Case Study An Albanian Open Source Telemedicine Platform
Gianluca Zangara, MS,1 Francesca Valentino, PhD,1 Gaetano Spinelli,1 Mario Valenza, MD,2 Angelo Marcheggiani, MD,3 and Francesco Di Blasi, PhD1 1
National Research Council, Institute of Biomedicine and Molecular Immunology ‘‘Alberto Monroy,’’ Palermo, Italy. 2 High Specialization Regional Hospital ‘‘Civico-Di Cristina-Benfratelli,’’ Palermo, Italy. 3 Local Health Region of Molise, Campobasso, Italy.
Abstract Introduction: The use of open source technologies to create collaboration platforms can produce huge advantages with small investment. Materials and Methods: We set up a telemedicine network for a healthcare district with typical centralization issues of developing countries. Our network was built using broadband Internet connection, and the digital divide in rural areas was reduced by means of wireless Internet connection. A software infrastructure was deployed on the network to implement the collaboration platform among different healthcare facilities. Results: We obtained an integrated platform with modest investment in hardware and operating systems and no costs for application software. Messaging, content management, information sharing, and videoconferencing are among the available services of the infrastructure. Furthermore, open source software is managed and continuously updated by active communities, making it possible to obtain systems similar to commercial ones in terms of quality and reliability. Conclusions: As the use of free software in public administration is being widely promoted across the European Union, our experience may provide an example to implement similar infrastructures in the field of healthcare and welfare. Key words: telemedicine, open source, network, videoconference, Digital Imaging and Communications in Medicine, Balkans
Introduction
T
elemedicine is the remote delivery of healthcare services and education over a telecommunication infrastructure including consultative and diagnostic services. An acute shortage of medical specialists occurs in many developing countries: available specialists and services are usually concentrated in cities, whereas general practitioners and healthcare workers who serve most of the population operate in rural settings and, consequently, lack specialist support. Those specialists who do practice in rural areas are often isolated from their colleagues. As a result of recent developments in information and communication technologies, new options for telemedicine and, more broadly, for sharing
DOI: 10.1089/tmj.2013.0239
knowledge remotely are becoming increasingly accessible to health workers in developing countries. The Balkans is a peninsula in Eastern Europe bordering the Trieste–Odessa geographic line northward, the Adriatic and the Ionian Sea to the southwest, the Aegean Sea to the southeast, and the Black Sea eastward. As shown by the relatively short history of Yugoslavia, this area is a melting pot of peoples, ethnic groups, languages, and religions that has had a turbulent history. Its territory is highly mountainous, with slopes falling steeply toward the coast and making mobility difficult. Albania is located westward in the Balkans. It is a parliamentary republic quickly emerging from its pre-1990 communist isolation. The Albanian population, composed of Albanians, Greeks, Romanians, Serbs, and Bulgarians, is generally very welcoming, friendly, and generous. The last census estimated that 52% of the population live in urban areas and 48% in rural areas. ‘‘Welfare and Health Cooperation in the Balkans,’’ a European Union–funded project aimed at developing a telemedicine environment in Albania, is included in a set of European Union–funded projects to create the conditions for people to enjoy comfortable standards of living, to have an efficient public healthcare system, and to ensure welfare. A team of the Welfare and Health Cooperation in the Balkans network participated in the project by deploying the telemedicine platform. The solution was built on a network relying on various software modules so as to increase collaboration between physicians and other healthcare staff as well as to empower healthcare users. The system aims at providing medical collaboration between physicians in rural areas and skilled physicians in large medical centers, similar to one previously developed.1 The system developed makes massive use of open source software, thus providing a means to accelerate dissemination of health information systems and reduce software costs. The solution presented is an approach to support health providers in a low-resource environment. Finally, telemedicine in the Balkans is primarily meant to lower costs and enable connectivity by using the state-of-the-art of information and communication technologies to develop complex systems cheaply.
Materials and Methods From early 2009 to 2012, Italian partners developed a telemedicine network to start collaboration between the healthcare facilities and players involved. Universities, hospitals, and regional institutions belong to the partner network. We started by collecting some information from the epidemiological analysis carried out by a project partner. Such information was useful to determine that the Albanian population shows an increasing ratio of chronic diseases and a decreasing ratio of infectious
ª M A R Y A N N LI E B E R T , IN C . VOL. 20
NO. 7 JULY 2014
TELEMEDICINE and e-HEALTH 673
ZANGARA ET AL.
ones, as is the case for any rising state. More specifically, diabetes and heart diseases are their major health issues. Family planning clinics are regional offices that serve each neighborhood in the territory of Shkoder. Besides giving assistance to pregnant women, they provide useful support to the more general public and replace hospitals in some cases. These clinics are a reference point for people with mobility issues and elderly patients who find it difficult to reach regional healthcare centers for periodic examinations. Furthermore, many patients come to clinics at advanced stages of disease, and for many others it is hard to reach healthcare services, as in rural areas.2 The doctor/nurse ratio is very high, with doctors usually having a low level of specialization and nurses being quite versatile. Target structures for this project were the regional Hospital of Scutari and four peripheral clinics. We also extended the network to two health facilities of two villages located in the hinterland at a distance of about 15 km from Shkoder: Postribe and Vau i Dejes. Some medical equipment was installed on the physical network and connected to the local area network. Furthermore, specific telemedicine software was deployed in order to enhance tools for information exchange among healthcare staff. This network allows decreasing centralization of public healthcare service by deploying specialized equipment across the territory and allowing information access to rural areas, as reported in the previous case study.3
(Santa Clara, CA) Xeon quad core and 4 GB RAM. As the server allows virtualization, we installed various services on different virtual machines to build Web servers, network concentrators, and other systems. Because the system was to manage confidential data about patients, each node was provided with a virtual private network (VPN) router that uses Internet protocol (IP)-Security protocol to ensure data privacy. This protocol uses cryptographic algorithms and a couple of private/public keys to establish a connection between two network nodes (commonly called a ‘‘tunnel’’). Communication packets are transparently routed into the tunnel and are safe if intercepted by a malicious user. The VPN was enabled by Cisco Systems (San Jose, CA) hardware, with a central VPN concentrator and several VPN clients in other sites (Fig. 1). Each healthcare facility was provided with a videoconferencingenabled workstation, a voice over IP phone, and a multifunction printer plus some extra medical devices. In fact, many of them were equipped with old workstations and did not have Internet access. At this stage, our aim was to supply the health facilities involved with a multimedia station allowing wide access to text/audio/video communication services. Furthermore, we decided to provide one clinic with a portable electrocardiograph. The device allows recording the electrical activity of the heart over a period of time, detected by electrodes
NETWORK The network was deployed across the city of Shkoder, embracing its Regional Hospital, four peripheral clinics, and a data center. Albanian territories are subject to the digital divide: whereas cities are equipped with the latest information and communication technologies and broadband Internet access via optical fiber, rural municipalities have ordinary public switched telephone network access or general packet radio service cellular network. Public switched telephone network and general packet radio service technologies allow low-band communication at a maximum bitrate of approximately 54 kilobits/s. Hence, in order to reach the nearby towns situated in the digital divide zone, 15 km away from the city, we used a wireless broadband access, allowing 10 megabits bidirectional throughput. Necessary software was installed in the central node of the network, located in the Shkoder city center, with a symmetric 20-megabit fiber optic Internet connection and a server with Intel
Fig. 1. Network chart. EKG, electrocardiogram; VOIP, voice over INternet protocol.
674 TELEMEDICINE and e-HEALTH J U L Y 2 0 1 4
TELEMEDICINE PLATFORM WITH OPEN SOURCE SOFTWARE
attached to the skin that send perceived signals to an external device. The electrocardiogram is a noninvasive test that records the activity of the heart and is useful for detecting heart diseases. The portable electrocardiograph is equipped with an Ethernet port that allows users to send test results to a workstation by the local area network network in real time, or afterward in the case of remote diagnosis. Once test results are uploaded into the telemedicine portal, the system arranges for specialist referral by making an appointment via a ticket or live chat. Specialists can access documents stored in patients’ file and exchange information with the referring physician by means of a messaging or a videoconferencing system. Another project partner also provided an ultrasound scanner. This device allows connection to a transmission control protocol/IP network via an Ethernet cable and communicate via the Digital Imaging and Communications in Medicine (DICOM) standard. DICOM defines a standard for medical images and a communication protocol that uses a transmission control protocol port to connect to scanners, printers, workstations, and medical devices in order to transmit highdefinition images.
SOFTWARE After the network was deployed and the hardware was supplied, the most important step was to provide the whole system with appropriate software to enable connectivity and enhance collaboration. Instead of buying software, we decide to install, configure, and customize some freely available software.
With the open source model, users do not have to pay a license to use software, and, frequently, the modifiable source code to add capabilities or integrate into their own systems is included. We set up the system on an open framework based on a Debian Linux operating system with a 2.6.· kernel, an Apache Web server version 2.0 configured with PHP version 5 scripting support, and a MySQL version 5.5 database server. The MySQL database management system stores the data of the collaboration platform, the public portal, the videoconferencing platform, and the medical files generated by connected equipment. Software was designed to enable healthcare staff to manage patient records and share data about patient exams when referring to specialists through advanced communication facilities. It was developed from scratch in PHP language by only using some frameworks for jQuery support (Fig. 2). A public portal was designed in compliance with the Patient Web Empowerment Index (PWEI) creation guidelines.4 The PWEI was developed considering the patient as a customer for the healthcare system. As in any business, ‘‘empowering’’ a customer is a goal to reach to ensure efficient service. The PWEI is a multidimensional index that combines eight weighted subindexes. These indexes define some features that a software, mainly a Web site, should have so as to increase user involvement, namely, Web site usability and accessibility (i.e., the information available about clinical data, clinical treatments, and devices used in healthcare facilities). The public portal was created using a Joomla! (OpenSourceMatters, New York, NY) version 2.5 content management system. It has a plug-in and a module management system to add several features. Major features of the system (Fig. 3) are: .
.
.
.
.
The purpose of a telemedicine collaboration module is to help manage a patient registry by storing personal, history, and diagnosis data, as users can attach various files associated with the patient into the registry. For
Fig. 2. Screenshot of the telemedicine portal: patient file management.
ª M A R Y A N N L I E B E R T , I N C . VOL. 20
multilanguage support for automatic translation of contents via Google (Mountain View, CA) Translate a contact page, including telephone numbers and a list of physicians’ e-mail addresses a standard of living guidelines page a list of medical devices and diagnostic tools in use at health facilities a collection of useful Web links.
NO. 7 JULY 2014
TELEMEDICINE and e-HEALTH 675
ZANGARA ET AL.
placed in the same local area network. When data are uploaded, the user is asked to input the patient’s data too, so that the system can enter such data into a specific patient’s file. In order to enable easy and effective communication between physicians,5 we set up a low-cost videoconferencing platform (Fig. 4) to dynamically generate chat rooms with up to 10 users. We used an OpenTok open source platform. Further developments of this platform will be presented elsewhere, and, more specifically, it will be available for tablet devices and smartphones with Android (Google) and Apple (Cupertino, CA) iOS operating systems. Vis-a`-vis Skype (a division of Microsoft, Palo Alto, CA) or other software, the system’s main advantage lies in that there is no need to install client-side software for videoconferencing. The only prerequisite is the presence of a Web browser and a microphone and/or a Webcam.
Fig. 3. Screenshot of the telemedicine portal: public user access.
instance, such a module makes it possible to receive an electrocardiogram output via a file upload mechanism. Moreover, the system could also be used to share ultrasound scans collected by a Conquest DICOM server. Indeed, an ultrasound scanner was configured to connect to the local area network via an IPv4 protocol. A function in the settings of a DICOM server permits setting its IP address so as to send an ultrasound scan when a user presses the ‘‘Store’’ or the ‘‘Print’’ button. More specifically, the ‘‘Store’’ button is for saving images in the local hard drive, whereas the ‘‘Print’’ one is to use the in-built printer. A DICOM server, which accepts inputs from other users, is
Results
During the infrastructure deployment, 10 h of on-site training courses was done for healthcare personnel, during which we have collected feedback on the platform and have revised some aspects to make software more suitable. Users tested the software for a 6-month trial, during which they tried to load data and request collaboration sessions via the videochat and message platform. Specifically, health center physicians many times have requested a second opinion from Italian expert physicians for gynecological and cardiac diagnoses. In a case, during a test session, the second opinion detected that a pregnant girl had a rare pathology in her fetus. In some cases, a second opinion was requested and done via the real-time videoconferencing system. Otherwise, Albanian physicians entered a ticket in the asynchronous messaging system, attaching diagnosis data, and got a response from experts in a few hours. The software is currently used in health centers, and it is desirable that in the next funded projects, other facilities are aggregated to this infrastructure, and the infrastructure itself can be expanded with other medical network-connected devices. Because of the difficult mobility over Fig. 4. Screenshot of the telemedicine portal: videoconferencing system. territories, healthcare workers appreciate
676 TELEMEDICINE and e-HEALTH J U L Y 2 0 1 4
TELEMEDICINE PLATFORM WITH OPEN SOURCE SOFTWARE
the use of mobile devices to enable platform access from anywhere. The use of open source software permits costs to be cut on software, still ensuring high-quality and efficient software modules, like enterprise class solutions. The use of open source software abided by Italian guidelines on software adoption by public institutions. The whole project was successfully developed with extremely limited financial resources. We have deployed a fully functional infrastructure. The telemedicine platform combines asynchronous communication services with real-time communication, thus allowing the better collaboration.
Acknowledgments This project was funded under Act 329 of 08/08/2007 of the Sicilian Region, which obtained funds from the Framework Programme for Western Balkans.
Disclosure Statement No competing financial interests exist.
REFERENCES
Discussion In the present study, we used some of the major collaborative technologies to enhance collaboration among healthcare staff and empower patients. Telemedicine tools play a key role in improving quality and efficiency of healthcare systems even in developing countries, as they offer new channels for communication and collaboration and enable dematerialization of several processes that are usually hindered by deficient physical infrastructures. Nevertheless, they also involve some risks, particularly in regard to the exchange of inappropriate or inadequate information, as well as potential malfunctioning due to any local digital divide between cities and rural areas. However, the digital divide can be reduced by using wireless technologies in accordance with local regulations on digital wireless communication, and the exchange of information can be restrained by using appropriate data validation in software. Telemedicine systems are mainly used to bring down healthcare costs, first by helping physicians not to move from place to place. As Albanian territories are mountainous, mobility is very difficult not only across rural areas, but also in cities. Moreover, because the Albanian healthcare system relies on limited human resources, time saving is an effective strategy to save money. However, this system was developed with open source technologies, ensuring cheap software modules that are very competitive and similar to commercial software. The use of open source software modules and technologies also means that they are continuously updated and maintained by the community to ensure a high level of safety and innovation. This system was appreciated by our Italian partners, who wish to adopt some of the technologies used within regional healthcare systems across Italy.
1. Pek E, Loncaric S, Margan A. Internet-based medical teleconsultation system. In: Proceedings of the 2nd International Symposium on Image and Signal Processing and Analysis, 2001. ISPA 2001. Piscataway, NJ: IEEE, 2001: 657–661. 2. Maia RS, von Wangenheim A, Nobre LF. A statewide telemedicine network for public health in Brazil. In: Proceedings of the 19th IEEE Symposium on Computer-Based Medical Systems (CBMS ’06). Piscataway, NJ: IEEE Computer Society, 2006:495–500. 3. Brauchli K, O’Mahony D, Banach L, Oberholzer M. iPath—A telemedicine platform to support health providers in low resource settings. Stud Health Technol Inform 2005;114:11–17. 4. Buccoliero L, Bellio E, Prenestini A. Patient Web Empowerment Index (PWEI): An index for assessment of healthcare providers’ web strategies. Case study: PWEI application in Italy. Stud Health Technol Inform 2010;160:38–42. 5. Gori A, Taddei A, Mota D, Rocca E, Carducci T, Piccini G, Ciregia A, Marcheschi P, Assanta N, Murzi B, Ricci G. Open-source teleconsulting system for international cooperative medical decision making in congenital heart diseases. In: Computing in Cardiology, 2010. Piscataway, NJ: IEEE, 2010;481–484.
Address correspondence to: Gianluca Zangara, MS Istituto di Biomedicina ed Immunologia Molecolare ‘‘A. Monroy’’ via Ugo La Malfa 153 90123, Palermo Italy
ª M A R Y A N N L I E B E R T , I N C . VOL. 20
E-mail: [email protected] Received: July 9, 2013 Revised: October 10, 2013 Accepted: October 14, 2013
NO. 7 JULY 2014
TELEMEDICINE and e-HEALTH 677
Gianluca Zangara, MS,1 Francesca Valentino, PhD,1 Gaetano Spinelli,1 Mario Valenza, MD,2 Angelo Marcheggiani, MD,3 and Francesco Di Blasi, PhD1 1
National Research Council, Institute of Biomedicine and Molecular Immunology ‘‘Alberto Monroy,’’ Palermo, Italy. 2 High Specialization Regional Hospital ‘‘Civico-Di Cristina-Benfratelli,’’ Palermo, Italy. 3 Local Health Region of Molise, Campobasso, Italy.
Abstract Introduction: The use of open source technologies to create collaboration platforms can produce huge advantages with small investment. Materials and Methods: We set up a telemedicine network for a healthcare district with typical centralization issues of developing countries. Our network was built using broadband Internet connection, and the digital divide in rural areas was reduced by means of wireless Internet connection. A software infrastructure was deployed on the network to implement the collaboration platform among different healthcare facilities. Results: We obtained an integrated platform with modest investment in hardware and operating systems and no costs for application software. Messaging, content management, information sharing, and videoconferencing are among the available services of the infrastructure. Furthermore, open source software is managed and continuously updated by active communities, making it possible to obtain systems similar to commercial ones in terms of quality and reliability. Conclusions: As the use of free software in public administration is being widely promoted across the European Union, our experience may provide an example to implement similar infrastructures in the field of healthcare and welfare. Key words: telemedicine, open source, network, videoconference, Digital Imaging and Communications in Medicine, Balkans
Introduction
T
elemedicine is the remote delivery of healthcare services and education over a telecommunication infrastructure including consultative and diagnostic services. An acute shortage of medical specialists occurs in many developing countries: available specialists and services are usually concentrated in cities, whereas general practitioners and healthcare workers who serve most of the population operate in rural settings and, consequently, lack specialist support. Those specialists who do practice in rural areas are often isolated from their colleagues. As a result of recent developments in information and communication technologies, new options for telemedicine and, more broadly, for sharing
DOI: 10.1089/tmj.2013.0239
knowledge remotely are becoming increasingly accessible to health workers in developing countries. The Balkans is a peninsula in Eastern Europe bordering the Trieste–Odessa geographic line northward, the Adriatic and the Ionian Sea to the southwest, the Aegean Sea to the southeast, and the Black Sea eastward. As shown by the relatively short history of Yugoslavia, this area is a melting pot of peoples, ethnic groups, languages, and religions that has had a turbulent history. Its territory is highly mountainous, with slopes falling steeply toward the coast and making mobility difficult. Albania is located westward in the Balkans. It is a parliamentary republic quickly emerging from its pre-1990 communist isolation. The Albanian population, composed of Albanians, Greeks, Romanians, Serbs, and Bulgarians, is generally very welcoming, friendly, and generous. The last census estimated that 52% of the population live in urban areas and 48% in rural areas. ‘‘Welfare and Health Cooperation in the Balkans,’’ a European Union–funded project aimed at developing a telemedicine environment in Albania, is included in a set of European Union–funded projects to create the conditions for people to enjoy comfortable standards of living, to have an efficient public healthcare system, and to ensure welfare. A team of the Welfare and Health Cooperation in the Balkans network participated in the project by deploying the telemedicine platform. The solution was built on a network relying on various software modules so as to increase collaboration between physicians and other healthcare staff as well as to empower healthcare users. The system aims at providing medical collaboration between physicians in rural areas and skilled physicians in large medical centers, similar to one previously developed.1 The system developed makes massive use of open source software, thus providing a means to accelerate dissemination of health information systems and reduce software costs. The solution presented is an approach to support health providers in a low-resource environment. Finally, telemedicine in the Balkans is primarily meant to lower costs and enable connectivity by using the state-of-the-art of information and communication technologies to develop complex systems cheaply.
Materials and Methods From early 2009 to 2012, Italian partners developed a telemedicine network to start collaboration between the healthcare facilities and players involved. Universities, hospitals, and regional institutions belong to the partner network. We started by collecting some information from the epidemiological analysis carried out by a project partner. Such information was useful to determine that the Albanian population shows an increasing ratio of chronic diseases and a decreasing ratio of infectious
ª M A R Y A N N LI E B E R T , IN C . VOL. 20
NO. 7 JULY 2014
TELEMEDICINE and e-HEALTH 673
ZANGARA ET AL.
ones, as is the case for any rising state. More specifically, diabetes and heart diseases are their major health issues. Family planning clinics are regional offices that serve each neighborhood in the territory of Shkoder. Besides giving assistance to pregnant women, they provide useful support to the more general public and replace hospitals in some cases. These clinics are a reference point for people with mobility issues and elderly patients who find it difficult to reach regional healthcare centers for periodic examinations. Furthermore, many patients come to clinics at advanced stages of disease, and for many others it is hard to reach healthcare services, as in rural areas.2 The doctor/nurse ratio is very high, with doctors usually having a low level of specialization and nurses being quite versatile. Target structures for this project were the regional Hospital of Scutari and four peripheral clinics. We also extended the network to two health facilities of two villages located in the hinterland at a distance of about 15 km from Shkoder: Postribe and Vau i Dejes. Some medical equipment was installed on the physical network and connected to the local area network. Furthermore, specific telemedicine software was deployed in order to enhance tools for information exchange among healthcare staff. This network allows decreasing centralization of public healthcare service by deploying specialized equipment across the territory and allowing information access to rural areas, as reported in the previous case study.3
(Santa Clara, CA) Xeon quad core and 4 GB RAM. As the server allows virtualization, we installed various services on different virtual machines to build Web servers, network concentrators, and other systems. Because the system was to manage confidential data about patients, each node was provided with a virtual private network (VPN) router that uses Internet protocol (IP)-Security protocol to ensure data privacy. This protocol uses cryptographic algorithms and a couple of private/public keys to establish a connection between two network nodes (commonly called a ‘‘tunnel’’). Communication packets are transparently routed into the tunnel and are safe if intercepted by a malicious user. The VPN was enabled by Cisco Systems (San Jose, CA) hardware, with a central VPN concentrator and several VPN clients in other sites (Fig. 1). Each healthcare facility was provided with a videoconferencingenabled workstation, a voice over IP phone, and a multifunction printer plus some extra medical devices. In fact, many of them were equipped with old workstations and did not have Internet access. At this stage, our aim was to supply the health facilities involved with a multimedia station allowing wide access to text/audio/video communication services. Furthermore, we decided to provide one clinic with a portable electrocardiograph. The device allows recording the electrical activity of the heart over a period of time, detected by electrodes
NETWORK The network was deployed across the city of Shkoder, embracing its Regional Hospital, four peripheral clinics, and a data center. Albanian territories are subject to the digital divide: whereas cities are equipped with the latest information and communication technologies and broadband Internet access via optical fiber, rural municipalities have ordinary public switched telephone network access or general packet radio service cellular network. Public switched telephone network and general packet radio service technologies allow low-band communication at a maximum bitrate of approximately 54 kilobits/s. Hence, in order to reach the nearby towns situated in the digital divide zone, 15 km away from the city, we used a wireless broadband access, allowing 10 megabits bidirectional throughput. Necessary software was installed in the central node of the network, located in the Shkoder city center, with a symmetric 20-megabit fiber optic Internet connection and a server with Intel
Fig. 1. Network chart. EKG, electrocardiogram; VOIP, voice over INternet protocol.
674 TELEMEDICINE and e-HEALTH J U L Y 2 0 1 4
TELEMEDICINE PLATFORM WITH OPEN SOURCE SOFTWARE
attached to the skin that send perceived signals to an external device. The electrocardiogram is a noninvasive test that records the activity of the heart and is useful for detecting heart diseases. The portable electrocardiograph is equipped with an Ethernet port that allows users to send test results to a workstation by the local area network network in real time, or afterward in the case of remote diagnosis. Once test results are uploaded into the telemedicine portal, the system arranges for specialist referral by making an appointment via a ticket or live chat. Specialists can access documents stored in patients’ file and exchange information with the referring physician by means of a messaging or a videoconferencing system. Another project partner also provided an ultrasound scanner. This device allows connection to a transmission control protocol/IP network via an Ethernet cable and communicate via the Digital Imaging and Communications in Medicine (DICOM) standard. DICOM defines a standard for medical images and a communication protocol that uses a transmission control protocol port to connect to scanners, printers, workstations, and medical devices in order to transmit highdefinition images.
SOFTWARE After the network was deployed and the hardware was supplied, the most important step was to provide the whole system with appropriate software to enable connectivity and enhance collaboration. Instead of buying software, we decide to install, configure, and customize some freely available software.
With the open source model, users do not have to pay a license to use software, and, frequently, the modifiable source code to add capabilities or integrate into their own systems is included. We set up the system on an open framework based on a Debian Linux operating system with a 2.6.· kernel, an Apache Web server version 2.0 configured with PHP version 5 scripting support, and a MySQL version 5.5 database server. The MySQL database management system stores the data of the collaboration platform, the public portal, the videoconferencing platform, and the medical files generated by connected equipment. Software was designed to enable healthcare staff to manage patient records and share data about patient exams when referring to specialists through advanced communication facilities. It was developed from scratch in PHP language by only using some frameworks for jQuery support (Fig. 2). A public portal was designed in compliance with the Patient Web Empowerment Index (PWEI) creation guidelines.4 The PWEI was developed considering the patient as a customer for the healthcare system. As in any business, ‘‘empowering’’ a customer is a goal to reach to ensure efficient service. The PWEI is a multidimensional index that combines eight weighted subindexes. These indexes define some features that a software, mainly a Web site, should have so as to increase user involvement, namely, Web site usability and accessibility (i.e., the information available about clinical data, clinical treatments, and devices used in healthcare facilities). The public portal was created using a Joomla! (OpenSourceMatters, New York, NY) version 2.5 content management system. It has a plug-in and a module management system to add several features. Major features of the system (Fig. 3) are: .
.
.
.
.
The purpose of a telemedicine collaboration module is to help manage a patient registry by storing personal, history, and diagnosis data, as users can attach various files associated with the patient into the registry. For
Fig. 2. Screenshot of the telemedicine portal: patient file management.
ª M A R Y A N N L I E B E R T , I N C . VOL. 20
multilanguage support for automatic translation of contents via Google (Mountain View, CA) Translate a contact page, including telephone numbers and a list of physicians’ e-mail addresses a standard of living guidelines page a list of medical devices and diagnostic tools in use at health facilities a collection of useful Web links.
NO. 7 JULY 2014
TELEMEDICINE and e-HEALTH 675
ZANGARA ET AL.
placed in the same local area network. When data are uploaded, the user is asked to input the patient’s data too, so that the system can enter such data into a specific patient’s file. In order to enable easy and effective communication between physicians,5 we set up a low-cost videoconferencing platform (Fig. 4) to dynamically generate chat rooms with up to 10 users. We used an OpenTok open source platform. Further developments of this platform will be presented elsewhere, and, more specifically, it will be available for tablet devices and smartphones with Android (Google) and Apple (Cupertino, CA) iOS operating systems. Vis-a`-vis Skype (a division of Microsoft, Palo Alto, CA) or other software, the system’s main advantage lies in that there is no need to install client-side software for videoconferencing. The only prerequisite is the presence of a Web browser and a microphone and/or a Webcam.
Fig. 3. Screenshot of the telemedicine portal: public user access.
instance, such a module makes it possible to receive an electrocardiogram output via a file upload mechanism. Moreover, the system could also be used to share ultrasound scans collected by a Conquest DICOM server. Indeed, an ultrasound scanner was configured to connect to the local area network via an IPv4 protocol. A function in the settings of a DICOM server permits setting its IP address so as to send an ultrasound scan when a user presses the ‘‘Store’’ or the ‘‘Print’’ button. More specifically, the ‘‘Store’’ button is for saving images in the local hard drive, whereas the ‘‘Print’’ one is to use the in-built printer. A DICOM server, which accepts inputs from other users, is
Results
During the infrastructure deployment, 10 h of on-site training courses was done for healthcare personnel, during which we have collected feedback on the platform and have revised some aspects to make software more suitable. Users tested the software for a 6-month trial, during which they tried to load data and request collaboration sessions via the videochat and message platform. Specifically, health center physicians many times have requested a second opinion from Italian expert physicians for gynecological and cardiac diagnoses. In a case, during a test session, the second opinion detected that a pregnant girl had a rare pathology in her fetus. In some cases, a second opinion was requested and done via the real-time videoconferencing system. Otherwise, Albanian physicians entered a ticket in the asynchronous messaging system, attaching diagnosis data, and got a response from experts in a few hours. The software is currently used in health centers, and it is desirable that in the next funded projects, other facilities are aggregated to this infrastructure, and the infrastructure itself can be expanded with other medical network-connected devices. Because of the difficult mobility over Fig. 4. Screenshot of the telemedicine portal: videoconferencing system. territories, healthcare workers appreciate
676 TELEMEDICINE and e-HEALTH J U L Y 2 0 1 4
TELEMEDICINE PLATFORM WITH OPEN SOURCE SOFTWARE
the use of mobile devices to enable platform access from anywhere. The use of open source software permits costs to be cut on software, still ensuring high-quality and efficient software modules, like enterprise class solutions. The use of open source software abided by Italian guidelines on software adoption by public institutions. The whole project was successfully developed with extremely limited financial resources. We have deployed a fully functional infrastructure. The telemedicine platform combines asynchronous communication services with real-time communication, thus allowing the better collaboration.
Acknowledgments This project was funded under Act 329 of 08/08/2007 of the Sicilian Region, which obtained funds from the Framework Programme for Western Balkans.
Disclosure Statement No competing financial interests exist.
REFERENCES
Discussion In the present study, we used some of the major collaborative technologies to enhance collaboration among healthcare staff and empower patients. Telemedicine tools play a key role in improving quality and efficiency of healthcare systems even in developing countries, as they offer new channels for communication and collaboration and enable dematerialization of several processes that are usually hindered by deficient physical infrastructures. Nevertheless, they also involve some risks, particularly in regard to the exchange of inappropriate or inadequate information, as well as potential malfunctioning due to any local digital divide between cities and rural areas. However, the digital divide can be reduced by using wireless technologies in accordance with local regulations on digital wireless communication, and the exchange of information can be restrained by using appropriate data validation in software. Telemedicine systems are mainly used to bring down healthcare costs, first by helping physicians not to move from place to place. As Albanian territories are mountainous, mobility is very difficult not only across rural areas, but also in cities. Moreover, because the Albanian healthcare system relies on limited human resources, time saving is an effective strategy to save money. However, this system was developed with open source technologies, ensuring cheap software modules that are very competitive and similar to commercial software. The use of open source software modules and technologies also means that they are continuously updated and maintained by the community to ensure a high level of safety and innovation. This system was appreciated by our Italian partners, who wish to adopt some of the technologies used within regional healthcare systems across Italy.
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Address correspondence to: Gianluca Zangara, MS Istituto di Biomedicina ed Immunologia Molecolare ‘‘A. Monroy’’ via Ugo La Malfa 153 90123, Palermo Italy
ª M A R Y A N N L I E B E R T , I N C . VOL. 20
E-mail: [email protected] Received: July 9, 2013 Revised: October 10, 2013 Accepted: October 14, 2013
NO. 7 JULY 2014
TELEMEDICINE and e-HEALTH 677
