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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-ordinator1, Title and Organisation: Despoina Rizou, Fraunhofer IGD
Tel: +49615155515
Fax: +496151155480
E-mail: [email protected]
Project website address: www.e-mednet.com
1
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
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
MEDNET architecture & technology
MEDNet system architecture and major components are: TeleConsult Jabber communicator AmerHis
TeleConsultTeleConsult, 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.
Example of the user interface of the TeleConsult platform while visualizing a fetus.
Jabber c communicator. Jabber [7,8] is an open-source, XML-based protocol for Instant Messaging and online-presence.
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.
AmerHisThe 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.
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.
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
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.
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.
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 (<80.000) offer high salaries (often over 10.000 up to 15.000 Euros per month) for physicians but nevertheless are unable to hire the necessary number of professionals (see http://g1.globo.com/jornal-hoje/noticia/2011/05/faltam-medicos-em-hospitais-e-postos-de-saude-no-interior-do-brasil.html).A survey by the Ministry of Health shows that are missing in rural Brazil, especially anesthesiologists, neurologists, neurosurgeons, psychiatrists and pediatricians.According to data released by the FCM - Federal Council of Medicine in 2010, the state capital of São Paulo has one doctor for every group of 239 inhabitants, above the average of countries with high human development indices. Germany, Belgium and Switzerland, for example, have a physician in activity for each group of 285, 248 and 259 inhabitants, respectively.When comparing the density of physicians throughout the state of Sao Paulo, the average is close to the U.S.: 413 people per professional in Sao Paulo, compaired to 411 in theUnited States. In the Federal District, there is one doctor for 297 inhabitants, the best average among the units of the Brazilian federation.Elsewhere, rates are African: in the interior of Amazonas State there is one doctor for every group of 8.944 inhabitants, in Roraima State, also in the Amazonian Region, one for 10.306.The medical network will connect isolated & underserved areas in Amazon over satellite communication and particularly in Maranhao state, in Brazil. Seven sites were chosen for the project MedNet in Brazil. Three sites in Amazonian legal region, see Figure 6, three sites in Rio Grande do Sul (RS), see Figure 7, and one in a large urban area where the referral hospital is located. São Borja (RS) city was chosen as a backup site in case that one city abandons the project in Rio Grande do Sul.
Amazonian legal region map
The health ministry of Maranhao, has already identified three remote site for the system deployment. The remote rural cities are:
Balsas
Carolina
Fortaleza dos Nogueiras
In general, after contacting the remote hospitals, we will identify the medical needs for each city. The requirements of the health network will be consolidated and the design specified. Before the deployment, application and services will be replicated in the laboratory of TASE in Madrid, Spain. Furthermore, during that period FhG IGD will elaborate on application enhancement meeting user requirements.As soon as the test finish successful, the real deployment of the tested system will go on and the medical trials will start as soon as the deployment in each city has been accomplished. After the end of the in-situ tests , between Balsas (remote clinic) and Porto Alegre (referral hospital), we will continue with the deployments to the rest cities. At the same time the medical trials will start between Balsas and Porto Alegre hospitals and a workshop will be held to show the health platform to the physician (experts and non-experts).Completing the deployment, two more satellite terminals will be deployed to remote clinic in Carolina and Fortaleza dos Nogueiras cities, respectively.
Remote sites at RS (red circle) and Porto Alegre (red square) where the referralhospital is located
Deployment in Brazil
In Brazil, there are in total six remote sites. Three satellite and three ADSL installations. The satellite installations are located in the Amazonian region in Maranhão state And ADSL installations are located in southern Brazil, in Rio Grande do Sul state. Fig. 2 illustrates the current network topology in Brazil.. The referral hospital is located in Porto Alegre, in a complex of hospitals, named Irmandade Santa Casa de Misericórdia de Porto Alegre that provides all types of medical expertise.
Network topology in Brazil.
Geographical position of Rio Grande do Sul (RS) and Maranhão (MA) State
MEDNET UtilizationInternet based network.
Application (& Objective) Comments
Teleconsult 2.6 (installation, configuration and basic usage).
The final version of TC 2.6 still doesn’t have an automatic installation.
Medical data in synchronous mode (TeleConsult on-line mode) On-line mode is technically operational in RS.
Medical data in asynchronous mode (TeleConsult off-line mode)
Off-line mode is technically operational in RS.Physicians prefer to use off-line mode because is difficult to match their agendas.
Netmeeting Removed from Windows 7.
Skype Physicians in RS prefer to use Skype. They find it more user friendly and easy to install.
MSN In RS Skype was chosen by the physicians.
LogMeIn Web application used for remote maintenance and support in RS.
Teleconsult 2.6 and Skype (Internet)
The system is running without technical problems.The sites in RS are operative and willing to contribute in the project. Lagoa dos Três Cantos is regularly sending exams to SACA’s specialists and has fully incorporated the system in the Health Care Center routine.
Summary of pilot test reports and current utilization in RS.
Maranhão (MA) – Amazonian RegionSatellite based network.
Application (& Objective) Comments
Teleconsult 2.6 (installation, configuration and basic usage).
The final version of TC 2.6 still doesn’t have an automatic installation.
Medical data in synchronous mode (TeleConsult on-line mode) On-line mode is technically operational in MA.
Medical data in asynchronous mode (TeleConsult off-line mode)
Off-line mode is technically operational in MA.Physicians prefer to use off-line mode because is difficult to match their agendas.
Netmeeting
Technically operational during Pilot Tests in MA sites.It is not going to be used anymore. This application was removed from Windows 7.
Skype Physicians in MA prefer to use Skype. They find it more user friendly and easy to install.
MSN In MA Skype was chosen by the physicians.
UltraVNC Software used for remote maintenance and support in the computers from MA.
Teleconsult 2.6, Netmeeting, MSN (satellite network – Amazonian Region)
The applications were tested. Good results during the pilot tests.From January 2010 until March 2010 few exams were sent from Balsas and Carolina. Fortaleza dos Nogueiras never had a chance to use the system during this period because the satellite link in this site worked for only one day since its installation until March 2010.In the second half of October the satellite link was recovered for all sites in MA. However, in the second half of November problems with the
installation did not allow the exchange of data among physicians.On November 25th, 2010, HISPAMAR solved the problem. Despite of the instability, most of the time the link is up and, since then, 290 exams were sent using the satellite network.
Simultaneous traffic flows (Validation of the establishment and maintenance of simultaneous traffic flows - online and offline)
Validated during pilot tests.When the link was recovered the system started to be used, especially in Balsas.
Simultaneous hospital – clinics communications (Validation of the establishment and maintenance of simultaneous hospital to clinics communications)
Validated during pilot tests.Satellite communication link was underused.
Summary of pilot test reports and current utilization in MA.
System exploitation
The main goal of MEDNET is to connect isolated areas in Amazonian region from Peru and Brazil utilizing European technology for satellite communication, providing broadband and quality of service (QoS) for real-time data transmission and video/audio conference.In Brazil, the entire network infrastructure was provided by SACA and CETA for the remote sites. The goal is not to use the system only to request second opinions from the specialists located in Porto Alegre, but also to make use of other Internet services like, email, Skype, MSN, etc. However, the instability of the satellite link until November 2010 significantly reduced the usefulness of the network. After some time the users gave up trying to use it, choosing the local internet service provider (despite of the slow bandwidth) to access internet services instead of the satellite connection.The satellite link was used only to send via satellite connection a reasonable number of second opinion requests in order to technically validate the system. If the connection was more stable, the system exploitation would be certainly easier.Despite of all the problems, CETA can confirm that when the link was up and stable, it worked very well. A very good bandwidth was verified in Maranhão in January 2011 when a CETA’s engineer was in the region. It was like to be connected to the Internet at home, in Porto Alegre (RS). Unfortunately this happened only when the project was already in the end.The system exploitation is unfeasible considering the price of the satellite connection and the QoS provided during the Pilot Execution, until November 2010.
Rio Grande do Sul State (RS)
Porto AlegreTimetable Monday Tuesday Wednesday Thursday Friday
08:00- 12:00
Carla Colares Bruno Hochhegger
Bruno Hochhegger
Bruno Hochhegger
Carla Colares
14:00-18:00
Bruno Hochhegger
Bruno Hochhegger
Bruno Hochhegger
Bruno Hochhegger
Bruno Hochhegger
The expert doctor’s agenda followed during the project in order to answer in teleconsultations was the following:
In the end of November 2010 HISPAMAR the performed a preventive maintenance in the satellite installations at Santa Casa de Porto Alegre. The LNB was very rusty and had to be replaced by a new one in order to avoid future problems, Error: Reference source not found. This action was very important
SACA’s LNB. Before and after HISPAMAR maintenance.
Lagoa dos Três CantosThis municipality has one generalist practitioner working exclusively to treat the population of Lagoa dos Três Cantos. By using the benefit that Lagoa dos Três Cantos has a small population, it is possible for the physician to have a personal relationship with his patients, this type of physician-patient is called “family medicine”, because the physician treats the person/family during their whole life. In addition to physician-patient relationship, the physician usually treats or visits the patient at home, to provide a better care. He assists the population of the city, maintaining a routine of preventive medicine and directing more serious cases to the other medical centers in bigger cities or to the Santa Casa de Porto Alegre Hospital.Telemedicine using MEDNET system was fully incorporated by Dr. Marcus Dalsasso, (the responsible physician) routine at the healthcare center. Almost every ultrasound exam is stored in the DICOM Database for future patient control. Error: Reference source not found shows Dr. Marcus Dalsasso’s office in Lagoa dos Três Cantos.
MEDNET installations in Lagoa dos Três Cantos.
Type of Exam Number of examsAbdomen, pelvic, obstetric. (U/S) 74
Number of exams sent for second opinion.
PelotasSanta Casa de Pelotas hospital has CT and RMI equipments, and was chosen as a pilot in MEDNET project in order to extend the system to other types of exams, in addition to ultrasound, that has already been used in other remote sites. However, these equipments are not connected to the hospital network; the exams are stored locally in a PC. When is necessary to transfer them to another PC the physicians use Re-Writable CDs. Internet connection was available only in the ultrasound room. For this reason the PC had to be installed there.The hospital also has a team of experienced radiologists. This site didn’t have a significant demand for second opinions because the local physicians could discuss any doubts and questions among them.When this situation was detected by the local coordination in Brazil, an effort was made in the sense of convincing these professionals to send exams in order to validate the system. Even though there is no doubt concerning the diagnostic.The results show that this town, like some others in MEDNET as well as in previous telemedine projects (T@lemed, T@his, e.g.), has not reached the expected levels of adherence to the project goals.
Type of Exam Number of examsCranium, hips, thorax. (CT) 3
Table 1 - Number of exams sent for second opinion.
AlegreteDr. Barradas from Santa Casa de Alegrete requested a new training in TC 2.6, performed on August 11th 2010. Since then many teleconsultations were remotely oriented by CETA. However Dr. Barradas is still not able to use the system alone.
Type of Exam Number of examsAbdomen. (U/S) 3
Number of exams sent for second opinion.
Maranhão State (MA) – Amazonian RegionThe system deployment and also the pilot tests were very much jeopardized in Maranhão. The main reason for that was the delay in the conclusion of the satellite installations.In the second half of October 2010 the link was recovered. However, the project scenario has changed in the meantime. We can mention change of staff (physician), equipment layout inside Balsas’ Clinic and also internet service providers arriving at the region, which in the beginning of the project not even have mobile phone coverage.In January 2011, CETA sent to Maranhão an engineer to review the installations and to give support (if necessary) for the physicians that were still having difficulties with Teleconsult 2.6.
BalsasDue to a renovation in São Carlos Clinic the equipment layout has changed. The formally implemented DICOM wireless network stopped working because the wireless signal is too weak to cross the walls that are in the way now. To overcome this problem a Bridge (LinkSys WAP54G) was sent to Balsas to be installed in the clinic. The purpose of a repeater bridge is to extend network connectivity inside the clinic.Error: Reference source not found shows the new topology of the wireless DICOM network.
New network topology using Bridge repeater.
Type of Exam Number of examsAbdomen, obstetric. (U/S) 290
Number of exams sent for second opinion.
Fortaleza dos NogueirasThe first opportunity to use the system was in the beginning of November 2010.A video conference between CETA and Mr. Uirajan (health secretary) were performed to test the video and audio quality. Only audio is OK, videostream (even at 320x240) seems to be too “heavy” for the allocated 1 Mbps bandwidth.The former physician, Dr. Percílio, left town. A new responsible physician was allocated in February 2011.When CETA's engineer arrived in Fortaleza dos Nogueiras the new physician had not started working yet. The local IT technician was trained to use Teleconsult 2.6 in order to assist the new physician when he starts working for MEDNET.
In addition to the training, a step by step tutorial (“for dummies”) was prepared by CETA and given to the local technician aiming to avoid more excuses for not using the system.Unfortunately, none of these efforts were enough. This site has not sent any exam.
Type of Exam Number of exams- 0
Number of exams sent for second opinion.
CarolinaContact with Dr. Idalcy was lost. The problem was similar to Fortaleza dos Nogueiras. The former responsible physician has a new job in another town and is not working at Carolina’sVideoconference tests were performed with a nurse from the hospital.The municipality Secretary of Health, Mr. Joaquim Dias Leal, was asked to help in the negotiation with Dr. Idalcy. CETA explained the importance of their participation in this phase of the project, but they don’t seem to care. Further contact showed no progress at all.
Type of Exam Number of examsAbdomen. (U/S) 3
Number of exams sent for second opinion.
Teleconsultation in Brazil
In Brazil, two different scenarios were put into operation. One in Rio Grande do Sul (RS) state in Southern Brazil, using ADSL and one in Maranhão (MA) state in Amazonian region using satellite communication over AmerHis.Six remote sites and one reference hospital are involved in the pilot: Rio Grande do Sul (RS)Reference hospital: Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (RS).Remote sites: Lagoa dos Três Cantos, Alegrete, Pelotas.In Rio Grande do Sul, MEDNet deployment started in July 2009 with the installations in Lagoa dos Três Cantos using ADSL connection. Dr. Marcus Dalsasso is using the MEDNet system from the first day and now is a routine at the healthcare center in Lagoa dos Três Cantos. Every ultrasound examination was sent to the referral hospital and stored in a DICOM compliant database for future patient control. Fig. 4 shows the number of exams sent per site in Rio Grande do Sul (RS).
Number of exams sent per site in RS.
City Type of Exam Teleconsultations
Lagoa dos Três Cantos
Abdomen, pelvic, obstetric. (U/S)
74
Alegrete Abdomen. (U/S) 3Pelotas Cranium, hips,
thorax. (CT)3
The use of MEDNet system gave the opportunity to avoid the transportation of 22 patients from Lagoa dos Três Cantos to the reference hospital in Porto Alegre. This represents almost 30% of the second opinions requested by Dr. Marcus Dalsasso.
A small testimony of Dr. Marcus Dalsasso about his experience with MEDNet is presented below: “…some answers sent by the specialists were very useful for me…many patients here won in the lottery,
they got their diagnosis, they were operated, now they are working…this has no price.”
The following figure shows the number of exams sent per month from Lagoa dos Três Cantos (RS) from July 2009 until March 2011.
Lagoa dos Três Cantos exams per month.
Maranhão (MA)Reference hospital: Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (RS).Remote sites: Balsas, Carolina, Fortaleza dos Nogueiras.The pilot tests in Maranhão started in December 2009 when the satellite installations were finished. The following figure and table show the number of exams sent by the sites in Maranhão (MA) until March.
Number of exams sent per site in Maranhão.
City Type of Exam Teleconsultations
Balsas Abdomen, obstetric. (U/S)
290
Carolina Abdomen. (U/S)
3
Fortaleza dos Nogueiras
- 0
A significant discrepancy is observed when the number of exams performed in Lagoa dos Três Cantos (RS) is compared to the rest of sites in RS. In Balsas (MA), the same behaviour is observed.
An essential knowledge in informatics by the users (physicians) has a relevant impact in the project results. This can be seen in the number of exams sent from Lagoa dos Três Cantos (RS) and from Balsas (MA). Both sites have physicians with experience in informatics and feel comfortable using the telemedicine system. On the other hand, the other physicians involved in MEDNet showed resistance using the telemedicine application, despite of the workshops, training and constant support given.
The following figure shows the number of exams sent from Balsas (MA) per month from December 2009 until March 2011. From February 2010 until December 2010 there is a period that the system was not operational due to technical problems in the satellite connection. Nevertheless MEDNet activities in Balsas were going on. The physician stored the ultrasound exams in the DICOM Database and when the connection was recovered he sent them to the reference hospital, which has already answered all his requests of second opinion.
Balsas Exams per month.
Achievements in Peru
Study area & backround
The department of Junin is located in Central Peru and consists of two main ecoregions: 46% Mountainous and 54% Jungle (Error: Reference source not found). Covering an area of 44, 197 km2, Junin has a population of 1,302,805 (2006). The rural population has been declining and represented approximately 34.5% of the population in 1993. The result of this migration has, amongst other things, led to a deterioration in rural areas and increased strain upon urban centres. The region is characterized by diverse climates and micro-climates. Politically, Junin consists of the provinces of Huancayo, Chanchamayo, Chupaca, Concepcion, Jauja, Junin, Tarma, Yauli and Satipo. In 2002, 63% of the population lived in poverty, with approximately 30% living in conditions of extreme poverty – above average for Peru. The general illiteracy rate (in 1993) was 12.8% - higher for females at 20.6%2. In 2004 Chronic infant malnutrition (<5 years) reached 31.4%. The reasons are attributed to Public Health and the level of maternal education, number of children and first language.There is a high prevalence of communicable diseases such as Malaria, poor maternal care, malnutrition and alcoholism. Malaria is endemic in the provinces of Chanchamayo and Satipo. Classic dengue is endemic in Junin in the provinces of Chanchamayo and Satipo. Yellow Fever is endemic in Junin, with two river basins Rio Tambo and Mantaro-Ene considered high risk. As a preventative measure, a vaccination programme began in 2004. As of January 2005 this programme had 62% coverage. There were 84 recorded cases of HIV-AIDS in 2004, slightly down on 146 recorded in 2003 but there has been a general upward trend since the first case was diagnosed in 19883.
2 INEI. Figures from June 20033 Oficina de Epidemiologia. NOTI.
There is also a high incidence of prenatal and maternal mortality due to poor maternal care during pregnancy and delivery. The maternal death rate in Junin during 2004 was 149.44 per 100, 000, slightly above Peru’s national average of 146. Approximately 65% of these cases occur due to puerperal fever – hemorrhaging accounting for 64% of these cases. With appropriate health services and nutrition during and after pregnancy, many of these deaths are preventable. The greatest causes of mortality are:
respiratory diseases
traumas
malignant tumors
chronic degenerative diseases in the adult population.Health service coverage in Junin is low. Approximately 89% of health centres in the region are delivered by Ministerio de Salud (MINSA), however, 97% of these are “puestos de salud” – a level of medical attention characterised by limited infrastructure and resources, in both equipment and professional personnel. With this lack of infrastructure it is difficult to effectively confront the health problems faced by the population. The region faces health workforce crises due to a lack of trained physicians in rural areas. Professional health workers perceive there to be a strong sense of isolation associated with working in rural areas, particularly in terms of continuing professional development.Telemedicine in this respect is an excellent tool in covering and integrating multiple areas of health care work, training and education. Poverty is an important factor in assessing access to health services. In 2000, of 100% of people declaring symptoms in need of treatment, only 69% received attention from a health care professional. Approximately 31% failed to access the health service – for economic reasons. According to a map of poverty produced by MEF in 2004, and the United Nations Human Development Index in 2006, the poorest districts in Junin were situated in the province of Satipo (e.g. Rio Tambo has a 50.3% rate of extreme poverty and 54.4 % rate of chronic infant malnutrition, Llayla 37.2%: 39.9% respectively) and Concepcion. Geography is another mitigating factor resulting in social exclusion. In the department of Junin, rural communities have a travel time of 152.78 minutes to their nearest hospital, as opposed to 76 minutes
Peru’s administrative network in Junin Department.
to the nearest “puesto de salud”4. These times can increase dramatically during heavy rains. The mud slides (Huaycos) that ensue can have devastating, often fatal, consequences, cutting transportation links and leaving many communities further isolated.
Deployment in Peru
In Peru there are in total eight satellite installations including the referral hospital in Huancayo.
Geographical position of the sites in Peru.
Deployment: WIMAX connectionFollowing the difficulty of associating a fixed public IP with a domain name for the Jabber Server in DIRESA Junín, the decision was taken by GRJ and DIRESA Junín to install a WIMAX connection between the referral hospital at D.A . Carrion and the satellite terminal installed at DIRESA Junín’s administrative offices in Huancayo, Peru (Figures 1, 3 & 4).
The need to complete a WIMAX installation was not envisaged in the original deployment plan and DoW but DIRESA Junín were keen to adopt this solution in order to fully connect the MEDNET infrastructure since it also enhanced the IT infrastructure within Hospital D.A. Carrion. The IT infrastructure of the referral hospital was poor and hadn’t been updated in a long time. Whilst the category of the hospital had increased along with the complexity of services offered, its IT systems had lagged behind. DIRESA Junín used involvement in the MEDNET project to justify this WIMAX installation. WIMAX installation was eventually completed during April 2010 in accordance
4 ENAHO 2001
Figure 1 Satellite terminal and WIMAX installation at DIRESA
Junín
with the chronogram presented during the MEDNET review in Brussels in March 2010 (Figures 1, 2, 3 & 4). With the installation of WIMAX connection, the IT infrastructure has received a major boost.
The reason why the satellite terminal was installed in the administrative offices of DIRESA Junín in Huancayo and not the referral hospital D.A. Carrion, thus eventually requiring WIMAX installation, was due to the fact that during September 2008 an indefinite health professionals strike in Huancayo highlighted the need to mitigate against the potential for loss and disruption to the whole of the network. The decision, agreed by the consortium, was to install the satellite in Lima, in order to ensure stability of the service to the remote sites. Following events of mid-2009 the satellite terminal was subsequently reinstalled in the administrative offices of DIRESA Junín.
The result of the WIMAX connection is that the referral hospital D.A. Carrion is now connected to the MEDNET network and appears as an additional connection on DIRESA Junín’s Local Area Network.
Outline of SW direction of signal towards Hospital D.A. Carrion
The distance from the administrative offices of DIRESA Junín to the referral Hospital D.A. Carrion is 1.72km. Figure 4 outlines detailed parameters of the WIMAX installation.
Outline of the WIMAX set up at Hospital DA Carrion, Huancayo. Signal from DIRESA Junín is received and then transmitted to DIRESAs store (blue) and the MEDNET PC (Red).
The WIMAX connection has a capacity of 10 MB and is connecting 1 PC in the hospital. It is also connecting approximately 14 PCs in DIRESAs "almacen".
Signal receiver located outside MEDNET consultation room in D.A. Carrion. See enlargement in figure 6
WIMAX signal from DIRESA Junin
DIRESA Junin’s “almacen” is now connected – strategically very important advancement
Details of WIMAX parameters
WIMAX receiver located just outside the MEDNET dedicated site at Hospital DA Carrion which received the signal.
The impact of connecting the referral hospital via WIMAX is outlined in the schematic overview of the current MEDNET architecture presented in the following figure.
Overview of the current MEDNET system with integrated WIMAX connection
MEDNET Utilization
The focus of deliverable 6.1 is the transition towards full utilization of the MEDNET system. Pilot tests were carried out to assess the systems functionalities was presented.
Application (& Objective) CommentsTeleconsult(installation, configuration and basic usage).
- WIMAX installation completed- Incompatibility issues between u/s and PC.
Medical data in synchronous mode (TeleConsult on-line mode)
-Specialists reluctant to participate – professional and financial reasons -Remote medics unwilling to seek second opinion from colleagues in Huancayo
Medical data in asynchronous mode (TeleConsult off-line mode)
-Specialists reluctant to participate – professional and remuneration reasons -Remote medics unwilling to seek second opinion from colleagues in Huancayo-Issue of second opinion based solely on jpg images questionned
Netmeeting and Real time communications (Real time Comms and Use of Netmeeting application)
-Initial tests revealed some configuration issue which reduced available Bandwidth-Netmeeting application not liked by users and has been replaced by Skype VC which has been main form of communication used.
PC Telephone -Tests repeatedly good and stable – however, users not keen. Continued use of PC Telephone might be via separate “IP telephone” / “Handsfree”
UltraVCN -DIRESA Junin routinely use this to enter and make any necessary reconfigurations. It is also used sometimes to initiate communications
Teleconsult, Netmeeting and PC Telephone (Validation of communications between two terminals with HP and LP connections simultaneously )
None of these applications are being used. From August 01 a regional directive obliges ALL users to use the MEDNET system.
Simultaneous traffic flows (Validation of the establishment and maintenance of simultaneous traffic flows - online and offline)
The system is currently being underused.
Simultaneous hospital – clinics communications (Validation of the establishment and maintenance of simultaneous hospital to clinics communications)
Specialists and remote medics reluctance to fully engage with MEDNET
Summary of pilot test reports and current utilization
System exploitation
The objective of MEDNET was to deploy a system that enabled transfer of medical images via satellite to a remote specialist, who in turn would review and provide expert second opinion. Users are currently exploiting the system in a variety of alternative ways including, accessing information via internet, chatting with colleagues and family and sending weekly epidemiological reports. Previously, the medic had to either travel to a local internet cafe (where available) or alternatively make a longer trip to Huancayo. The cost of this was not reimbursed – but the benefit was the trip itself (to visit family etc).
There have been difficulties in using the system as originally planned as a consequence of several different factors, including: the delivery of ultrasound machines was subject to long delays associated with a long public procurement process; when finally delivered, 6 of the 8 ultrasound machines purchased were/are not compatible with Teleconsult and have resulted in a complicated and time consuming workflow; training in imaging diagnostics and use of ultrasounds provided but to some medics who have since relocated to other sites.
As described in deliverable D2.1, a number of stakeholder needs were identified as part of an assessment of clinical requirements. The principal required was identified as:
“...Lack of basic medical diagnostic equipment: Stakeholders prioritized the need for ultrasound machines to improve maternal health during pregnancy and avoid the need, or at least improve preparedness, for emergency deliveries”.
This was a stated health care priority for the Regional Health Care provider - DIRESA Junín - in 2008. Since the clinical requirements Work Package was completed by Geopac and DIRESA Junín / GRJ, stakeholders may have actually been confirming the health priority as decreed by the regional health authority (DIRESA Junín). Additional requirements were identified as the need for:
1. Improved communications (for both the community and access to medical information):2. Expert second opinion:3. Improved institutional efficiency:4. Capacity building programmes:5. Stable electrical supply: The local municipality at each remote site agreed to satisfy this basic
requirement.
The MEDNET system, as currently being used, meets the requirements of points 1 and 3. An interesting socio-professional issue has been raised by Point 2 (discussed in further detail in the section on Organizational Aspects).
Negotiations to extend the network and utilize the system for professional CPD (point 4) have been started between DIRESA Junín and the Universidad Peruano Cayetano Heredia (UPCH) whilst the issue of stable electrical supply (point 5) was resolved by each local municipality involved in the project.
Although the majority of medics in the remote sites in Peru are competent in ICT, the development of a system based on u/s image transfer has been challenging. Aside from potential socio-professional and remuneration conflicts, the Specialist medics in Huancayo have raised doubts about
their ability to provide an expert second opinion based on a .jpg image and have suggested that the system is too vulnerable on user ability.
Remote site utilization
Rio NegroCurrent situation:
Medical images are transferred (approximately 36 per month) using FTP The Medic Dr Darwin Ruiz Flores, who was trained in imaging diagnostics via ultrasound temporarily
refused to continue execution of ultrasound examinations (reasons why are not fully clear). Internet is used to send and receive health care information A technical assistant has been assigned to facilitate all communication links
Dr Karina Bastidas assumed responsibility for the health centre at Rio Negro in Jan 2010. Dr Bastidas and Dr Darwin Ruiz Flores attended the imaging diagnostics training workshop in April 2010 on behalf of Rio Negro. However, Dr Darwin temporarily stopped this service and an obstetric nurse took over this duty for a while. Dr Ruiz Flores, in accepting the training delivered by DIRESA Junín has a duty and responsibility to continue this service. DIRESA Junín reminded Dr Ruiz of this responsibility and soon after Dr Ruiz resumed full service.
A reluctance to use the referral system to specialists at Huancayo was noted.
At Rio Negro, the effectiveness of DIRESA Junín’s technical assistant system was demonstrated. Ing. Jesus has proved to be an extremely capable and responsible technical assistant and has transferred all images taken to date over FTP to DIRESA Junín. Jesus quickly appreciated the Teleconsult video tutorial and successfully completed online and offline consultations. Jesus will be the crucial link between the medics and the network operation.
DIRESA Junín have adopted the strategy of designating a technical assistant at each remote site who will act as coordinator and bridge any gaps between the remote medics and the MEDNET system.
SM de Pangoa Internet is exploited to send health care information (epidemiological reports etc). Optimum use of ultrasound machines – 70+ u/s examinations per month Ultrasound and PC equipment operational – a web cam needs to be replaced Internal dissemination has been weak – medics seem unaware of MEDNET’s system functionalities
The MEDNET consultation room in SM de Pangoa
There are encouraging signs throughout the MEDNET sites to suggest high levels of ICT competence and personal eReadiness. Dr Ali Larrca Mego, attending at SM de Pangoa demonstrated how he is currently using his Blackberry to transfer images informally to colleagues for advice on treatment (Figure 10). The key issue here is that this consultation is requested from colleagues with whom there is a prior connection and bon. It is totally informal and storage of images would not comply with appropriate medical standards. An additional factor is the ease of use associated with a mobile phone. The current workflow associated with Teleconsult is deemed too time consuming.
The remote medics in Peru are technologically capable. Here Dr Ali Larrca Mego, general surgeon at SM de Pangoa demonstrates how he seeks expert second opinion from colleagues using his Blackberry
Mazamari High use of internet (including sending / receiving health care information) and videoconference Ultrasound machine (TELEMED) was found in storage and is not used. Replaced by alternative, more
advanced, ultrasound model. On average 23+ u/s examinations performed monthly. Lack of personnel – difficulty in assigning a technical assistant On a routine visit the satellite router was located in a sub-standard location: advice provided to
mitigate risk Poor internal dissemination of the MEDNET system
The Director of C.S. Mazamari, Dra Yuli, also confirmed a sense of professional unease at requesting “second opinions” from the Specialists in Huancayo. The perception felt by Mazamari (and confirmed in Puerto Ocopa, SM de Pangoa and Rio Negro) is that the Specialists were not open and approachable. There is a professional unease at seeking advice for fear of ridicule and rejection. Culturally, negative perceptions towards the jungle region, in part the cause of unequal distribution of resources, exacerbates this situation. This has been the main reason for a reluctance to fully engage with the MEDNET project to date.
Another issue to emerge from this reluctance to engage has been a fully to see how the system could be adapted and exploited to meet specific needs.
The MEDNET consultation room at Mazamari
Mobile coverage has reached all remote sites since the start of the MEDNET project - rapid penetration of mobile phones is phenomenal – Previously there was limited coverage beyond Satipo.
Puerto Ocopa Computer equipment and portable computer were inoperative (in storage) and consequently the
satellite platform was not being used (Frequent) Change of Medical personnel New personnel untrained in use of Ultrasound machines – training required. Average of 10+ u/s
examinations performed monthly. Unable to designate a technical assistant: currently personnel identified for this role are located in
Satipo (in receipt of training) The new PC delivered has compatibility issues (particularly Audio)
Puerto Ocopa is the remotest site in the MEDNET project in Peru. Over 70% of its patients are native Ashaninka. Connection and configurations to the communications element of the MEDNET infrastructure (ie everything except for Teleconsult) were completed in December 09. However, the PC was found to be inadequate and needed to be replaced. Training in imaging diagnostics was provided to Medical staff but they left their post shortly afterwards.
There then followed a poor chain of command and communication and handover of roles and responsibilities relating to the MEDNET project resulting in the new Director having very limited knowledge of the background and content of the project. The new Director, Dra Victoria Dominguez, also has limited experience in use of ultrasound machines and needs to access training and capacitation in performing u/s examinations and imaging diagnostics. The current reality is that there is a certain level of fear with using the current equipment. In order to address this issue, and a symbol of camaraderie between health care workers within Satipo, C.S. Pangoa has offered to provide training and practical experience in ultrasound examinations. An additional factor is that the PC provided is still inappropriate and drivers for the microphone are missing and cannot be covered by generic drivers.
Dra Victoria Dominguez, the new Director of C.S. Puerto Ocopa
ComasMedics have been undertaking large number of ultrasound examinations, on average more than 46 per month, although use of Teleconsult is limited.
PariahuancaPersonnel left their posting shortly after receiving training in April 2010. Their replacements required training and have been rather reluctant to participate. As a consequence, less than 10 u/s examinations are performed monthly.
Chongos AltoMedics have been undertaking ultrasound examinations (average of 15 per month) although use of Teleconsult is restricted.
In order to stimulate MEDNET activity, DIRESA Junín passed a resolution “obliging” daily utilisation of the network.
Teleconsultations in Peru
In the following figure we can see the number of exams per site in Peru.
Number of exams per site in Peru.
All the teleconsultations in Peru, are Ultrasound consultations. In the following table presents more detailed the number of exams was sent through the system to the other sites and the exams were locally consulted. The main type of exam was obstetric and abdomen.
Sustainability
Telemedicine has pioneered the use of communication technologies within healthcare. Hence telemedicine services are principally available for decades – some even say for as much as 130 years (referring to an early telephone based medical consultation). Nevertheless, telemedicine in rural areas is relative new and not so many innovative changes were reported. MEDNET is one of the pilot telemedicine projects in Brazil & Peru.
MEDNET is a representative proof of case for telemedicine. MEDNET provides second opinion and sometimes even first opinion, between non-expert doctors in rural areas of Brazil & Peru with expert doctors located in big cities. Find below a testimony from a non-expert doctor in a rural area in Brazil who participated to MEDNET:
“…some answers sent by the specialists were very useful for me…many patients here won in the lottery, they got their diagnosis, they were operated, now they are working…this has no price.”
The impact of MEDNET in the life of the people in rural areas was mostly huge. Therefore needs to be finding a sustainable telemedicine plan for Brazil & Peru. Because of the different realities between the two countries, two different sustainability strategies will be presented in the following chapters.
In Peru, Telehealth offers the potential for electronic communication between healthcare professionals if expanded across Junín’s 48 centro salud sites. It needs an emphasis on ultrasound and general electronic communication to create multi-skilled teams in remote areas. An indicative assessment shows reasonable potential returns. These need confirming with specific estimates as part of a comprehensive telehealth strategy that complies with several recognised good practices5 in eHealth, including:
Engagement of healthcare professionals and other stakeholders from the outset
Usability
Utilisation for benefits
Creating effective multi-skilled teams
Regular reviews and corrective action
Focus on benefits and benefit realisation.
Using telehealth at all 48 centro salud sites should maximise the use of terrestrial communications instead of satellite in some locations which will reduce costs.An estimated cost is some PEN 27 million over ten years. Estimated benefits are some PEN 35 million with an estimated socio-economic return of about 24%. This indicative net benefit confirms the potential for these options to be developed, assessed and one to be pursued.
Sustainability for Brazil
Sustainability strategy is a term used to describe whatever action plan is taken to preserve an existing resource or maintain a process over a given period of time. What in the case of MEDNET is the service to be maintained?
Mednet impact in Brazilian rural areas (cities in agricultural regions with population under 20.000 inhabitants) was very important in the sense that it opened everybody’s mind to the staggering possibilities unveiled by technology and the rearrangement of existing processes.
Small cities are getting together, clustered in Consortiums, in order to accreditate and hire health services in a agile, faster and cheaper way. This is also applicable to telemedicine.
Thus, in regions with a chronic difficulty to hire qualified physicians, a new model of health service is potentially available, at least for those with a minimum connectivity level (see the Brazilian Broadband National Plan and it’s goals in http://www.mc.gov.br/plano-nacional-para-banda-larga).
Scope and access type
Goals for 2014
Collective fixed access
To take broadband access to 100% of the organs of government including:• 100% of the units of the Federal, States and Municipalities.• 100% of public schools have not met (more than 70,000 rural).• 100% of health units (177.000).• 100% of public libraries (over 10.000).• 100% of public safety agencies (over 14.000).
Deploy 100.000 new Federal Telecenters 2014.
5 www.ehealth-impact.org www.ehr-impact.eu
The PNBL (Brazilian Broadband National Plan) goals for 2014, although impressive are quite feasible given the rapid development of communications and IT infrastructure in the country.
This leads to a major reduction in connectivity prices, allowing the planning of internet based services, including SaS applications (cloud computing).
The sustainability strategy then aims to keep running a service - remote readings, and will use for that whatever available means. Focus will be in the stability and quality of the service, its traceability and, last but not least, cost-benefit ratio.
A detailed business plan based on the strategy above can be found in MEDNET deliverable D8.3.
Sustainability for Peru
Demography and geographyA population pyramid for the MEDNET sites reveals a young and expansive population shown in figure 3. Segmenting the total MEDNET population by eco-region reveals that there has been a significant increase in the population in the central jungle region, especially Rio Negro, Mazamari, Pangoa and Puerto Ocopa, as shown in figure 4. Population forecast profiles for 2011 of the seven districts using MEDNET are broadly similar except for Chongos Alto. Here, the population aged over 50 is a greater percentage of the total population than the other six districts. The age group aged 25 to 44 is a slightly lower percentage. The difference is between 1% and 3% points depending on the narrower age bands.
Figure 3 - Population Pyramid for Combined Seven MEDNET Sites
The pyramid reveals a young and expansive population. About 40% of the MEDNET population is aged below 15 years.
The total MEDNET population is increasing in the central jungle region. Figure 4 shows the segmented differences.
Male Female
Figure 4 - Segmenting the Total MEDNET Population by Eco-region
Health issuesThere are many health issues and challenges. Infectious diseases like tuberculosis, HIV/AIDS, malaria, leishmaniosis, Chagas’ disease, dengue, Bartonellosis, yellow fever, anthrax, and plague remain major public health problems. Most of these are under constant surveillance either using individual forms or tally sheets for mandatory notification. Acute respiratory diseases make up nearly 80% of all deaths followed by 28% from urinary tract diseases. Table 2 shows the principles causes of morbidity in Junín:
Table 2 - Principle Causes of Morbidity Registered in External Consultations June 2008
CAUSES OF MORBIDITYTOTAL MALE FEMALENº % Nº % Nº %
TOTAL 1,177,420 100 414,616 100 762,804 100Acute upper respiratory tract diseases (J00-J06)
257,263 21.8 114,471 27.6 142,792 18.7
Diseases of the oral cavity, salivary glands and jaws (K00-K14)
109,324 9.3 18,105 4.4 91,219 12
Intestinal infectious diseases (A00-A09) 73,442 6.2 35,452 8.6 37,990 5Helminthiases (B65-B83) 46,965 4 20,929 5 26,036 3.4Infections with predominantly sexual mode of transmission (A50-A64)
31,924 2.7 804 0.2 31,120 4.1
Disorders of other endocrine glands (E20-E35) 31,757 2.7 47 0 31,710 4.2Other acute lower respiratory tract diseases (J20-J22)
30,380 2.6 15,169 3.7 15,211 2
Other maternal disorders mainly related to pregnancy (O20-O29)
30,189 2.6 0 30,189 4
Other diseases of urinary system (N30-N39) 26,984 2.3 4,805 1.2 22,179 2.9Diseases of the oesophagus, stomach and duodenum (K20-K31)
25,603 2.2 7,622 1.8 17,981 2.4
Lower socio-economic classes exhibit a trend towards mental health problems, alcoholism, obesity and tobacco abuse6. There is also a high incidence of prenatal and maternal mortality due to poor maternal care during pregnancy and delivery. With appropriate health services, early detection of
6 Applicaciones de Telecommunicaciones en Salud en la Subregion Andina. Telemedicina. Poliszuk and Salazar Gomez (2006). OPS/OMS.
high-risk pregnancies, and good nutrition during and after pregnancy, many of these deaths are preventable.
A lack of trained physicians in rural areas results in an increased demand on healthcare resources in more urban areas. However, centralised healthcare specialists present an opportunity for telemedicine. Continuing the improvement in dealing with this wide range of diseases and conditions, needs increased and sustained investment in the resources for health and healthcare. The potential role and impact of Telehealth could be a valuable contribution.
Telehealth in the health systemPeru’s continuous healthcare development through its PHS and its successes in improving health since its inception provide the context for MEDNET. It is another initiative aiming to enhance the performance of PHS, and exploring the potential of ICT as a new approach to improving healthcare. There is a plan for Telehealth. In April 2003, the Ministry of Transport and Communications (MTC) created the National Telehealth Committee (RS Nº 009-2003-MTC). Its members are representatives of the MTC, National Institute for Research and Training in Telecommunications (INICTEL), the telecommunications regulator (OSIPTEL), National Institute of Statistics and Informatics (INEI), EsSALUD and MINSA. It produced the National Plan for Telehealth approved in 2005 by the MTC (DS Nº. 028-2005-MTC).
The Plan proposed an Integrated Telehealth System to increase the provision of healthcare services in underserved and remote areas. Most of the policies deal with general ICT matters, developed outside the health sector. Significantly, there is very low compliance to these policies.
A scoping document for Telehealth in October 2008 designated responsibility to the regional DIRESAs. Norma Tecnica de Salud de Telesalud (NTS No 067-MINSA/DGSP-V.01). It concludes that each DIRESAs is responsible for developing a plan to implement the Technical Law in healthcare establishments under their jurisdiction to incorporate the different telehealth applications, including information and capacity-building activities. Although recent WHO policy publications highlight how, if properly applied, telehealth solutions can effectively contribute to the health MDGs, Peru has still to make progress. Attempts to redress this situation by involving DIRESA Junín include developing an eHealth network to improve maternal and child healthcare. In 2010, about 13% of Junín’s population accessed healthcare at a facility benefiting from telehealth technologies. This could increase to 15% of the population based on current population growth trends.
These limited telehealth initiatives parallel an uncoordinated ICT strategy for healthcare. Consequently, there is a fragmented health information system both between the various healthcare providers and within MINSA. Most ICT projects are individual initiatives developed by universities and NGOs. Peru is at an emergent stage in eHealth. MEDNET provides an opportunity to advance in part of this field.
Telehealth in Junín
OrganisationsDIRESA Junín is an organ of the Regional Government of Junín. It is legally responsible for delivering healthcare in the Junín region and regulating the laws concerning doctors in the region. DIRESA Junín controls seven hospitals, 48 health centres, the centro salud (CS) and 374 more rural health outposts, the puesto salud (PS).
Healthcare Establishments in Junín Region, Peru.
Region MINSA/DIRESA Junín OTHER Total
Total Hospital CS PS IPSS PNP FFAA PrivateValle del Mantaro
139 2 25 112 2 1 1 10 153
Jauja 69 1 10 58 10 1 1 5 86Tarma 58 1 5 52 2 1 0 6 67Chanchamayo 51 1 3 47 2 1 0 3 57Satipo 91 1 2 88 1 1 0 0 93Junín 21 1 3 17 1 0 0 2 24Total 429 7 48 374 18 5 2 26 480
The regional government in Junín published its vision that by 2012 “the region is healthy, productive, with a high index of human development, an integrated health system, which is efficient, united and transparent and guarantees the rights and equal access to a quality service to the most vulnerable sections of the community”7.
Limited telehealth facilities using MEDNET are deployed at the referral hospital D A Carrion and seven remote health centres at Rio Negro, Mazamari, SM de Pangoa, Puerto Ocopa, Comas, Pariahuanca and Chongos Alto. All these are controlled by DIRESA Junín.
Concepcion ComasHuancayo Chongos Alto
PariahuancaSatipo Mazamari
Saint Martin de PangoaRio NegroPuerto Ocopa
Telehealth and Junín’s eHealth strategyTwo main features of Junín’s healthcare system are:
It faces a wide range of diseases and conditionsMany people have to travel very long distances for healthcare.
These indicate that the goal of an eHealth strategy should be to improve access to healthcare for a wide range of people and many different types of patients.
At telehealth sites in Junín, many patients have to travel long distances to reach a rural health centre, the puesto de salud. Often, due to a lack of basic diagnostic equipment and medicines and an inability to obtain an expert opinion, local doctors refer patients to other facilities, especially district hospitals. Many patients are unable to deal with this cost, so are either unable to access appropriate healthcare or are assisted by their doctor’s personal generosity.
Currently, using teleHealth is not part of the regional strategy. Such an initiative is consistent with Junín’s vision that by 2012 “the region is healthy, productive, with a high index of human
7 Plan Concertado, Regional Government of Junín.
development, an integrated health system, which is efficient, united and transparent and guarantees the rights and equal access to a quality service to the most vulnerable sections of the community”8. There is a need to develop eHealth policies, strategies and infrastructure, including developing and improving standards, protocols, and training in medical and health informatics.
In October 2010, the regional government changed. Initially, the new administration identified a need for an integrated health information system. This offers new opportunities. Innovations need to develop locally relevant telehealth solutions for the region. MEDNET offers a way to start the finance research, development and implementation in this area9.
Health services affected
According to MINSA’s statistics for Human Resources in 2009, 9% of doctors in the Junín region are involved in the MEDNET project. Three of the health centres, the centro salud, in DA Carrion, the referral hospital in Valle del Mantaro, and four health centres in Satipo, two centro salud and two puesto de salud, are part of MEDNET. These represent 2% of healthcare facilities for 13% of the population.
Number of DIRESA Junín Establishments in MEDNET
Region MINSA/DIRESA Junín
Total Hospital CS PSValle del Mantaro (High Andes)
4 1 3 0
Satipo (central jungle region)
4 0 2 2
Total 8 1 5 2
The main health services support by MEDNET are for maternal and child health. Ultrasound equipment and training is now in place for maternity services, and is available for other conditions. The infrastructure provides a broadband and Internet link for all healthcare professionals at the sites to use to connect directly to other healthcare professionals and to health information available on the Internet.
The range of diseases and conditions that the MEDNET pilot supports is narrower than the health challenges summarised at 2.3 Health issues. This sustainability plan reviews the potential of telehealth for all 48 centro salud sites over several years.
This section must be of suitable quality to enable direct publication by the Commission and should preferably not exceed 40 pages. This report should address a wide audience, including the general public.
The publishable summary has to include 5 distinct parts described below:
An executive summary (not exceeding 1 page).
8 Plan Concertado, Regional Government of Junín.9 Curioso, W., Castagnetto, J., et al. eHealth in Peru (2008): A Country Case Study
A summary description of project context and objectives (not exceeding 4 pages).
A description of the main S&T results/foregrounds (not exceeding 25 pages), The potential impact (including the socio-economic impact and the wider societal
implications of the project so far) and the main dissemination activities and exploitation of results (not exceeding 10 pages).
The address of the project public website, if applicable as well as relevant contact details.
Furthermore, project logo, diagrams or photographs illustrating and promoting the work of the project (including videos, etc…), as well as the list of all beneficiaries with the corresponding contact names can be submitted without any restriction.
Use and dissemination of foreground
Section A (public)
TEMPLATE A1: LIST OF SCIENTIFIC (PEER REVIEWED) PUBLICATIONS, STARTING WITH THE MOST IMPORTANT ONES
NO. Title Main author
Title of the periodical or the series
Number, date or frequency Publisher Place of
publicationYear of publication
Relevant pages
Permanent identifiers10
(if available)
Is/Will open accessprovided to this publication?
1 E-Health in Practice – No.2 HealthConnect Internationalhttp://www.ehealthnews.eu/content/view/1087/66/
June 19 2008
2 Article: “Para o CETA, o longe não existe” at the magazine “Revista Indústria em Ação” (Industry in Action Magazine)
July 2009
3 “DVB technologies for an improved World MedNET: Intelligent DVB Satellite at the service of Telemedicine”,HISPASAT
DVB World 2010, Lisbon
10 A permanent identifier should be a persistent link to the published version full text if open access or abstract if article is pay per view) or to the final manuscript accepted for publication (link to article in repository). 11 Open Access is defined as free of charge access for anyone via Internet. Please answer "yes" if the open access to the publication is already established and also if the embargo period for open access is not yet over but you intend to establish open access afterwards.
NO. Type of activities12 Main leader Title Date Place
1 Conference Despoina Rizou present the paper “Satellite based health network in Brazil and Peru”
ITAB2008&IS3BHE2008 30-31/5/2008 Shenzhen, China
2 Conference TAS-E will present the paper “Telemedicine over remote areas through AmerHis Regenerative DVB-RCS/S Platform”.
14th Ka and Broadband Communications Conference
24-26/09/2008
3 Conference Wayne Menary: networking opportunity IV Regional ATALAAC MEETING 2008 –
Aug 15-17 Panama City, Panama
4 Conference Dimitris Panopoulos will present “MEDNET: Telemedicine via satellite combining improved access to health care services with enhanced social cohesion in rural Peru”
ISD2008 Aug 25-27 Paphos, Cyprus
5 Conference Wayne Menary to present “Telemedicine via satellite: linking eHealth and development in rural Peru and Brazil”
INFOLAC 2008 Oct 30 – 01 Nov
Buenos Aires, Argentina
6 Conference “Health Network in Peru and Brazil”Despoina Rizou
ICS2008 Nov 08 Tamsui, Taiwan
7 Conference Wayne Menary to present: MedNET: Establishing a sustainable eHealth initiative in rural Peru and Brazil
TeleMed & eHealth 08 Nov 24 &25 London, UK
8 Conference Exhibition: eHealth via satellite in Peru and Brazil ICT 2008 Nov 25-27 Lyon, France
9 Conference Jon Haitz Legarreta – Chairman of “Telehealth, Telecare and Services” – Presents last developments on Vital Sign Monitoring.
Med-e-Tel 16-18/4/2008 Luxemburg
12 A drop down list allows choosing the dissemination activity: publications, conferences, workshops, web, press releases, flyers, articles published in the popular press, videos, media briefings, presentations, exhibitions, thesis, interviews, films, TV clips, posters, Other.
10 Conference Jon Haitz Legarreta presents last developments on Vital Sign Monitoring.
CARS 25-28/06/2008
11 Conference XXIII Simposium Nacional de la Unión Científica Internacional de Radio (URS I ).
MEDNET: Intelligent satellites in the service of Telemedicine
23-24/9/2008
12 Conference Telecom I+D Congress. MEDNET: Intelligent satellites in the service of Telemedicine
29-31/10/2008
13 Conference “Broadband health care network in Brazil and Peru “Despina Rizou
Eatis2008- Euro American conference on Telematics and Information Systems
September 10-12
14 Conference “TraumaStation: A portable Telemedicine station”Despina Rizou
EMBC 2009, 2-6/09/2009 Minneapolis, USA
15 Conference MedNET: TeleMedicine over AmerHis system
THALES
IWSSC 2009, International Workshop on Satellite and Space Communications (IWSSC 2009)
10-11/09/2009 Italy
16 Conference Mr. Jon Legarreta (VT) Mrs. Cristina Arias Perez (HISPASAT) Mr. Antonio Arana (HISPASAT) Mr. Ekaitz Gonzalez (HISPASAT) Mrs. Ana Solano (TASE) Mrs. Carla Salas (TASE) Mr. Juan Ramón Gonzalez (TASE) Mrs. Ana Yun Garcia (TASE) Mr. Floiran Callupe (GEOPAC) Mrs. Despoina Rizou (IGD) Mr. Luca Salvatore (MEDCOM)
Workshop in Madrid 02/02/09-05/02/09
Madrid
Mr. Alex Bernsts Tronchoni (CETA)17 Conference “Traumastation: A telemedicine tool”
Despina Rizou
MEDETEL, 14-16/04/2010 Luxembourg
18 Exhibitiom Rizou Despina: Promotion and establishment of synergies thus ensuring sustainability and dissemination of MEDNET
CeBIT, 04-06/03/2010 Hannover
19 Conference Rizou Despina: Promotion and establishment of synergies thus ensuring sustainability and dissemination of MEDNET
ICT Conference 2010, 27-29/09/2010 Brussels
20 Conference Rizou Despina: Poster presentation ITAB 2010, 02-02/11/2010 Corfu
21 Conference MEDNET poster ,HISPASAT HISPASAT representatives (HISPASAT’s president,
directives, sales managers, etc) mention MedNet project in several European and American congresses and events related to the Telecommunication and Satellite sector as well as in interviews offered in press and television.
Matelec exhibition 25/10/2010
22 Exhibition MEDNET presentation , HISPASAT Satellite 30-31/5/2008 Washington23 Conference Dr. Bruno Hochhegger, Santa Casa Hospital, Porto Alegre,
Brazil
Medetel: Latin America Health Care Network under the Global eHealth Strategy Symposium 6-8 April 201
Luxembourg
Section B (Confidential13 or public: confidential information to be marked clearly)Part B1
TEMPLATE B1: LIST OF APPLICATIONS FOR PATENTS, TRADEMARKS, REGISTERED DESIGNS, ETC.
Type of IP Rights14:
Confidential Click on YES/NO
Foreseen embargo datedd/mm/yyyy Application
reference(s) (e.g. EP123456)
Subject or title of application
Applicant (s) (as on the application)
13 Note to be confused with the "EU CONFIDENTIAL" classification for some security research projects.
14 A drop down list allows choosing the type of IP rights: Patents, Trademarks, Registered designs, Utility models, Others.
Part B2
Type of Exploitable Foreground15
Descriptionof exploitable foreground
ConfidentialClick on YES/NO
Foreseen embargo datedd/mm/yyyy
Exploitable product(s) or measure(s)
Sector(s) of application16
Timetable, commercial or any other use
Patents or other IPR exploitation (licences)
Owner & Other Beneficiary(s) involved
Ex: New superconductive Nb-Ti alloy
MRI equipment 1. Medical2. Industrial inspection
20082010
A materials patent is planned for 2006
Beneficiary X (owner)Beneficiary Y, Beneficiary Z, Poss. licensing to equipment manuf. ABC
In
1519 A drop down list allows choosing the type of foreground: General advancement of knowledge, Commercial exploitation of R&D results, Exploitation of R&D results via standards, exploitation of results through EU policies, exploitation of results through (social) innovation.16 A drop down list allows choosing the type sector (NACE nomenclature) : http://ec.europa.eu/competition/mergers/cases/index/nace_all.html
Report on societal implications
A General Information (completed automatically when Grant Agreement number is entered.
Grant Agreement Number: 215479
Title of Project: Latin America Health Care Network
Name and Title of Coordinator: Despoina RizouB Ethics
1. Did your project undergo an Ethics Review (and/or Screening)?
If Yes: have you described the progress of compliance with the relevant Ethics Review/Screening Requirements in the frame of the periodic/final project reports?
Special Reminder: the progress of compliance with the Ethics Review/Screening Requirements should be described in the Period/Final Project Reports under the Section 3.2.2 'Work Progress and Achievements'
YES
2. Please indicate whether your project involved any of the following issues (tick box) :
YES
RESEARCH ON HUMANS
Did the project involve children? YES Did the project involve patients? YES Did the project involve persons not able to give consent? NO Did the project involve adult healthy volunteers? NO Did the project involve Human genetic material? NO Did the project involve Human biological samples? NO Did the project involve Human data collection? YES
RESEARCH ON HUMAN EMBRYO/FOETUS Did the project involve Human Embryos? NO Did the project involve Human Foetal Tissue / Cells? NO Did the project involve Human Embryonic Stem Cells (hESCs)? NO Did the project on human Embryonic Stem Cells involve cells in culture? NO Did the project on human Embryonic Stem Cells involve the derivation of cells from Embryos? NO
PRIVACY Did the project involve processing of genetic information or personal data (eg. health, sexual
lifestyle, ethnicity, political opinion, religious or philosophical conviction)?YES
Did the project involve tracking the location or observation of people? NORESEARCH ON ANIMALS
Did the project involve research on animals? NO Were those animals transgenic small laboratory animals? NO Were those animals transgenic farm animals? NO Were those animals cloned farm animals? NO Were those animals non-human primates? NO
RESEARCH INVOLVING DEVELOPING COUNTRIES Did the project involve the use of local resources (genetic, animal, plant etc)? NO Was the project of benefit to local community (capacity building, access to healthcare, education
etc)?YES
DUAL USE Research having direct military use NO Research having the potential for terrorist abuse NO
C Workforce Statistics 3. Workforce statistics for the project: Please indicate in the table below the number of
people who worked on the project (on a headcount basis).Type of Position Number of Women Number of Men
Scientific Coordinator 4 7Work package leaders 2 3Experienced researchers (i.e. PhD holders) 1 4PhD Students 1 0Other
4. How many additional researchers (in companies and universities) were recruited specifically for this project?
12
Of which, indicate the number of men: 9
D Gender Aspects 5. Did you carry out specific Gender Equality Actions under the project?
YesNo
6. Which of the following actions did you carry out and how effective were they? Not at all effective
Veryeffective
Design and implement an equal opportunity policy Set targets to achieve a gender balance in the workforce Organise conferences and workshops on gender Actions to improve work-life balance Other:
7. Was there a gender dimension associated with the research content – i.e. wherever people were the focus of the research as, for example, consumers, users, patients or in trials, was the issue of gender considered and addressed?
Yes- please specify
No
E Synergies with Science Education
8. Did your project involve working with students and/or school pupils (e.g. open days, participation in science festivals and events, prizes/competitions or joint projects)?
Yes- please specify
No
9. Did the project generate any science education material (e.g. kits, websites, explanatory booklets, DVDs)?
Yes- please specify
No
F Interdisciplinarity
10. Which disciplines (see list below) are involved in your project? Main discipline17: Associated disciplineError: Reference
source not found: Associated disciplineError: Reference source not
found:
G Engaging with Civil society and policy makers11a Did your project engage with societal actors beyond the research
community? (if 'No', go to Question 14)
YesNo
11b If yes, did you engage with citizens (citizens' panels / juries) or organised civil society (NGOs, patients' groups etc.)?
No Yes- in determining what research should be performed Yes - in implementing the research Yes, in communicating /disseminating / using the results of the project
17 Insert number from list below (Frascati Manual).
Project website, Tutorial for the system use, Manuals for the software
11c In doing so, did your project involve actors whose role is mainly to organise the dialogue with citizens and organised civil society (e.g. professional mediator; communication company, science museums)?
YesNo
12. Did you engage with government / public bodies or policy makers (including international organisations)
No Yes- in framing the research agenda Yes - in implementing the research agenda Yes, in communicating /disseminating / using the results of the project
13a Will the project generate outputs (expertise or scientific advice) which could be used by policy makers?
Yes – as a primary objective (please indicate areas below- multiple answers possible) Yes – as a secondary objective (please indicate areas below - multiple answer possible) No
13b If Yes, in which fields?Education, Training, Youth Public Health
13c If Yes, at which level? Local / regional levels National level European level International level
H Use and dissemination
14. How many Articles were published/accepted for publication in peer-reviewed journals?
3
To how many of these is open access18 provided? 3
How many of these are published in open access journals? 3
How many of these are published in open repositories? 0
To how many of these is open access not provided? 0
Please check all applicable reasons for not providing open access: publisher's licensing agreement would not permit publishing in a repository no suitable repository available no suitable open access journal available no funds available to publish in an open access journal lack of time and resources lack of information on open access other19: ……………
15. How many new patent applications (‘priority filings’) have been made? ("Technologically unique": multiple applications for the same invention in different jurisdictions should be counted as just one application of grant).
0
16. Indicate how many of the following Intellectual Property Rights were applied for (give number in each box).
Trademark 0
Registered design 0
Other 0
17. How many spin-off companies were created / are planned as a direct result of the project?
0
Indicate the approximate number of additional jobs in these companies:
18. Please indicate whether your project has a potential impact on employment, in comparison with the situation before your project:
Increase in employment, or In small & medium-sized enterprises Safeguard employment, or In large companies Decrease in employment, None of the above / not relevant to the project Difficult to estimate / not possible to quantify
19. For your project partnership please estimate the employment effect resulting directly from your participation in Full Time Equivalent (FTE = one person working fulltime for a year) jobs:
Indicate figure:
18 Open Access is defined as free of charge access for anyone via Internet.19 For instance: classification for security project.
Difficult to estimate / not possible to quantify
I Media and Communication to the general public
20. As part of the project, were any of the beneficiaries professionals in communication or media relations?
Yes No
21. As part of the project, have any beneficiaries received professional media / communication training / advice to improve communication with the general public?
Yes No
22 Which of the following have been used to communicate information about your project to the general public, or have resulted from your project?
Press Release Coverage in specialist press Media briefing Coverage in general (non-specialist) press TV coverage / report Coverage in national press Radio coverage / report Coverage in international press Brochures /posters / flyers Website for the general public / internet DVD /Film /Multimedia Event targeting general public (festival, conference,
exhibition, science café)
23 In which languages are the information products for the general public produced? Language of the coordinator English Other language(s)
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