Remember Tilos, the little island in the Greek Dodecanneso. Here, an inspired team from the Post-graduate School of Emergency Surgery at the University of Pisa, is working hard on the realization of an exportable model for telemedicine services in rural and isolated areas, with assistance of the resident physician and two nurses. VMW Magazine closely has been following their efforts throughout the spring, summer and autumn of 1998. Professor Enrico Cavina and his team performed a clinical mapping of almost the entire island population and launched the very first successful teleconsultation sessions with a profound respect to local habits, which are deeply rooted in the people's hearts and minds. Winter calls for yet another visit to "Tilos Medicine & Tele-medicine" to assess the impact of seasonal conditions on the project.
From December 18th 1998 to January 8th 1999, the Pisa team of Tim-Tem researchers analysed four different elements which might influence the results of telemedicine support in winter time. First, the efficiency and quality of the telecommunications and telematic equipment were evaluated. Seen in the light of a regular Telemedicine Station to be implemented on the island, the telematic system should be reliable and operative 24 hours a day. Conventional phone lines and cellular GSM devices work fine, even in the most extreme weather conditions. Yet, sudden breakdowns due to humidity in the electric circuit require the presence of a built-in electric generator as well as a spare basic computer instrumentation with accessories in case of emergency. Internet connections suffer from overall slowness which causes the team to seriously consider the use of fast ISDN and satellite systems.
The second important factor constitutes the climatic condition with regard to the availability of guaranteed transport over sea for patients in critical need. Inconstancy dominates the weather evolution in the Greek archipelago. High seasonal temperatures alternate with icy-cold northern wind storms which might interrupt the regular ferry boat, hydrofoil, hydroplane and helicopter services for several days. A quiet water-level suddenly can turn into a rough sea in only a short distance, making it impossible to reach other islands or the mainland. This fact alone demonstrates the need to support the health care system on Tilos with a permanent Telemedicine Station, that is run by a properly trained staff of two "dedicated" technicians and two or three high-school students, living on the island, who maybe could be paid by the government to take the Telemedicine service up as a professional activity.
The interchanging flow of people leaving and returning to Tilos in winter time forms a third vital factor of variability. While the elderly population remains on the island, the younger ones temporarily move to Cos, Rhodos or Athens. In turn, islanders who work on the continent spend their Christmas holidays on Tilos. Although there is no tourist traffic, the preparation of the summer season brings building traders personnel to the island to reconstruct hotels. In comparison with the regular population of nearly 300 souls, there exists a fluctuation between 200 and 250 people during winter. Part of them doesn't actually belong to Tilos which means that these people were not involved in the preventive Tim-Tem screening in the spring of 1998. This might face the Telemedicine service with possibly unknown, sporadic pathologies.
The population's clinical mapping in May also had a remarkable impact on the ambulatory routine as a fourth major element of verification. The local physician had not a single emergency case during the months of October, November and December thanks to the earlier diagnosis of three people with high risk diseases who were immediately hospitalized at the time. In former years, the doctor had to deal with an average of five to six acute cases in the same period. The ambulatory activity has noticeably dropped while the team carried out its observation task. Some very old islanders receive home care but there is no sufficient follow-up. In this regard, some expert consultation by means of specific lab data would be very useful to the resident physician whose diagnosis and therapy are simply based on clinical observation and anamnestic knowledge.
The on-field verifications are capital for the future direction of the Tim-Tem initiative, which has been self-supporting up till now. As the project moves into the final planning stage, Professor Cavina urgently needs to find funds to implement a regular Telemedicine Station as a model to be reproduced for other remote areas. Therefore, the Pisa team aims to attract the attention of qualified partners and institutions to assist with the further improvement of the already tangible results. In order to turn Tilos into an operative station, also for other islands, a full medical and telematic equipment is required as well as the availability of two computer experts to manage the installation on the island for at least one year. The second phase of the project, relating to the so-called "Dispatch", has been temporarily put aside but in any case needs to be reconsidered sooner or later.
As a matter of fact, the "Dispatch" system is already available at the Department of Surgery in Pisa. Multiple files are actively applied on a computerized programme in a modulated answer/question system, in order to direct the physician to the most effective treatment in case of emergency. For the Tilos experiment however, there remains a linguistic obstacle, since the Greek language is characterized by the use of peculiar fonts. In addition, the station operators have to be specifically trained for this type of service. Dispatch is particularly useful to assist a temporary physician, substituting the resident doctor and therefore faced with situations which sometimes are difficult to handle. Dying to catch up with the full project story? Then you should consult the Tim-Tem home page or read the VMW article Objective human factors' analysis prevails over abstract methodology in telemedicine project on Greek island in the January 1999 issue.