EMISPHER and the Virtual Euro-Mediterranean Hospital (VEMH) as Best Practice for Bridging the Digital Divide in Healthcare

G. Graschew, T.A. Roelofs, S. Rakowsky, P.M. Schlag

Surgical Research Unit OP 2000, Max-Delbrueck-Centrum and Robert-Roessle-Klinik, Charité – University Medicine Berlin, Lindenberger Weg 80, 13125 Berlin, Germany Email: graschew@mdc-berlin.de, Phone: +49 30 9417 1630, Fax: +49 30 9406 3405

Abstract: EMISPHER (Euro-Mediterranean Internet-Satellite Platform for Health, medical Education and Research) has successfully implemented an internet-satellite platform with 10 sites in the Euro-Mediterranean region. Based on EMISPHER the Virtual Euro-Mediterranean Hospital (VEMH) aims to facilitate the interconnection of the various services through real integration. This integration must take into account the social, human and cultural dimensions. VEMH will include the EU, its neighbours in the South and the East and will put special emphasis on the New EU Member States and the Associated Candidate Countries. VEMH will provide a heterogeneous integrated platform combining satellite links and terrestrial links for a wide range of medical services. Yet, the methodologies for the VEMH are medical-needs-driven instead of technology-driven. Through fellowship programmes VEMH will invest in a new generation of young physicians able to work with different needs and in cultures.

Keywords: Digital Divide, telemedicine, e-learning, satellite communication, terrestrial communication, integrated platform

1. Introduction

   Telemedicine aims at equal access to medical expertise irrespective of the geographical location of the person in need. New developments in Information and Communication Technologies (ICT) have enabled the transmission of medical images in sufficiently high quality that allows for a reliable diagnosis to be determined by the expert at the receiving site [1-3].
   At the same time, however, these innovative developments in ICT over the last decade bear the risk of creating and amplifying a digital divide in the world, creating a disparity between the north and the south and the west and the east.
   The digital divide in the field of health care has a direct impact in the daily life of the citizens and on their quality of life. In recent years, different institutions have launched several Euro-Mediterranean telemedicine projects [4-6]. All of them aimed to encourage the Euro-Mediterranean cooperation between the European member states and the Mediterranean Countries (Syria, Palestinian Authority, Jordan, Lebanon, Israel, Tunisia, Morocco, Egypt, Libya, Algeria, Turkey).
   All these projects have demonstrated how the digital divide is only a part of a more complex problem, the need for integration. Therefore, provision of the same advanced technologies to the European, to the Mediterranean and to the Adhering Countries (Poland, Malta, Cyprus, Hungary, Slovenia, Czech Republic, Estonia, Lithuania, Leetonia, Slovakia) should be the final goal for contributing to their better dialogue for integration.
   Due to the experience in the exploitation of previous European telemedicine projects and, in particular to activities carried out in the framework of the EUMEDIS programme, an open Euro-Mediterranean consortium would like to propose the VEMH initiative.
   

2. From EMISPHER towards the VEMH

   2.1. The EMISPHER Network for Telemedical Applications
   As part of the EC-funded EUMEDIS programme, EMISPHER (Euro-Mediterranean Internet-Satellite Platform for Health, medical Education and Research, 1.9.2002-31.12.2004, www.emispher.org) has successfully implemented an internet-satellite platform with 10 sites in the Euro-Mediterranean region (Morocco, Algeria, Tunisia, Egypt, Turkey, Cyprus, Greece, Italy, France and Germany) [7] (see Fig. 1) hosting various services in the fields of real-time Telemedicine, medical E-Learning and medical assistance.
   EMISPHER’s achievements were officially qualified by experts from the EC as best practice for eHealth and eLearning and were recommended as key element for the Virtual Euro-Mediterranean Hospital – VEMH.
   

   
   Fig. 1. Centers of Excellence in the EMISPHER project interconnected by a satellite-based network for bridging the digital divide in the Euro-Mediterranean healthcare area.
   
   2.2 Virtual Euro-Mediterranean Hospital Services

   VEMH goals. VEMH aims to facilitate and accelerate the interconnection and interoperability of the various services being developed (by different organisation at different sites) through real integration. This integration must take into account the social, human and cultural dimensions; that strive towards common approaches but open and respectful of cultural differences: multi-lateral cooperation instead of aid. VEMH is not only to justify and demonstrate telemedical demands in the Mediterranean area but also to integrate the medical expertise in this region and to assist the transfer of “know how” from the north to the south and from the west to the east.
   VEMH is dedicated to bridging such a digital divide by establishing high quality equal access to real-time and on-line services for healthcare for all of the countries of the Euro-Mediterranean area. Tele-consultation between experts and referring doctors contributes to improved patient care through recommendations for new treatment and timely access to specialist knowledge. VEMH will provide a heterogeneous integrated platform consisting of a satellite link, such as in the EMISPHER project, and a terrestrial link (GEANT, EUMEDCONNECT) for the application of various medical services, such as medical e-learning, real-time telemedicine and medical assistance. Evidence Based Medicine (EBM) will be more and more integrated in these three main dedicated medical services. VEMH would also like to benefit from the results and experience of different cooperation projects such as EMISPHER, BURNET, PARADIGMA, EMPHIS, EUMEDGEN, ODISEAME, EUMEDCONNECT and GALENOS. VEMH services and activities:

   • Mediterranean Medical University,
   • Real-time telemedicine,
   • Medical assistance,
   • Fellowship programme.
   
   E-learning. In the project the Mediterranean Medical University (MeMU) will be developed. The leading medical centres integrated in the network provide pedagogical material and modules for synchronous and asynchronous e-learning in their medical specialities: endoscopic surgery, gynaecol_ ogy-obstetrics, reproductive medicine, infections diseases, interventional radiology, liver and multi-organ transplantation, tumour diagnosis and therapy, etc. The central gateway to MeMU is an integrated satellite- and terrestrial-based platform and will provide the users with access to various contents in the network and support the participation in real-time e-learning events (see Fig. 2).
   
   Fig. 2. e-Learning session with transmission of live ultrasound videos from Charité (Berlin) to Ain Shams University (Cairo), Agence Nationale de Documentation de la Sante (Algiers), Faculte de Medicine et de Pharmacie (Casablanca) and University of Cyprus (Nicosia).
   The exchange between the partners of various countries and availability of standardised educational modules allows for improved qualification of undergraduate and graduate students, hospital staff, general practitioners, healthcare officers and other professionals in the medical field.
   
   

   Real-time telemedicine. VEMH will offer second opinion, tele-teaching & tele-training (demonstration and spread of new techniques), tele-mentoring (enhancement of staff qualification), undergraduate teaching courses, optimisation of the learning curve as categories of applications.
   The leading medical centres in the project provide expertise in the medical fields of open and minimally-invasive surgery, multi-organ transplant- tation, endoscopy, pathology, radiology, interven- tional imaging, infectious diseases, oncology, gynaecology and obstetrics, reproductive medicine and emergency and disaster medicine.
   These real-time interactive tele-medical applications contribute to improved quality of patient care and to accelerated qualification of medical doctors in their respective speciality (see Figs. 3 and 4). Thus, this international network of distributed but integrated competence contributes directly and indirectly to improved

   
   Fig. 3. Interactive multipoint tele-consultation during laparoscopy (Charité (Berlin), Ain Shams University (Cairo), University of Cyprus (Nicosia) in the EMISPHER project.
   

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   Fig. 4. Second Opinion during a telepathological consultation between Charité (Berlin) and Faculte de Medicine et de Pharmacie (Casablanca).
   Medical assistance. As tourism constitutes a substantial economical factor in the Mediterranean region and because of the increasing mobility of the population, continuity of care through improved medical assistance is of major importance for improved healthcare in the Euro-Mediterranean region. The introduction of standardised procedures, integration of the platform with the various local and national communication systems, and training of the medical staff involved in medical assistance allow for shared management of files related to medical assistance (medical images, diagnosis, workflow, financial management, etc.) and thus for improved care for travellers and expatriates in the Euro-Mediterranean region.
   The next service in VEMH will be the Evidence-Based Medicine (EBM). EBM cannot substitute the agreement on concrete and individual therapeutic procedures to be followed; however, even for the individual patient EBM provides a more solid base for individual decisions. EBM contributes to better disease management. Health care policy makers can also expect great potential from EBM.
   Fellowship programme. VEMH will offer individual grants to 20 young medical doctors coming from the Mediterranean and from accession countries. Each fellow will be trained, for a minimum period of 18 months, in one of field of the MeMU trough the tele-teaching and tele-training VEMH services. This training programme will include an internship period in some of the clinical and scientific institutions of the VEMH consortium. The VEMH faculty will constantly monitor the progresses of the fellows and will evaluate them at the end of the training period.
   The scope of the fellowship programme is to allow young medical doctors to develop and gain experience in a multicultural and multidisciplinary environment. This will facilitate the creation of a new generation of physicians that are able to understand and work with different needs and cultures. The fellowship programme is a major component for the real integration among all the countries.
   

3. Methodology and System Architecture of VEMH
   

   3.1. Improvement of the methodology in the VEMH medical network of competence

   VEMH medical networks enable:

   • management of the clinical outcomes, integration of different telemedical solutions in one platform to support many different medical applications (matrix structure):
     • individualisation of the user needs per country (contents as matrix columns);
     • applications with integrated technological solutions (contents as matrix rows).
   Selection criteria: Low access costs.
   

   3.2. Properties of the VEMH distributed medical networks

   VEMH modular networks have the following properties: modular network:

   • integration and optimisation of various applications;
   • developed new methodologies and applications should be useable for more than one disease.
   Optimization criteria: from technique-oriented towards medical-need-oriented solutions.
   

   3.3 Data Security

   Security of data will be assured by the fact that the communication system adopts a coding algorithm owned by members of the Consortium. The transmitted data can only be decoded by this software. As one of the members of the Consortium owns the software licences, this provides an initial level of data security through the license distribution and management. During the course of the project an additional 128 kbit security key will be implemented to differentiate between different (parts of the) networks, as required.
   

   3.4. Data Privacy

   Privacy will be assured during the validation project simply by the fact that anonymous examinations will be done, and the patient will be identified only with an ID code. However when the service is deployed, the guarantees of privacy will be given by the data security system. This system will ensure that a comprehensive set of controls comprising best practices in information security are used by the service.
   

4. Evaluation of the VEMH

   The justification of the various VEMH services and applications will be assessed by using a com- prehensive evaluation methodology. This will in particular examine various outcomes including clinical, organisational, and economic as well as other relevant outcomes. The criteria under which such services can be evaluated are based upon the work of Bashshur [8]. The rationale for using this type of methodology is to ensure that the services or applications are capable of having an immediate and positive impact upon patient care in the VEMH region.
   Each service or application will be properly evaluated using the appropriate quantitative/qua- litative tools and measurement processes. The quantitative assessment tools that will be used are cost-benefit analysis and cost-effectiveness analysis. Cost-benefit analysis compares the discounted future streams of incremental programme benefits with incremental service or application costs; the difference between these two streams being the net social benefit of the service or application. The aim of the analysis is to identify whether a service’s or application’s benefits exceed its costs. Cost-effectiveness analysis is designed to find the minimum cost of meeting a given target and, unlike cost-benefit analyses; no attempt is made to estimate the benefits. This may be a more acceptable method to use when benefits are hard to measure or seen as incommensurate with costs. Both tools are required for a rational appraisal of the case for adoption, or on-going use, of various services or applications. Failure to conduct these analyses can result in a waste of human and financial resources that ultimately have an effect on patient care.
   

5. Conclusions

   VEMH will foster cross-Mediterranean cooperation between the leading medical centres of the participating countries by establishing a permanent medical and scientific link. Through the deployment and operation of an integrated satellite and terrestrial interactive communication platform, VEMH will provide for medical professionals in the whole Euro-Mediterranean area access to the required quality of medical service depending on the individual needs of each of the partners. Building on the best practice approaches developed in EMISPHER and other projects, the VEMH contributes to an improved health care all over Europe and its neighbours and build the basis for the introduction of evidence-based medicine.
   

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