Abstract
Although academically speaking, the international telemedicine community has been productive and creative, we cannot be satisfied with our current work, our current achievements, our current standards, our current questions, and most importantly, our current answers.
Background
Telemedicine in developing countries is not new. However, as with many innovations, it has taken decades for telemedicine to enter the mainstream as a healthcare delivery system, despite having great potential. Indeed, it has already brought hope to many developing countries and remote areas. However, real concerns remain that the full potential of telemedicine has not yet been realized, either in the developing world or even in developed countries.
We have previously reported on establishing the telemedicine program of Kosova as a successful model for developing countries or countries in transition. 1 –3 The aim of this article is to report the results of the “Initiate-Build-Operate-Transfer” (IBOT) strategy as well as lessons that we have learned during this decade that go beyond the IBOT strategy.
Materials and Methods
We reviewed retrospectively the results of International Virtual e-Hospital's (IVeH's) core strategy, IBOT. 2 Each of these elements, described previously in detail, 2,3 has been instrumental in establishing telemedicine in the Balkans with sustainability as the key goal.
Results
Using the IBOT concept, IVeH has established telemedicine in Kosova (2002–2007) and in Albania (2008–2011). Each program consists of a National Telemedicine Center, in the respective capitals of Prishtina and Tirana, and Regional Telemedicine Centers (RTCs) in Gjilan, Prizren, Gjakove, Peja, Mitrovica, and Skenderaj in Kosova and Shkodra, Kukesi, Durresi, Vlora, and Korqa in Albania. In addition, three other hospitals and one Regional Autistic Center of Albania are connected with the telemedicine program. Each center provides clinical services, virtual educational programs, an electronic library, and technical support services. Since inception of these programs, 16 hospitals are a part of the functional telemedicine network. Each program has been provided with electronic medical library access to healthcare professionals and with established local leadership to operate and manage national telemedicine programs and RTCs in both countries.
Using the same strategy, the IVeH is in the process of or has initiated the implementation of national telemedicine programs in Macedonia, Montenegro, 4 –6 Moldova, Gaza, Palestine, Cape Verde, Tanzania, Nigeria, and Southeast Asia. 7 Each of these programs has been established and/or is supported by Ministries of Health and/or organizations that play key roles in their regions in both healthcare and education and funded by different organizations. 7
Lessons Learned and Future Direction
Although the IBOT strategy has been adopted by many countries, the results of our analysis suggest that further development should focus on eight additional critical elements that include: 1. Flexibility of architectural design of the network and infrastructure 2. Multidisciplinary and functional interoperability of well-trained, actively participating individuals and teams from various clinical and technical disciplines 3. Delivery of effective consultative clinical services 4. Locally relevant, structured educational content through discipline-specific seminars and leadership courses 5. Professional dedication of healthcare providers to telemedicine 6. Strategic flexibility in program implementation 7. Continuous advocacy 8. Development of specific indicators that go beyond creating the program and or a center
In this article, we briefly expand on each of these critical elements. Further studies are needed to perform analytical and scientific evaluation of the effectiveness of each of these elements.
1. Robust architectural design of the network and infrastructure
The architectural design of a telemedicine network should make possible special intelligence and future logical additions, without major disruptions in the flow of clinical and educational processes provided by the telemedicine network. It should allow for conceptual agility, programmatic growth, and improvements in performance. This requires forward thinking and close collaboration with technical designers of the programs and should not be “locked” on a specific framework that does not allow expansion, without changing the entire technical system. Use of wireless technologies should be considered when appropriate, as long as security of such networks and technologies is maintained.
2. Multidisciplinary and functional interoperability of well-trained, actively participating individuals and teams
There is a great need to focus on additional forms of interoperability in addition to technical interoperability. We need to focus on multidisciplinary and functional interoperability as our modus operandi. In particular, it is important that the clinical establishment works very closely with information technology personnel, policy makers, and administration in creating and maintaining telemedicine efforts.
3. Delivery of effective consultative clinical services
Each region of the world has its major needs for clinical services. Telemedicine should adapt to those needs, and telemedicine champions should make sure that based on the assessment, these needs are fulfilled from telemedicine for family medicine and primary care all the way to trauma and emergency management, as the most sophisticated and dramatic form of telemedicine services.
4. Local educational needs
Local educational needs should be fulfilled using local as well as international expertise. These programs should be structured based on the requirements of local universities and other local institutions. Major issues such as diabetes, cardiovascular diseases, and infectious diseases should be a priority, but based on local needs.
5. Professional dedication
There is a need for professional dedication to telemedicine from the clinical establishment around the world. In our medical practice around the world today, telemedicine and e-health are not practiced every day, everywhere. The average doctor does not have telemedicine and does not have all of the e-health tools at his or her fingertips. We cannot, and should not, continue to treat telemedicine as a professional “mistress” or a hobby; rather, we need to make it part of our daily practice. For this it takes professional dedication.
6. Strategic flexibility
Although we have outlined our new strategic approach focused on critical thinking and significant needs, we simply cannot blindly follow such an approach if our test results and evidence point in different directions. We need to keep our options open and flexible. We do need to more cohesively and efficiently incorporate the expertise and viewpoints of diverse representatives from the fields of technology, administration, research, and outreach.
7. Continuous advocacy and lobbying
There is need for continuous advocacy with governments, medical associations, and hospital administrators as well as individual practitioners. Associations and other telemedicine groups need to make this a priority and part of their mission with dedicated resources for public relations.
8. Development of indicators of success
The IVeH has concentrated on establishing centers and national programs, and this has served as one indicator of success. However, there is need for new indicators to be developed concurrently with milestones of the programs for each country and each program. The telemedicine program itself, and the programmatic content of it, needs to be solid, palpable, and structural, providing bona fide intellectual and practical substance for the country and overall international telemedicine.
Discussion
Overall, telemedicine has made great strides, from both a research standpoint and an organizational standpoint. IVeH continues to pursue its core IBOT strategy but is cognizant of the need to further develop the concepts and expand on commitment for the long haul. Clearly, the IVeH has developed a powerful concept, has successfully implemented several beta site projects, (as have many other organizations around the world), and has added a significant contribution in the form of scholarly works, including peer-reviewed articles and textbooks. We aim to pursue with sufficient discipline and genuine creativity these additional elements (although some of these have been used in the past decade) using the resources and tools that our concept has to offer. Mostly, we need to add new and innovative concepts such as mobile health and other forms of telemedicine that are sound and deployable. However, we need to further test the effectiveness of these elements as principal components of the programs and real infrastructure.
We are aware of the limitations of this article. First, it is a retrospective review of our two programs in the Balkans, and this article does not have the data to demonstrate the effectiveness of these programs, in terms of both clinical and educational aspects. This was not the intent of this article. We previously have published the cost-effectiveness of the telemedicine program of Kosova. 7 Clearly, there is a need for vigorous analysis of these programs, and we need to wait for others to demonstrate the effectiveness of the IBOT strategy in other parts of the world.
Conclusions
IBOT has been successful, but further studies are needed to demonstrate its effectiveness in countries beyond the Balkans. We suggest that the IBOT strategy be supplemented with eight other components that in our view are required for successful and sustainable telemedicine programs in developing countries. Their effectiveness, however, needs to undergo vigorous analysis before we can recommend them.
Footnotes
Disclosure Statement
No competing financial interests exist.