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PROJECT FINAL REPORT

Grant Agreement number:

Project acronym: MEDNET

Project title: Latin America health care network

Funding Scheme: Small or medium scale focused research project (STREP/CISCA)

Period covered: from 01/01/2008 to 31/05/2011

Name of the scientific representative of the project's co-ordinator[1], Title and Organisation: Despoina Rizou, Fraunhofer IGD

Tel: +49615155515

Fax: +496151155480

E-mail: drizou@igd.fraunhofer.de

Project website address: e-

Final publishable summary report

Executive Summary

“MEDNET – Latin America Health Network” has introduced an eHealth model to the provision of health services in strongly underserved regions in Peru and Brazil. The implementation of this model is supported on current telehealth technologies as well as on evidence based medicine. The target clinical applications include general ultrasound applications such as pregnancy control, urology and abdomen control. The implemented telehealth networks connect high-level healthcare resources available in large cities with low-level healthcare facilities in underserved regions. The trial of this model, reflected in the deployment and pilot tests of telehealth stations, has demonstrated local health authorities the benefits of information technologies for health provision and social development.

The MEDNET project consisted of two subprojects in which two main actions in the two target countries Brazil and Peru have been carried out. The subproject MEDNET-Brazil implemented teleconsultation services for diagnoses and treatment of pregnancy control, dermatology and radiology for underserved regions in Brazil by using and adapting an extended version of the telehealth platform Teleconsult.

In the subproject MEDNET-Peru teleconsultation services for ultrasound examinations such as OB/Gyn, pregnancy control and urology have been implemented for rural hospitals in Peru, using also the Teleconsult platform.

Both subprojects were implemented in parallel according to the same work plan that consists of 8 consecutive, technical work packages. In accordance with the workplan in total 8 telehealth pilot networks in Peru and 7 in Brazil, have been successfully implemented in strongly underserved rural or remote regions. Seven sites were chosen for the project MedNet in Brazil. Three sites in Amazonian legal region, three sites in Rio Grande do Sul (RS) , and one in a large urban area Porto Alegre where the referral hospital is located. In total three (3) remote areas in Amazon were interconnected through satellite link. Those cities are located in Maranhao states. In Peru the The main DIRESA Junin hospital in Huancayo was the referral hospital. And it was connected via satellite with 7 sites in the rural area.

The cases of Peru and Brasil are examined independently. Given the very low utilisation of the system in Peru and the unwillingness shown in using the system, the assessment follows a more high level perspective. On the other hand, a detailed evaluation process has taken place for Brasil, focusing on the acceptance rate of the system by its users, but also taking into account the technical performance of the network. For both cases the main outcome is that the system can be considered as successful and characterized as sustainable as long as its potential users get motivated to use it in their everyday practice. Concerning the costs of the network, in comparison always with the money saved due to teleconsultations performances, they are considered as affordable for Brazil, but extremely high for Peru. In both cases it has been proven that the main cost in the total operational cost is the one related to the satellite communication. Even for Peru, where the operational costs were considered as extremely high for the financial sizes of the country, it is obvious that less reliance on satellite communication could be the key for expanding and transferring the MEDNET network in the whole region.

MEDNET has conducted innumerable dissemination activities such as an international telemedicine symposium in Brazil that made the project well known as a best practise telemedicine pioneer project in the public, in the health policy and in health organisations in our target countries Brazil and Peru but also in the global telemedicine community. The project stimulated the political dialogue in these countries that leaded already to better basic conditions for broad application of telemedicine.

Conclusively, the knowledge gained from the MEDNET project offers valuable insights for developing region wide opportunities for eHealth. An option with minimized telecommunication costs – something that in Brazil is already being offered for the remote sites that have broadband internet installed – can lead to a sustainable network with many positive effects on the health status of the population in the remote rural areas.

Summary Description of Project Context and Objectives

It was the main aim of the MEDNET project to implement and demonstrate an eHealth model for evidence based rural telemedicine based on current information technologies and telehealth systems by which the access and the quality of public health system resources for those people living in under-served regions in Latin America can be improved.

The project was organised in eight workpackages (WPs) combining the necessary partners and expertise for assuring successful execution and accurate market orientation, ending up to a sustainable project. The leadership of each WP is determined by the principal interests and expertise of the project partners.

The technological background was offered by partners with deep experience in medical systems and medical imaging processing and architectures design and development (FhG IGD, MC, TASE, VT, HISPASAT,HISPAMAR).

Project Workflow

[pic]

Workpackage list

|Work Package No |Work package Name |

|WP1 |Project Management |

|WP2 |Clinical requirements |

|WP3 |Specification of technical requirements |

|WP4 |Technology adaptation |

|WP5 |Organizational and technical preparation |

|WP6 |System deployment |

|WP7 |System Demonstration & evaluation |

|WP8 |Dissemination & Exploitation |

3 MEDNET architecture & technology

MEDNet system architecture and major components are:

• TeleConsult

• Jabber communicator

• AmerHis

TeleConsult

TeleConsult, is the next generation of the software running on the TeleInViVo [4] station and provides medical doctors with all necessary tools for communicating and exchanging medical information over different communication channels such Internet, ADSL, or conventional phone lines. TeleConsult provides a wide spread of possibilities to enrich a given image material with additional information and to send it as a message. This can happen in offline-mode or in online-mode. Moreover, the online-mode gives the opportunity to communicate over long distances with a given partner in real time. In this case, both doctors observe the same image data set and through text messages and transferred mouse actions to the remote PC, they can discuss interactively over a medical case.

A client/server architecture over Instant Messaging protocol provides the central storage of all data of a telemedicine center and the access to this data from every fixed or mobile computer station, which is equipped with the client-software. Members of a telemedicine network store their data in their local database and send their queries to the consultant centre via Internet, ADSL or any other available communication channels. The medical history of a patient, necessary for the assessment of a case, is sent anonymously and automatically along with the messages. In general this application allows:

• The loading and handling of 2D and 3D medical images

• The transmission and reception of messages including annotated medical images over Internet, ADSL or PSTN line in off-line or on-line mode.

• The enrichment of the images with graphical and textual annotations and pictograms.

• The interaction of the physicians involved in the on-line mode using chat windows and mouse movements, while the workstations employed share the same display (“what you see is what I see)The storage of images, patient relevant information, and exchanged messages in a central database accessed by doctors belonging to the same network.

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Example of the user interface of the TeleConsult platform while visualizing a fetus.

Jabber ccommunicator.

Jabber [7,8] is an open-source, XML-based protocol for Instant Messaging and online-presence.

[pic]

A jabber instant messaging system consists of a hub server and many remote nodes, which are able to be connected to the server. The hub is responsible for keeping tracks of users’ presence status and to forward the messages to the right user.

The communication moduleof the TeleConslt application makes use of jabber protocol for both exchanging medical data and application synchronization data.

In an on-line teleconsltation session the data are sent to the recipient directly through the jabber server.

In case of an off-line teleconsultation tha data are stored to the jabber server.

AmerHis

The AMERHIS system integrates a Broadcasting Multi-Media network with an Interaction network by combining two standards, the DVB-S and DVB-RCS, into one unique regenerative and multi-spot satellite system. In this manner, the users calling for broadband and interactive services will be able to utilize standard stations (RCSTs) at both transmitting and receiving sides. In this system, the DVB-RCS return channel standard is applied by all users to access through a standard uplink to the satellite.

DVB-RCS is a system that allows users receive and transmit capabilities via a geostationary non-regenerative satellite. The DVB-RCS return channel standard is applied by all users to access through a standard uplink to the satellite. On board, the regenerative payload (OBP) is in charge of multiplexing that information from diverse sources into one or more DVB-S data streams capable of being received by any standard IRD equipment. The on board repeater is not only capable of multiplexing signals coming from the same uplink, but also cross-connecting and/or broadcasting channels coming from separate uplink coverage areas to different downlink coverage areas.

The Management Station manages all the elements of the system. It also controls the sessions, resources and connections of the ground terminals. It is composed by: NMC (Network Management Center), in charge of the management of all the system elements. NCC (Network Control Center), which controls the Interactive Network, provides session control, routing and resource access to the subscriber RCSTs and manages the OBP configuration. . The NCC can directly transmit to the satellite the signaling and timing information for network operation by using the same DVB-RCS standard and receiving the different return channels via DVB-S signal. NCC_RCST, the satellite terminal of the MS, supporting modulation and demodulation functions to access to the satellite.

[pic]

AmerHis architecture outlook

The RCST (or simply terminal) is the interface between the System and external users. These terminals are able to work in transparent or in OBP-based systems by a simple change of software. In OBP-based systems they allow different kinds of connectivity: single satellite-hop mesh (unicast and multicast) connections, single satellite-hop connections with ISDN through the RSGW and single satellite-hop connections with terrestrial IP networks (Internet, Intranet). It order to provide more complete Triple Play or Corporate services the RCST can have different equipment attached to it.

4 Subproject in Brazil

The areas where the Telemedicine network installation have been done, correspond with the health centres and reference hospitals where the telemedicine network defined in the project has been finally deployed. For a continuity of the project after the end of 2010, the number of remote sites could be extended to other areas or countries in Latin America with similar problematic in an easy and scalable manner.

In Brazil

Referral hospital: Santa Casa hospital in Porto Alegre.

Spokes:

1. Balsas,

2. Fortaleza dos Nogueiras,

3. Carolina

In addition, Santa Casa hospital extended the medical network to three remote hospitals in Rio Grade do Sul states (Pelotas, Alegrete and Lagoa dos Três Cantos), that need medical tele-consultation on MRI and CT cases. These three remote sites will make use of ADSL communication for data exchange.

Partners in Brazil & Roles.

|SENAI-CETA |BR |Research Institution |Facilitating implementation of project in Brazil |

|SACA |BR |Hospital |Pilots running |

5 Subproject in Peru

In Peru

Referral hospital: Huancayo

Spokes:

1. Chongos Alto,

2. Comas,

3. Pariahuanca,

4. Puerto Ocopa,

5. Mazamari,

6. Rio Negro,

7. S.M. de Pangoa

In total 8 installations in Peru all connected via satellite.

|GEOPAC |UK |SME |Facilitating implementation of project in Peru |

| | | |Evaluation of Peru |

|DIRESA |PE |Public Health Authority |Provide medical expertise for implementation of project and run the |

| | | |pilots, communicate problems and recommendations in order to resolve |

| | | |outstanding issues. |

|GRJ |PE |Local Government |Supervise implementation of project, identify synergies with |

| | | |modernisation reforms, and communicate problems and recommendations in|

| | | |order to resolve outstanding issues. |

Objectives & Foreseen activities

By utilizing and exploiting these European standards and techniques MedNet has the following impacts in Peru and Brazil:

1. Strengthen the intelligence gathering capacity of health systems and their ability to use information for decision making. This contributes to the advancement of medical research, diagnosis and treatment methods, through the efficient collection and sharing of data on treatment outcomes and patient demographics.

2. Enhance clinical services - particularly in terms of extending health service coverage to rural and isolated areas. This enables the efficient and cost effective use of high level and high quality medical resources available in large cities for improvement of health services for residents in remote and rural underserved regions. MedNet helps reduce morbidity and mortality in underserved regions by providing a means for early detection and treatment of contagious diseases such as malaria and tuberculoses by the use of telematics and e-health technologies.

3. Capacity building - MedNet allows health care personnel to access information and programmes of continuing professional development. This directly combats the current sense of professional isolation, improving levels of personal and professional satisfaction. It also facilitates knowledge transfer through the use of telematic ultrasound systems that connect expert's know-how in large cities to remote area.

1 General objectives

MedNet established a collaborative framework with counterparts in Latin America to promulgate access in underserved regions of Latin America to efficient, cost effective, high level and high quality medical resources.

The proposed healthcare database and medical platform directly impacts on patient safety by enhancing clinical services and improving the primary healthcare in the pilot locations. This was achieved through advanced diagnosis and treatment methods, efficient collection and sharing of data on treatment outcomes and patient demographics and collaborative medical research.

This system effectively embedded European medical protocols and standards for medical information exchange, storing and representation .

Counterparts from Latin America were directly involved in the adaptation and customization of the medical platform. Additionally, MedNet established a collaboration framework conducive to the development of e-Health in the region through a dissemination and exploitation plan that identified and engaged with stakeholders through a series of meetings, showcases, workshops and conferences.

The pilot study locations were connected over satellite communication based on DVB-RCS protocol utilizing the European AmerHis system. This enhanced the medical network, in terms of add-on components, scalability and reliability, and provide opportunities to exploit the network infrastructure by developing platforms for education and commerce.

Summarizing, MedNet covers all the objectives of the call, since it aimed to:

• Knowledge transfer from European to Latin America, in technological and medical levels. Our Latin American partners had the opportunity to work with well-established medical application for medical tele-consultations. Technician will acquire knowledge of the technological background of the medical application and physician got familiar with on-line medical application and tested it in real situations.

• Patient safety. MedNet provided physicians with a tool to follow the patient health status, and provide in a very short time, medical advices, consulting expert physicians in urban cities.

• Electronic health records. The medical application used enables a medical database, following openEHR. Within the scope of the project was the development of an open health database where medical cases will be stored, supporting evidence based medicine, for future references, which was succeeded.

• Promotion of the European medical standards. European medical standards for medical information storing, exchange and representation were supported.

2 Specific objectives

Nowadays, hundreds of cities in Latin America have no access to primary health care, and moreover simple tests such as blood tests, ultrasonography, and electrocardiogram cannot be performed straightforward. Our health network connected isolated regions of Latin America with central hospitals, where remote physicians could discuss medical cases with specialists.

The cities were connected over satellite communication based on DVB-RCS protocol and making use of the European AmerHis system which can provide concurrently up to 4/8 Mbits in the upload and download links respectively. In addition, the medical platform was based on the results of TeleInViVo, T@LEMED, @HOME project (IST-2000-26083). Our Latin American partners were involved to the adaptation and customization of the platform. In that way, Latin American organisation, universities and companies made use and take advantage of the European standards and techniques.

To conclude, the clinic impact and adding value of MEDNET are:

• To enable the efficient and cost effective use of high level and high quality medical resources available in large cities for improvement of health services for residents in remote and rural underserved regions.

• To help reduce morbidity and mortality in underserved regions by providing a means for early detection and treatment by the use of telematics and e-health technologies.

• To improve the primary healthcare by the use of telematic ultrasound systems to connect expert's know-how in large cities to remote area.

• To contribute to the advancement of medical research, diagnosis and treatment methods, through the efficient collection and sharing of data on treatment outcomes and patient demographics.

• MedNet offered the possibility to compare two different access technologies (transparent and regenerative satellites) in order to assess the benefits of the mesh connectivity offered by AmerHis and to compare the cost of operation of both alternatives.

These general objectives were split into more detailed specific objectives with a social, clinical or technical impact in the target countries.

Social impact:

• To reduce the gap between underserved regions and large cities in medical service levels, and consequently, contribute to the reduction of the social complication.

• The image of equal opportunity of receiving government medical care, especially for minorities will be created and promoted.

• MEDNET aims to increase education and economic opportunities through the provision of training related to eHealth technology.

• To develop strategies for sustainable telehealth services. The telemedical services developed and implemented in MEDNET will be compliant to and complementary with national health strategies in the target countries.

Clinical impact:

• To enable the efficient and cost effective use of high level and high quality medical resources available in large cities for improvement of health services for residents in remote and rural underserved regions.

• To help reduce morbidity and mortality in underserved regions by providing a means for early detection and treatment by the use of telematics and eHealth technologies.

• To improve the primary healthcare by the use of telematic ultrasound systems to connect expert's know-how in large cities to remote area.

• To contribute to the advancement of medical research, diagnosis and treatment methods, through the efficient collection and sharing of data on treatment outcomes and patient demographics.

Technological impact:

• To develop intelligent user interfaces for health professionals and patients to use the telehealth platform in networks with clinical databases. Electronic guidelines, diagnosis and treatment results transmitted using information technology will generate the database for evidence based medicine in the targeted regions.

• To increase the public sensitiveness for medical data. The security technology will be used to protect medical data from unauthorized access. A public key infrastructure for eHealth application will be implemented and promoted.

• Use of DICOM standard for diagnostic image storage, retrieval and transfer or the

• Interoperability with Latin American telehealth technology and telehealth network will be demonstrated.

• MEDNET can also develop and promote the “eHealth” community as a forum for discussions, to exchange experiences about telehealth systems and services and to get and give advice about eHealth related questions.

Description of the Main S&T Results/Foregrounds

Achievements in Brazil

Study area & backround

Brazilian national health system (NHS) is composed of a large public, government managed system, the SUS (Sistema Único de Saúde), which serves the majority of the population, and a private sector, managed by health insurance funds and private entrepreneurs.

The public health system, SUS, was established in 1988 by the Brazilian Constitution, and sits on 3 basic principles of universality, comprehensiveness and equity. Universality states that all citizens must have access to health care services, without any form of discrimination, regarding skin color, income, social status, gender or any other variable.

The public system is still grossly under-funded and lacking quality, though that's been improving greatly in the last few years. Important legal issues, such as the regulation of Constitutional Amendment 29, are expected to minimize some of those problems. In 2006, the most notable health issues were infant mortality, child mortality, maternal mortality, mortality by non-transmissible illness and mortality caused by external causes (transportation, violence and suicide).

Private Health Insurance is widely available in Brazil and may be purchased on an individual-basis or obtained as a work benefit (major employers usually offer private health insurance benefits). Public health care is still accessible for those who choose to obtain private health insurance. As of March, 2007, more than 37 million Brazilians had some sort of private health insurance.

A major issue is the concentration of resources, both material and medical personnel on rich areas (in the richest regions and in biggest cities), in particular for high complexity.. This affects the health sector in both dimensions – public and private.

It is important to notice that Brazil lacks a policy for redeployment of medical personnel according to the needs, physicians as they graduate, are free to work all over the country. Small cities ( ................
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