EDUCATION & PRACTICE/Praxis
A hybrid approach to telepathology in Cambodia
Journal of Telemedicine and Telecare 19(8) 475–478 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1357633X13512071 jtt.sagepub.com
Varsha Kadaba1, Tho Ly1, Saqib Noor1, Serey V Chhut2, Nora Hinsch3, Gerhard Stauch4 and James Gollogly1
Summary We established a hybrid telepathology network at the Children’s Surgical Centre (CSC) in Cambodia, based on store-andforward communication using iPATH and videoconferencing using Skype. We retrospectively analysed all data from the CSC stored on the iPATH server and reviewed the patient notes over an 8-month period. Of 115 patients for histopathology diagnosis during the study period, 38 cases were uploaded onto iPATH for further telemedicine discussion. The median number of days it took a specialist, other than the local one, to comment on the case on iPATH was 5 days (range 0–15). In three cases (8%) there was no reply from a specialist on iPATH. During the study period, seven clinical conferences were held, with an average of 6 cases (range 4–7) discussed at each conference. All 38 cases discussed had a final agreed diagnosis and firm management plans were made. Of the 24 cases where proactive management was advised, 17 patients followed through with the recommendations. Although the combination of video consultations and store-and-forward communication has not been used much before in the developing world, it has benefited patient care and outcomes at the CSC. Accepted: 23 September 2013
Introduction The predominant clinical application of telemedicine in developing countries is for second opinions, where difficult cases are discussed with an international community for further advice on diagnosis and management.1 Telemedicine has been used successfully in a number of medical fields, including ophthalmology, dermatology and pediatric neuro-oncology.2 Telemedicine has also been used successfully in Cambodia, with email consultations to rural communities.3,4 A case report from Siem Reap highlighted the success of using an email-based system to resolve a diagnostic problem in collaboration with specialists from the USA.5 There are few reports of videobased consultations in resource poor settings. Telepathology, a subspecialty of telemedicine in which pathology is discussed, has also been utilised in many settings across the developing world.6 Establishing a telepathology network in a resource poor setting can be complicated and so basic web-based/email systems have been used. The iPATH network (the Internet Pathology Suite) is an open access platform designed for discussing medical information in a store-and-forward format.7 The iPATH network has been used successfully in Tanzania,8 the Philippines9 and East Africa.10
Children’s Surgical Centre The Children’s Surgical Centre (CSC) in Phnom Penh is a non-governmental organisation set up to provide
rehabilitative surgery, free of charge, to patients in Cambodia. The aim of the CSC is to provide sustainable and high quality services to its patients.11 Due to the limited number and experience of trained pathologists in Cambodia, it was difficult to obtain accurate diagnoses of bone tumours and unusual pathological conditions in patients who attended the CSC. Often, the histological diagnosis seemed completely different from the radiological and clinical impressions. This problem led the CSC to send glass slide pathology specimens overseas to reliable university laboratories, but as time went on, the possibilities for doing this diminished due to stricter regulations coming into force regarding the transport of biological tissues, and the introduction of computerized tracking of samples in western laboratories. We therefore established a hybrid telepathology network, based on store-and-forward communication using iPATH and videoconferencing using Skype.
1
Children’s Surgical Centre, Phnom Penh, Cambodia Phnom Penh Institute of Pathology, Phnom Penh, Cambodia 3 Department of Pathology, MVZ Lukaskrankenhaus Neuss GmbH, Neuss, Germany 4 Pathaloge Aurich, Aurich, Germany 2
Corresponding author: Varsha Kadaba, Children’s Surgical Centre, Kien Khleang National Rehabilitation Centre, Road 6A, Khan Ruseykeo, Sangkat Chroy Changvar, Phnom Penh, Cambodia. Email: [email protected]
476
Store-and-forward communication Difficult pathology cases presenting to the CSC are selected by a nominated oncology surgeon, and anatomical tissues are sent for histology to a Cambodian laboratory. The slides are prepared using paraffin blocks and cut using a manual microtome. Still images are taken from the slides (1024 pixel resolution, 24 bit colour) and uploaded onto the iPATH network12 along with diagnostic comments and a working diagnosis from a Cambodian general pathologist. Specialists from around the world, who have been invited to join the group, are then notified of each case, and given a chance to comment via the store-and-forward system and provide a second opinion on the cases.
Videoconferencing From October 2012, monthly case conferences have used Skype videoconferencing to discuss, with whoever chooses to join, all the cases uploaded for the month. Before the conferences, participants are able to see all clinical, radiological and pathological data and can make comments on the clinical features, radiology, histology and treatment options for specific clinical cases. Each clinical conference takes place in the conference room at the CSC, usually in the presence of the senior doctors, the pathologist who prepared the slides, and the patients, who can be videoed and demonstrated to all participants. Each case is discussed individually by all attending parties, and the diagnosis and treatment options spelled out for the benefit of all. The workflow is summarised in Figure 1.
Methods We retrospectively analysed all data from the CSC stored on the iPATH server and reviewed the patient notes over an 8-month period (October 2012–May 2013). Demographic details, confirmed histopathology diagnoses, time to the first response on iPATH, number of responses, Skype conference outcome and follow-up data, were evaluated.
Results Of 115 patients for histopathology diagnosis during the study period, 38 cases were uploaded onto iPATH for further telemedicine discussion. During the 8-month study period, seven clinical conferences were held. The average age of the 38 patients (18 female, 20 male) was 36 years (range 2–85). Indications for referral were either treatment queries (22 cases), diagnosis queries (8 cases) or both treatment and diagnosis queries (8 cases). An average of 6 cases (range 4–7) was discussed at each conference. All 38 cases uploaded onto the iPATH server were discussed and definite plans made, taking into account the advice given. At the CSC, all surgical staff and two visiting doctors (pathologist and oncologist), amounting to over 20 people, attended each conference.
Journal of Telemedicine and Telecare 19(8) From abroad, 3–4 experts in the fields of pathology, oncology and orthopaedics were consulted in each case. The range of confirmed histopathological diagnoses is shown in Table 1. The median number of days it took a specialist, other than the local one, to comment on the case on iPATH was 5 days (range 0–15). In three cases (8%) there was no reply from a specialist on iPATH. Those who commented were specialists in the fields of oncology, pathology, radiology and haematology and were located around the world, particularly Europe. There was an average of 10 days between the storeand-forward comments and the Skype videoconference (range 0–34). Following the case discussion and pathology findings, advice on further patient management was discussed at the conference via Skype. Advice was tailored to the setting and facilities available in Cambodia. Plans included advising further surgery, medical and chemotherapy treatment, further diagnostic tests and repeat biopsies, referral to other specialists, or conservative management. The advice given after the case conferences is summarised in Table 2. The clinician in charge of the patient at the CSC made the final decision regarding the care of the patient. The outcomes of the 24 patients where consensus advice suggested a further form of treatment or referral to another institution are shown in Table 3.
Case reports Case 1. A 72-year old male presented to the CSC with a one-year history of right hip pain and difficulty in weight bearing. He described being involved in a road traffic accident one month prior to the onset of hip pain. Clinically, he appeared thin, with a limited range of movement of the right hip and a palpable lymph node in the right groin. Radiographs of the hip revealed an apparent pathological fracture of the right proximal femur. An initial biopsy, however, reported ‘‘reactive fibrosis after a fracture’’. After comments on iPATH there were still uncertainties about the diagnosis because the radiograph appearances did not correlate with the histological opinions. However, in real time discussion and debate with international pathologists at the next case conference, the suggestion was made to histochemically stain further slides with CD20. This was done, and the final diagnosis was confirmed as a pathological fracture through an infiltration of a B cell lymphoma. Despite iPATH store-and-forward communications discussing the case prior to the meeting, it was only through a real time debate that the suggestion for further CD20 staining was made, which effectively led to the correct diagnosis. This example highlights the potential benefit of real time collaboration between healthcare professionals over asynchronous communication methods. Case 2. A 12-year old male presented to the CSC with fever, malaise, bilateral exophthalmia and weakness and stiffness of the jaw. Following medical consultation, a
Kadaba et al.
477
Figure 1. Workflow of the hybrid telemedicine process.
Table 1. Histopathological conditions discussed. Non neoplastic and inflammatory lesions Benign tumours Suture granuloma Hyperostosis Pseudotumor Osteomyelitis Rheumatoid arthritis Non specific arthritis Actinomycosis Tuberculosis
Ameloblastoma Desmoid tumour Nasopharyngeal angiofibroma Schwanoma
Table 2. Advice given after the case conference. Number
Malignant tumours Liposarcoma Melanoma Thyroid carcinoma Burkitt’s lymphoma Hodgkin’s lymphoma Non Hodgkin’s lymphoma Malignant peripheral nerve sheath tumour Ewing sarcoma Pleomorphic sarcoma Chondrosarcoma Osteosarcoma
preliminary diagnosis of melioidosis, an infectious disease caused by a Gram-negative bacterium, Burkholderia pseudomallei, was made and systemic antibiotic therapy was commenced. A biopsy from a lymph node was taken and the case was uploaded onto the iPATH server. An interim pathology report suggested a diagnosis of Burkitt’s lymphoma and at the next conference, the diagnosis was confirmed as stage 4 Burkitt’s lymphoma. Unfortunately, advice from oncologists in Europe suggested a poor prognosis even with a complicated chemotherapy regime, involving more than five chemotherapeutic drugs. After a lengthy discussion between all healthcare professionals in the conference, it was deemed impossible to treat the condition effectively in Cambodia due to lack of chemotherapy agents and funding. His treatment for assumed meliodosis
Requires further surgery and/or chemotherapy Commence antibiotics Referral to another institution Repeat biopsy required Continued observation No further treatment available in Cambodia
14 5 3 2 7 7
Table 3. Patient outcomes. Number Complied with treatment Refused treatment Lost to follow up Died before starting treatment Successful referral (patient attended referral) Unsuccessful referral
14 3 2 1 3 1
was discontinued. The patient died at home about two weeks later. The videoconference in this case allowed the correct diagnosis to be made, incorrect treatment to be stopped, and further treatment options discussed. From an educational perspective, international doctors were able to understand the limitations of Cambodian medicine and local doctors were educated in the diagnosis and treatment of lymphomas.
478
Discussion Prior to the telepathology system, doctors at the CSC did not have a reliable way to ask for advice in difficult cases. Usually, email advice would be sought, perhaps with attached photographs of the X-rays. Occasionally, complicated cases had tissues sent to foreign medical contacts for diagnosis and advice, or visiting doctors at the centre would take tissues home for diagnosis or treatment decisions. As a result, not all patients benefited from the system. The wide range of diagnoses in the present series (Table 1) demonstrates the need for specialist advice and a multidisciplinary approach to these complicated cases. Following the introduction of iPATH, doctors at the CSC have been able to discuss complicated cases with their specialist colleagues from around the world. Anecdotally, the number of cases being discussed has increased compared to the email queries previously. The increased dialogue probably results in firmer management decisions and better documentation. The addition of Skype consultations has clarified the comments made by specialists (which were written in French, English or Italian) and allowed the treatments to be made more relevant to Cambodia, as demonstrated by one of the case reports above. Often, treatment options suggested on the iPATH server were simply not available in Cambodia, and the Skype conferences were useful in explaining this to the participants. Moreover, the cases presented at the CSC were usually quite late in their presentation, and so are often rare in the industrialised world, providing substantial interest for the participating expatriate experts. The combination of video consultations and store-and-forward methods has not been used frequently in the developing world. All 38 cases discussed in the conferences had a final agreed diagnosis and firm management plans were made. Of the 24 cases where proactive management was advised, 17 patients followed through with the recommendations from the conference collaboration. This shows that the hospital was able to use the advice given, even in a resource poor country where medical treatment is often not as advanced or readily available as in an industrialised country. There are logistical challenges to operating a telepathology link. Establishing a network and organising conferences requires a combination of technical resources, adequate technical support and committed healthcare staff to attend the meetings. A cost analysis of this process was not attempted. From a clinical perspective, obtaining full outcome data of patients is often difficult in Cambodia, since patients are easily lost to follow up or
Journal of Telemedicine and Telecare 19(8) difficult to track if they are referred on to different institutions. As a result, an evaluation of changed diagnoses or diagnostic error was not performed. In conclusion, setting up an international telepathology email and videoconferencing syatem has been very useful for the CSC by giving greater clarity to cases and helping to plan treatment. It has unquestionably benefited patient care and outcomes. A prospective study to evaluate its cost-effectiveness needs to be undertaken. Acknowledgements We thank Monika Hubler, administrator of iPATH, Basel, Switzerland, for helping us to organize the Surgical Friends of Cambodia iPATH group and case conferences.
References 1. Wootton R, Bonnardot L. In what circumstances is telemedicine appropriate in the developing world? JRSM Short Rep 2010;1:37. 2. Qaddoumi I, Mansour A, Musharbash A, et al. Impact of telemedicine on pediatric neuro-oncology in a developing country: the Jordanian-Canadian experience. Pediatr Blood Cancer 2007;48:39–43. 3. Heinzelmann PJ, Jacques G, Kvedar JC. Telemedicine by email in remote Cambodia. J Telemed Telecare 2005;11(Suppl. 2):44–7. 4. Brandling-Bennett HA, Kedar I, Pallin DJ, Jacques G, Gumley GJ, Kvedar JC. Delivering health care in rural Cambodia via store-and-forward telemedicine: a pilot study. Telemed J E Health 2005;11:56–62. 5. Froehlich W, Seitaboth S, Chanpheaktra N, Pugatch D. Case report: an example of international telemedicine success. J Telemed Telecare 2009;15:208–10. 6. Weinstein RS, Descour MR, Liang C, et al. Telepathology overview: from concept to implementation. Hum Pathol 2001;32:1283–99. 7. Brauchli K, Oberholzer M. The iPath telemedicine platform. J Telemed Telecare 2005;11(Suppl. 2):3–7. 8. Kru¨ger C, Niemi M. A telemedicine network to support paediatric care in small hospitals in rural Tanzania. J Telemed Telecare 2012;18:59–62. 9. Marcelo A, Fatmi Z, Firaza PN, et al. An online method for diagnosis of difficult TB cases for developing countries. Stud Health Technol Inform 2011;164:168–73. 10. Gimbel DC, Sohani AR, Prasad Busarla SV, et al. A staticimage telepathology system for dermatopathology consultation in East Africa: the Massachusetts General Hospital experience. J Am Acad Dermatol 2012;67:997–1007. 11. Children’s Surgical Centre. See http://www.csc.org (last checked 20 September 2013). 12. iPATH network. See http://www.ipath-network.com/ipath/ (last checked 9 August 2013).
Copyright of Journal of Telemedicine & Telecare is the property of Sage Publications, Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
A hybrid approach to telepathology in Cambodia
Journal of Telemedicine and Telecare 19(8) 475–478 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1357633X13512071 jtt.sagepub.com
Varsha Kadaba1, Tho Ly1, Saqib Noor1, Serey V Chhut2, Nora Hinsch3, Gerhard Stauch4 and James Gollogly1
Summary We established a hybrid telepathology network at the Children’s Surgical Centre (CSC) in Cambodia, based on store-andforward communication using iPATH and videoconferencing using Skype. We retrospectively analysed all data from the CSC stored on the iPATH server and reviewed the patient notes over an 8-month period. Of 115 patients for histopathology diagnosis during the study period, 38 cases were uploaded onto iPATH for further telemedicine discussion. The median number of days it took a specialist, other than the local one, to comment on the case on iPATH was 5 days (range 0–15). In three cases (8%) there was no reply from a specialist on iPATH. During the study period, seven clinical conferences were held, with an average of 6 cases (range 4–7) discussed at each conference. All 38 cases discussed had a final agreed diagnosis and firm management plans were made. Of the 24 cases where proactive management was advised, 17 patients followed through with the recommendations. Although the combination of video consultations and store-and-forward communication has not been used much before in the developing world, it has benefited patient care and outcomes at the CSC. Accepted: 23 September 2013
Introduction The predominant clinical application of telemedicine in developing countries is for second opinions, where difficult cases are discussed with an international community for further advice on diagnosis and management.1 Telemedicine has been used successfully in a number of medical fields, including ophthalmology, dermatology and pediatric neuro-oncology.2 Telemedicine has also been used successfully in Cambodia, with email consultations to rural communities.3,4 A case report from Siem Reap highlighted the success of using an email-based system to resolve a diagnostic problem in collaboration with specialists from the USA.5 There are few reports of videobased consultations in resource poor settings. Telepathology, a subspecialty of telemedicine in which pathology is discussed, has also been utilised in many settings across the developing world.6 Establishing a telepathology network in a resource poor setting can be complicated and so basic web-based/email systems have been used. The iPATH network (the Internet Pathology Suite) is an open access platform designed for discussing medical information in a store-and-forward format.7 The iPATH network has been used successfully in Tanzania,8 the Philippines9 and East Africa.10
Children’s Surgical Centre The Children’s Surgical Centre (CSC) in Phnom Penh is a non-governmental organisation set up to provide
rehabilitative surgery, free of charge, to patients in Cambodia. The aim of the CSC is to provide sustainable and high quality services to its patients.11 Due to the limited number and experience of trained pathologists in Cambodia, it was difficult to obtain accurate diagnoses of bone tumours and unusual pathological conditions in patients who attended the CSC. Often, the histological diagnosis seemed completely different from the radiological and clinical impressions. This problem led the CSC to send glass slide pathology specimens overseas to reliable university laboratories, but as time went on, the possibilities for doing this diminished due to stricter regulations coming into force regarding the transport of biological tissues, and the introduction of computerized tracking of samples in western laboratories. We therefore established a hybrid telepathology network, based on store-and-forward communication using iPATH and videoconferencing using Skype.
1
Children’s Surgical Centre, Phnom Penh, Cambodia Phnom Penh Institute of Pathology, Phnom Penh, Cambodia 3 Department of Pathology, MVZ Lukaskrankenhaus Neuss GmbH, Neuss, Germany 4 Pathaloge Aurich, Aurich, Germany 2
Corresponding author: Varsha Kadaba, Children’s Surgical Centre, Kien Khleang National Rehabilitation Centre, Road 6A, Khan Ruseykeo, Sangkat Chroy Changvar, Phnom Penh, Cambodia. Email: [email protected]
476
Store-and-forward communication Difficult pathology cases presenting to the CSC are selected by a nominated oncology surgeon, and anatomical tissues are sent for histology to a Cambodian laboratory. The slides are prepared using paraffin blocks and cut using a manual microtome. Still images are taken from the slides (1024 pixel resolution, 24 bit colour) and uploaded onto the iPATH network12 along with diagnostic comments and a working diagnosis from a Cambodian general pathologist. Specialists from around the world, who have been invited to join the group, are then notified of each case, and given a chance to comment via the store-and-forward system and provide a second opinion on the cases.
Videoconferencing From October 2012, monthly case conferences have used Skype videoconferencing to discuss, with whoever chooses to join, all the cases uploaded for the month. Before the conferences, participants are able to see all clinical, radiological and pathological data and can make comments on the clinical features, radiology, histology and treatment options for specific clinical cases. Each clinical conference takes place in the conference room at the CSC, usually in the presence of the senior doctors, the pathologist who prepared the slides, and the patients, who can be videoed and demonstrated to all participants. Each case is discussed individually by all attending parties, and the diagnosis and treatment options spelled out for the benefit of all. The workflow is summarised in Figure 1.
Methods We retrospectively analysed all data from the CSC stored on the iPATH server and reviewed the patient notes over an 8-month period (October 2012–May 2013). Demographic details, confirmed histopathology diagnoses, time to the first response on iPATH, number of responses, Skype conference outcome and follow-up data, were evaluated.
Results Of 115 patients for histopathology diagnosis during the study period, 38 cases were uploaded onto iPATH for further telemedicine discussion. During the 8-month study period, seven clinical conferences were held. The average age of the 38 patients (18 female, 20 male) was 36 years (range 2–85). Indications for referral were either treatment queries (22 cases), diagnosis queries (8 cases) or both treatment and diagnosis queries (8 cases). An average of 6 cases (range 4–7) was discussed at each conference. All 38 cases uploaded onto the iPATH server were discussed and definite plans made, taking into account the advice given. At the CSC, all surgical staff and two visiting doctors (pathologist and oncologist), amounting to over 20 people, attended each conference.
Journal of Telemedicine and Telecare 19(8) From abroad, 3–4 experts in the fields of pathology, oncology and orthopaedics were consulted in each case. The range of confirmed histopathological diagnoses is shown in Table 1. The median number of days it took a specialist, other than the local one, to comment on the case on iPATH was 5 days (range 0–15). In three cases (8%) there was no reply from a specialist on iPATH. Those who commented were specialists in the fields of oncology, pathology, radiology and haematology and were located around the world, particularly Europe. There was an average of 10 days between the storeand-forward comments and the Skype videoconference (range 0–34). Following the case discussion and pathology findings, advice on further patient management was discussed at the conference via Skype. Advice was tailored to the setting and facilities available in Cambodia. Plans included advising further surgery, medical and chemotherapy treatment, further diagnostic tests and repeat biopsies, referral to other specialists, or conservative management. The advice given after the case conferences is summarised in Table 2. The clinician in charge of the patient at the CSC made the final decision regarding the care of the patient. The outcomes of the 24 patients where consensus advice suggested a further form of treatment or referral to another institution are shown in Table 3.
Case reports Case 1. A 72-year old male presented to the CSC with a one-year history of right hip pain and difficulty in weight bearing. He described being involved in a road traffic accident one month prior to the onset of hip pain. Clinically, he appeared thin, with a limited range of movement of the right hip and a palpable lymph node in the right groin. Radiographs of the hip revealed an apparent pathological fracture of the right proximal femur. An initial biopsy, however, reported ‘‘reactive fibrosis after a fracture’’. After comments on iPATH there were still uncertainties about the diagnosis because the radiograph appearances did not correlate with the histological opinions. However, in real time discussion and debate with international pathologists at the next case conference, the suggestion was made to histochemically stain further slides with CD20. This was done, and the final diagnosis was confirmed as a pathological fracture through an infiltration of a B cell lymphoma. Despite iPATH store-and-forward communications discussing the case prior to the meeting, it was only through a real time debate that the suggestion for further CD20 staining was made, which effectively led to the correct diagnosis. This example highlights the potential benefit of real time collaboration between healthcare professionals over asynchronous communication methods. Case 2. A 12-year old male presented to the CSC with fever, malaise, bilateral exophthalmia and weakness and stiffness of the jaw. Following medical consultation, a
Kadaba et al.
477
Figure 1. Workflow of the hybrid telemedicine process.
Table 1. Histopathological conditions discussed. Non neoplastic and inflammatory lesions Benign tumours Suture granuloma Hyperostosis Pseudotumor Osteomyelitis Rheumatoid arthritis Non specific arthritis Actinomycosis Tuberculosis
Ameloblastoma Desmoid tumour Nasopharyngeal angiofibroma Schwanoma
Table 2. Advice given after the case conference. Number
Malignant tumours Liposarcoma Melanoma Thyroid carcinoma Burkitt’s lymphoma Hodgkin’s lymphoma Non Hodgkin’s lymphoma Malignant peripheral nerve sheath tumour Ewing sarcoma Pleomorphic sarcoma Chondrosarcoma Osteosarcoma
preliminary diagnosis of melioidosis, an infectious disease caused by a Gram-negative bacterium, Burkholderia pseudomallei, was made and systemic antibiotic therapy was commenced. A biopsy from a lymph node was taken and the case was uploaded onto the iPATH server. An interim pathology report suggested a diagnosis of Burkitt’s lymphoma and at the next conference, the diagnosis was confirmed as stage 4 Burkitt’s lymphoma. Unfortunately, advice from oncologists in Europe suggested a poor prognosis even with a complicated chemotherapy regime, involving more than five chemotherapeutic drugs. After a lengthy discussion between all healthcare professionals in the conference, it was deemed impossible to treat the condition effectively in Cambodia due to lack of chemotherapy agents and funding. His treatment for assumed meliodosis
Requires further surgery and/or chemotherapy Commence antibiotics Referral to another institution Repeat biopsy required Continued observation No further treatment available in Cambodia
14 5 3 2 7 7
Table 3. Patient outcomes. Number Complied with treatment Refused treatment Lost to follow up Died before starting treatment Successful referral (patient attended referral) Unsuccessful referral
14 3 2 1 3 1
was discontinued. The patient died at home about two weeks later. The videoconference in this case allowed the correct diagnosis to be made, incorrect treatment to be stopped, and further treatment options discussed. From an educational perspective, international doctors were able to understand the limitations of Cambodian medicine and local doctors were educated in the diagnosis and treatment of lymphomas.
478
Discussion Prior to the telepathology system, doctors at the CSC did not have a reliable way to ask for advice in difficult cases. Usually, email advice would be sought, perhaps with attached photographs of the X-rays. Occasionally, complicated cases had tissues sent to foreign medical contacts for diagnosis and advice, or visiting doctors at the centre would take tissues home for diagnosis or treatment decisions. As a result, not all patients benefited from the system. The wide range of diagnoses in the present series (Table 1) demonstrates the need for specialist advice and a multidisciplinary approach to these complicated cases. Following the introduction of iPATH, doctors at the CSC have been able to discuss complicated cases with their specialist colleagues from around the world. Anecdotally, the number of cases being discussed has increased compared to the email queries previously. The increased dialogue probably results in firmer management decisions and better documentation. The addition of Skype consultations has clarified the comments made by specialists (which were written in French, English or Italian) and allowed the treatments to be made more relevant to Cambodia, as demonstrated by one of the case reports above. Often, treatment options suggested on the iPATH server were simply not available in Cambodia, and the Skype conferences were useful in explaining this to the participants. Moreover, the cases presented at the CSC were usually quite late in their presentation, and so are often rare in the industrialised world, providing substantial interest for the participating expatriate experts. The combination of video consultations and store-and-forward methods has not been used frequently in the developing world. All 38 cases discussed in the conferences had a final agreed diagnosis and firm management plans were made. Of the 24 cases where proactive management was advised, 17 patients followed through with the recommendations from the conference collaboration. This shows that the hospital was able to use the advice given, even in a resource poor country where medical treatment is often not as advanced or readily available as in an industrialised country. There are logistical challenges to operating a telepathology link. Establishing a network and organising conferences requires a combination of technical resources, adequate technical support and committed healthcare staff to attend the meetings. A cost analysis of this process was not attempted. From a clinical perspective, obtaining full outcome data of patients is often difficult in Cambodia, since patients are easily lost to follow up or
Journal of Telemedicine and Telecare 19(8) difficult to track if they are referred on to different institutions. As a result, an evaluation of changed diagnoses or diagnostic error was not performed. In conclusion, setting up an international telepathology email and videoconferencing syatem has been very useful for the CSC by giving greater clarity to cases and helping to plan treatment. It has unquestionably benefited patient care and outcomes. A prospective study to evaluate its cost-effectiveness needs to be undertaken. Acknowledgements We thank Monika Hubler, administrator of iPATH, Basel, Switzerland, for helping us to organize the Surgical Friends of Cambodia iPATH group and case conferences.
References 1. Wootton R, Bonnardot L. In what circumstances is telemedicine appropriate in the developing world? JRSM Short Rep 2010;1:37. 2. Qaddoumi I, Mansour A, Musharbash A, et al. Impact of telemedicine on pediatric neuro-oncology in a developing country: the Jordanian-Canadian experience. Pediatr Blood Cancer 2007;48:39–43. 3. Heinzelmann PJ, Jacques G, Kvedar JC. Telemedicine by email in remote Cambodia. J Telemed Telecare 2005;11(Suppl. 2):44–7. 4. Brandling-Bennett HA, Kedar I, Pallin DJ, Jacques G, Gumley GJ, Kvedar JC. Delivering health care in rural Cambodia via store-and-forward telemedicine: a pilot study. Telemed J E Health 2005;11:56–62. 5. Froehlich W, Seitaboth S, Chanpheaktra N, Pugatch D. Case report: an example of international telemedicine success. J Telemed Telecare 2009;15:208–10. 6. Weinstein RS, Descour MR, Liang C, et al. Telepathology overview: from concept to implementation. Hum Pathol 2001;32:1283–99. 7. Brauchli K, Oberholzer M. The iPath telemedicine platform. J Telemed Telecare 2005;11(Suppl. 2):3–7. 8. Kru¨ger C, Niemi M. A telemedicine network to support paediatric care in small hospitals in rural Tanzania. J Telemed Telecare 2012;18:59–62. 9. Marcelo A, Fatmi Z, Firaza PN, et al. An online method for diagnosis of difficult TB cases for developing countries. Stud Health Technol Inform 2011;164:168–73. 10. Gimbel DC, Sohani AR, Prasad Busarla SV, et al. A staticimage telepathology system for dermatopathology consultation in East Africa: the Massachusetts General Hospital experience. J Am Acad Dermatol 2012;67:997–1007. 11. Children’s Surgical Centre. See http://www.csc.org (last checked 20 September 2013). 12. iPATH network. See http://www.ipath-network.com/ipath/ (last checked 9 August 2013).
Copyright of Journal of Telemedicine & Telecare is the property of Sage Publications, Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
