system in collaboration with the Greek hospitals should involve the second phase. Although the system is already being applied via the use of multiple files on a computerized programme at the Department of Surgery in Pisa, phase two will be postponed in the Tim-Tem project, considering the lack of telecommunications and emergency services in the Aegean area.

The team will therefore concentrate on the third phase, which constitutes the building of operative telemedicine applications, to start with the organization of an efficient teleconsultation system. Initially, data and still images will be used for transmission but at a later stage, real time imaging will be provided. The first phase included the collection of anagraphical data; clinical history; physical examination; blood pressure assessment; Electrocardiogram (ECG); neck, breast and abdomen sonography; and occasionally doppler and colour doppler sonography. The team used a portable Cardiovox Device, enabling a twelve derivations ECG to be transferred by telephone to the remote Centro Diagnostico Milano for immediate analysis. In turn, the equipment used for sonography consisted of a fixed echo colour doppler device with cardiologic software and three different probes, and a portable one with two probes. If needed, the images were sent by email to a senior sonographer in Pisa.

In addition, the team has stored the patient data, together with the relevant medical images, in a computerized database for immediate retrieval in case of emergency. Dermatological and radiological images have been captured and inserted online by means of a digital camera. The resident physician and nurses have also received a basic computer and sonographic training. The major obstacles during the first phase were the lack of ISDN phone lines and hardware devices on Tilos. In order to improve the present situation, a collaboration was set up with the Department of Informatics of the Aegean University for the delivery of some computers to the island, as well as the necessary computer training facilities for the health care personnel. In the meanwhile, the Pisa team has used GSM mobile phones for transmission of ECG and patient data.

The clinical mapping of the island population extended to 129 men and 139 women between the age of 3 and 88. Four persons were suffering from high risk cardiologic pathologies whereas the team detected two surgical cases of aneurysm in the abdominal aorta and two cases of possibly suspect cancer development. Patients with severe disease were immediately transported to the regional hospital to receive appropriate care. Over 25% of the people suffered from renal stones, biliary tree stones, and other minor ailments. In five cases, a teleconsultation took place with remote exchange of sonographic or dermatologic images. The high degree of participation of the local people to the project greatly exceeded the team's initial expectations. It appeared that the islanders were extremely conscious of their isolated situation and the difficult logistic conditions in which the local physician has to operate.

As a result, the Tilos people appreciate the efforts taken to support the local doctor with advanced diagnostic methods and treatment equipment as well as telemedicine applications. The team even noticed a tendency to abuse the telematic services, since many islanders requested a teleconsultation session for banal cases. The same conduct is observed in direct drug distribution due to the special relationship between the local inhabitants and the doctor, who also acts as the pharmacist. The patients beseech medical prescriptions that often are abusive. The Tilos experience shows that the introduction of telemedicine in rural areas should be prepared with utmost care as not to enter into conflict with the deeply rooted habits in the relationship between patient and physician because of too strictly applied protocols or decisional algorithms. A smooth integration with basic methods of teleconsultation can turn telematic support into a compatible tool with the existing cultural level in the considered area.

For more detailed information on the project, you can consult the Tim-Tem home page. We equally refer to the VMW article on the Tilos experience in the April 1998 issue.


Leslie Versweyveld

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