Extending the Patient Exchange Program Between

Extending the Patient Exchange Program between

St Vincent’s Hospital Sydney

the

NationalReferralHospitalHoniara

via a tele-medicine link

MedTech Outreach Australia

Solomon Islands Tele-medicine Network

Endorsed by:

Trevor Garland, Honorary Consul GeneralSolomonIsland

Project team:

Mr Fred Hersch

Dr Lilijana Mikuletic

Dr Mitchell Lawlor

Mr James Postle

Dr Dov Hersh

1Project Summary

1.1Background

One aspect of the ‘information revolution’ has been vastly increased access to the Internet email. In the medical field, this has enabled medical experts to exchange discuss information with colleagues all over the world.

MedTech Outreach Australia (MedTech) is a non-government organisation that has expertise using information technology to facilitate medical information sharing between doctors in developing nations colleagues in Australia.

Currently within the Solomon Islands, there is a project underway to develop an internal tele-medicine network using the iPath tele-medicine platform.

The proposed projects aim to extend the use of the tele-medicine system to facilitate closer communication sharing of medical information between doctors within the Solomon Islands their colleagues at St Vincents Hospital, NSW.

A brief description of each project follows:

1.1.1PEP-Link

Currently there exists a Patient Exchange Program (PEP) between the Solomon’s Islands St Vincent’s Hospital Sydney. The aims of the PEP-Link program are to augment this program through the development of a tele-medicine link. This would improve the exchange of information relating to patients difficult cases before, during after the patient exchange.

MedTech Outreach Australia will facilitate the establishment of this tele-medicine link as an extension to the existing Solomon Islands Tele-medicine network as well as provide the necessary training of the Doctors within Australia.

The proposed system will provide the following benefits:

• Cases can be submitted by doctors in the Solomon Islands for review by specialists at St Vincent’s Hospital
• Cases can be directed to specialists within the relevant subspecialty within St. Vincent’s
• Cases remain open for discussion, allowing doctors in the Solomon Islands within Australia to submit responses receive feedback
• Cases are stored allowing for later review, audit or teaching
• A teaching facility for online ‘grand rounds’ style presentations

1.1.2Funding requirements

Costs fall into three categories:

1. Fixed costs set up (software, hardware communications)
2. Running costs ongoing maintenance
3. Traveling training expenses

This project can be implemented with existing infrastructure; however some infrastructure funding will allow for significant improvements in the quality speed with which information can be transferred between Australia the Solomon Islands.

The provision of information technology within the Solomon Islands would greatly enhance the ability for doctors to be involved in the program.

Furthermore, through the provision of dedicated resources, health professionals within the Solomon’s would gain invaluable access to online journals other web based resources.

There is potential for funding to provide:

-Technology equipment (PC’s, Printers, Digital cameras) within the Solomon Islands

-Internet access (if required)

-Access to online journals (could involve subscriptions)

-Funding for on-going support of the program

2Background

2.1Solomon Islands Health Issues

The Solomon Islands archipelago includes more than 900 islands with a total population of approximately 520,000. The National Referral Hospital (NRH) in Honiara is the largest hospital in the Solomon Islands with 400 beds. There are 7 provincial hospitals offering secondary level care: Gizo, Auki, Tulagi, Taro, Buala, Kirakira, Lata. Whilst more than 80% of the population has access to basic health services, nursing stations often provide primary care in rural areas.

Vast distances between communities provide transport communication difficulties therefore create ongoing challenges for Governments in delivering health services. This is further exacerbated by the lack of suitably trained health professional servicing these wide ranging communities. At present the majority of specialist services, where available are only accessible from the NationalReferralHospital in Honiara.

Poor rural services disproportionate allocation of staff funds to the NRH mean that families with the means increasingly travel to Honiara for care. This model leaves most of the community without adequate access to health care is a substantial imposition on those in rural remote areas.

2.2Solomon Islands Tele-medicine – iPath

To date, there have been several tele-medicine initiatives in the Solomon Islands. One major project currently underway is the Solomon Islands Tele-medicine Network, a joint project of the NationalReferralHospital in Honiara, South Pacific Medical Projects the University of Basel.

This network is based on the use of the iPath tele-medicine system developed by the University of Basel. The network provides for internal discussion of cases in order to manage referrals to the NationalReferralHospital in Honiara. Furthermore, difficult cases can then be referred onto expert groups composed on international experts.

2.3MedTech Outreach Australia

MedTech is a non-government organisation that uses expertise in information technology to facilitate medical information sharing between doctors in developing nations colleagues in Australia.

Since 2000, MedTech have been a leader in this field, establishing one of the first Australian tele-medicine links as part of the Hoc Mai project in Vietnam. This project, established in 2002, involved developing, implementing maintaining a low-cost tele-medicine service between three hospitals in Vietnam RoyalNorthShoreHospital in Sydney.

More recently, MedTech has adopted the iPath tele-medicine server as the technical platform for providing tele-medicine links. MedTech focuses on identifying existing relationships where a tele-medicine link can add value, then facilitating the establishment of those links.

Experience has identified two major requirements for successful implementation of tele-medicine projects in developing countries. The first is suitable technology; complex technological solutions often sit unused in the corner. The second is the importance of building on existing relationships; individuals are unlikely to use technology to create a new working relationship, but they will use technology to maintain develop existing relationships.

3Existing Relationships between St Vincent’s the Solomons

St Vincent’s Hospital has demonstrated a long-term commitment to the people of the Solomon Islands. This commitment is consistent with the philosophy which the Sisters Of Charity espouse. PEP-Link aims to develop existing projects that already successful operate at St Vincent’s.

3.1The ‘Ten Bed Agreement’

The ‘Ten Bed Agreement’ was signed in July 1990 between the Solomon Islands Ministry of Health St Vincent’s Hospital. It provides for 10 patients per year requiring high-level tertiary care to be transferred to Australia. It includes provision for paediatric patients to be referred to the Children’s Hospital in Sydney for tertiary level paediatric care (not presently funded). The project surrounding the Ten Bed Agreement is known as the Patient Exchange Program.

The Patient Exchange Program has helped patients directly by providing life saving treatment through specialised care not otherwise available in the Solomon Islands. Patients invariably have diseases that without appropriate treatment have high mortality morbidity. Since its inception, a minimum of ten patients are transferred each year, usually involving the specialties of cardiology, oncology, haematology, infectious diseases.

The Patient Exchange Program has also provided benefit to health care staff. It has fostered relationships between specialists from both countries, has given Australian doctors insight into the significant constraints influencing their Pacific colleagues. All health care professionals involved in the care of Solomon Islander patients benefit from contact with individuals from different cultural backgrounds medical conditions rarely seen in Australia.

Currently, patients are referred to St Vincent’s by telephone/fax following discussion with the Solomon Islands Overseas Referral Committee. This method of referral is often not at a clinician to specialist level, which can have implications for effective communication between consultants.

3.2Rotational Registrar program

In 1995, in a further commitment to the Solomon Islands, a program began to provide a rotating St Vincent’s Hospital physician trainee to GizoHospital. This program encourages Australian doctors to gain three months of clinical experience with Solomon Islands health professionals, to share their skills knowledge with their Pacific colleagues.

The program remains very popular term amongst trainee Australian doctors. On their return, individuals report that the experience of working in the Solomon Islands is a highlight of their medical training allows a markedly different perspective on health care delivery.

3.2.1The Problem

While the Patient Exchange Program between St Vincent’s Hospital the NationalReferralHospital in Honiara has provided an invaluable service, there are specific areas that can be improved. Particular opportunities for improvement include follow-up, referral, triage support.

3.2.1.1Follow-up

Consultants at St Vincent’s have expressed concern that there is limited, if any, follow-up of patients returning to the Solomon Islands after treatment at St Vincent’s. This is of particular concern given that many procedures performed at St Vincent’s either requires close monitoring or a particular medication regime over the following months.

3.2.1.2Triage

With a limited number of patients able to access treatment at St Vincent’s, it is imperative that referral is limited to those patients most able to benefit from treatment. While there are established eligibility criteria for transfer, there has at times been difficultly with communication between doctors in the Solomon’s their colleagues at St Vincent’s.

3.2.1.3Referral

While many referrals contain accurate clinical information about the referred patient, there is concern that in some instances the clinical history is not adequate. A more appropriate method of communicating detailed information about the patients past history clinical progression is required.

3.2.1.4Support

Trainee registrars from St Vincent’s Hospital have the opportunity to spend three months working at the Solomon Islands Provincial Hospital Gizo. During this time there are limited options for the trainee doctors to obtain support, either general training or about a particular case.

3.3The Solution: PEP-Link

3.3.1Aims

1. To ensure iPath is used as the method of referral for prospective patients to be transferred under the Ten Bed Agreement

The current method of referring patients that are thought to require transfer to St Vincent’s is by telephone/fax. PEP-Link will mean that referrals will now be made through the iPath System, via the Solomon Islands consulate office.

1. To allow follow-up of patients returning to the Solomon Islands

Access to the iPath system will allow Australian doctors involved in the Ten Bed Agreement to more easily follow up their patients after they return home to the Solomon Islands.

1. To support for trainee Australian doctors in the Solomon Islands

The tele-medicine link can also be used to provide support for trainee Australian doctors working at GizoProvincialHospital. This would allow both Australian local registrars to more effectively communicate with the doctors at the National Referral Hospital Australian specialists at St Vincent’s Hospital.

1. Provide on-going support within the Solomon Islands

It is envisaged, that trainee doctors (above) will be able to follow up with Doctors within the Solomon's as part of their rotation. This way we feel confident that any issues can be easily addressed will ensure the ongoing success of the program.

3.4Implementation Requirements

This project requires the coordination of three elements, doctors, technology funding.

3.4.1Doctors

Several doctors currently support the Patient Exchange Program. From St Vincent’s these include Dr Peter Duval (radiation oncologist), Dr John Grygiel (oncologist), Dr David Dalley (oncologist), Dr Michael Jensen (head neck oncologist), Dr Richard Gallagher (Ear, Nose Throat surgeon); Dr R Jagilly, a surgeon from the National Referral Hospital, Honiara.

The existing relationships between St Vincent’s Hospital the Solomon Islands are the most important factor that will influence the success of this project. Initial focus must be directed toward developing existing doctor-doctor relationships within the St Vincent’s Patient Exchange Program.

Important steps in the implementation of PEP-Link include:

1. Identify all doctors currently involved with the Patient Exchange Program. This includes doctors from St Vincent’s Hospital doctors from the Solomon Islands.

1. Provide training in use of the iPath tele-medicine system for these doctors. Doctors from St Vincent’s will receive training from members of MedTech, doctors from the Solomon’s will receive training from local doctors who already use the iPath system.

1. Identify resource requirements. For St Vincent’s doctors this will mainly include the time they have available for receiving cases, for Solomon’s doctors this will include equipment necessary for their specialty. For example, this may include a digital camera for trauma injuries.

1. Assess legal implications for the transfer of medical advice

1. Re-establish guidelines for the transfer of patients under the ‘Ten Bed Agreement’ review the Memorandum of Understanding so that all doctors are aware of the criteria for transfer.

1. Publicise throughout St Vincent’s to identify other doctors who may wish to support the system.

1. Provide trainee doctors leaving St Vincent’s for the Solomon Islands with appropriate training in the iPath system.

3.4.2Technology

3.4.2.1Tele-medicine platform

The iPath system is a web based tele-medicine system that requires only access to the Internet (via a web browser). The system is currently already established operational. In collaboration with the providers of the system, the University of Basel, the necessary groups will be hosted on their existing infrastructure. As such in the initial stages of the project, there is no requirement for establishing a new server. This can be re-visited in future phases.

3.4.2.2Computer Access

At the most basic level what is required is a computer dial-up Internet access. However, the system is significantly enhanced with a scanner a digital camera, allowing pictures more detailed information to be transmitted along with the case. Doctors in both the Solomon IslandsSt Vincent’s Hospital already have access to the hardware required for implementation as well as the software.

3.5Process

When a patient is deemed suitable for transfer, the Solomon Islander doctors will log into the iPath system create a case for that particular patient. This includes any relevant attachments including photographs or other investigations. This case is then emailed to the relevant Australian specialists who will either request more information or give an opinion as to whether the patient should be transferred to Australia. This opinion will be tabled at the Overseas Referral Committee for review.

Access is available to the secure system through the Internet at any time, all cases are stored allowing later retrieval of interesting or relevant cases.

Cultural considerations can be incorporated where appropriate. One particular part of Solomon Islander culture is that doctors prefer to have some form of visual contact with their Australian colleagues. Including photographs of participating specialists as part of the system may be an initially way to address this

MedTech will facilitate the establishment of the necessary 'links' for the PEP-Link project in collaboration with the Solomon Islands Tele-medicine Network. iPath access training will be available to all participating doctors at the NationalReferralHospital in Honiara St Vincent’s Hospital Sydney.

A flow diagram outlining how the system will work is shown in figure 1.

Figure 1: Flow diagram showing procedure for doctors involved in the St Vincents PEP.

Funding

Expenses to set up continue this project based revolve around technology, education relationship building. We see it important that the key individuals in the Solomon Islands who will be involved in the project travel to Australia to meet up with their colleagues in Australia. Furthermore, long term success of the project would be greatly facilitated if two members of the Medtech team were to travel to the various hospitals in the Solomons at set-up stage at six months.

3.5.1.1Technology

While there are already computers located at both the NRH GizoHospital, additional computers will be required to provide more comprehensive access.

Item / Cost
Computers / $1,200/computer
Digital Cameras / $200 – 300/unit
Software development (eg. for future videoconferencing capabilities) / $1000
Item / Cost
Internet access / Unknown within the Solomon islands
Hardware support
Software support
Access to medical journals

3.5.1.2Internet Kiosk

We would like to provide the Solomon Islander doctors with a committed, easily accessible telemedicine referral link with St Vincent’s Hospital. We believe this would be most successful with a computer centre or ‘kiosk’, that would be based within the grounds of the NationalReferralHospital. Indeed there are many costs for such a project quotes from within the Solomon Islands would need to be obtained.

Item / Cost
Infrastructure – tables/chairs / Unknown within the Solomon Islands
Computers (four) / $1300 each
Internet access / Unknown within the Solomon Islands
Computer support / Unknown within the Solomon Islands

3.5.1.3Visit by Solomon Islander key stakeholders to St Vincents

Costs based on travel by two people from the Solomon Islands to Sydney, length of stay 10 days.

Item / Cost
Airfare (return Honiara – Sydney) / $3000
Accommodation ($200 per night) / $4000
Transport / $200
Per diem ($100 per day) / $2000

Total: $9200

3.5.1.4Visit by Medtech members to Solomon Islands

To show our commitment to the project, two members of Medtech will travel to the participating Solomon Islander hospitals at two critical stages: initial set-up at six months. The first visit will allow the Medtech team to work with the local team who will be using the system to set up begin to initiate case transfer. There will also be a period of education instruction in addition to trouble-shooting identifying potential system problems. After six months, the Medtech team would return to evaluate how the system is working, again identify change any problems that may have arisen.

Costs based on two people for one trip, length of stay 10 days.

Item / Cost
Airfare (return Sydney-Honiara, Honiara – Gizo) / $4000
Accommodation ($100 per night) / $2000
Transport / $200
Per Diem ($50 per day) / $1000

Total (one trip): $7200