Skip to main content

iNTER Support Action (International Network of Teleconsultation Excellence & Referral)

Final Report Summary - ISA (iNTER Support Action (International Network of Teleconsultation Excellence and Referral))

Executive summary:

The ISA Project is a cooperative medical support network founded by the following institutions: Hospital Universitari Son Espases (Spain), Instituto Valenciano de Oncologia (Spain), Hospital Universitari Vall d'Hebron (Spain), Hospital Sant Joan de Deu (Spain), Hospital Regional de Bata (Equatorial Guinea), Desarrollo 2000 en Africa NGO (Equatorial Guinea), Hospital Regional Docente de Trujillo (Peru), Instituto Nacional de Cancerologia (Mexico), Centro de Cancerologia de Colima (Mexico), St. John of God Hospital (Sierra Leone), Christian Missionary Fellowship Maasai Health Ministries (Kenya), and the College of Health Sciences of the University of Nairobi in collaboration with Kenyatta National Hospital (Kenya).

The network, coordinated by Hospital Universitari Son Espases (Balearic Islands Health Service) provides web-based diagnostic and therapeutic support for complex / rare medical cases requiring specialised second opinions in different health areas (mainly infectious diseases and oncology, among a constantly growing variety of specialties). The communication among doctors and the sharing of medical cases is performed via the ISA platform (see http://www.ISAplatform.com online), a free web 2.0 tool that facilitates the transmission of medical images, videos and reports.

Strategic goals of the project include the facilitation of web communication for international knowledge exchange to develop diagnostic, therapeutic and technological support actions within Africa and Latin America, the encouragement of human resource, technology and infrastructure investment policies, the implementation of multinational web-based continuing medical education (CME) programs, the creation of clinical research groups and the extension of the ISA Platform social network for global clinical case sharing.

The main general outcome obtained by the ISA project is the technical and clinical validation of the ISA platform as an effective sustainable tool to improve healthcare and medical decision making in Latin American and African hospitals and healthcare centres. A key aspect of this validation was the consolidation and proven usefulness of clinical case sharing among primary care centres, regional hospitals and national centres of expertise in each ISA country. Under a web 2.0 social network approach, third-level ISA hospitals act as hospitals of reference to provide second opinions to smaller health centres and clinics within their territories, many of them in remote areas. The conclusion is that the ISA platform collaboration model provides an attractive, beneficial and free channel to improve the diagnosis and treatment of patients regardless of their location and resources leading this to increased social equity. Therefore, this simple and cost-effective web-based model can be offered widely to other ICPC communities where medical expertise is deeply needed and resources are limited.

In parallel to the validation of the ISA platform, the ISA project led to the definition and initial development of specific actions of strategic impact for the participating ICPC communities. In general, the future actions defined require low investments yet their social benefit is considered wide and highly valuable. For example, the development of ISA national networks in Peru and Mexico, in different medical specialties, is to improve and confirm diagnosis and treatment decisions considerably in critical diseases in which expert knowledge is crucial. These functional national models can be exported to other countries of Latin America and Africa.

ISA also included specialised trainings of key personnel of Kenya and Equatorial Guinea (continuously supported by ISA specialists of reference), which open the door to the provision of oncology services for large regions where no cancer diagnosis or treatments have ever been offered to patients. This is a major national advancement in the case of Equatorial Guinea.

From an academic point of view, the ISA platform is to grow as a valuable teaching tool for medical students worldwide, providing a free knowledge repository of real-life clinical cases with educational purposes.

The global sustainability of the ISA actions rests on voluntary knowledge and experience transfers of committed medical experts, the support of local authorities, the low technical maintenance costs of the ISA platform and simple technology that facilitates quick adoption and interaction.

The following future actions were defined as a result of the collaborations established in the ISA project:

1. ISA platform consolidation and extension
2. ISA platform Peru national network
3. Trujillo paediatric palliative care program
4. ISA platform Mexico national oncology network
5. Hospital regional de Bata pilot oncology service
6. CMF oncology day hospital
7. CMF nursery training program
8. CMF web-based network for TB management in Narok district
9. University of Nairobi lymphoma research project
10. Implementation of cost-effective molecular biology techniques
11. ISA web-based teaching program
12. Kolda-Dantec tele-ophthalmology project

Project context and objectives:

The ISA project (see http://www.theISAproject.eu online) is an international cooperative network of health professionals pertaining to the following organizations:

Hospital Universitari Son Espases of Palma de Mallorca (Spain) Servei de Salut de les Illes Balears (SSIB) (Coordinator)
Instituto Valenciano de Oncologia of Valencia (Spain) IVO
Hospital Universitari Vall d'Hebron of Barcelona (Spain) ICS
Hospital Sant Joan de Deu of Barcelona (Spain) HSJD
Hospital Regional Docente de Trujillo (Peru) HRDT
Instituto Nacional de Cancerologia de Mexico (Mexico) INC
CMF Maasai Health Ministries (Kenya) CMF
College of Health Sciences of the University of Nairobi (Kenya) UON
Kenyatta National Hospital of Nairobi (Kenya) KNH

Additionally, the network counts on the participation of the following institutions:

Hospital Regional de Bata (Equatorial Guinea) HRB
Saint John of God Hospital (Sierra Leone) SJG
Instituto Nacional de Enfermedades Neoplasicas (Peru) INEN
Instituto Regional de Enfermedades Neoplasicas (Peru) a IREN
Hospital Belen de Trujillo (Peru) HBE
Centro de Cancerologia de Colima (Mexico) COL
Desarrollo 2000 en Africa (Spain) D2A
C2C Consultoria TSIS, S.L. (Spain) C2C

The 30-month initiative, launched in September 2009 by SSIB, provides web-based diagnostic and/or therapeutic support for complex and/or rare medical cases requiring specialized second opinions in different specialties (mainly infectious diseases and oncology, among a growing variety of specialties).

The founding ISA workgroup gathers nearly 50 doctors of Europe, Latin America and Africa, who use the ISA platform (see http://www.ISAplatform.com online) to discuss clinical cases in order to share knowledge and improve diagnostic and therapeutic decisions. The ISA platform facilitates the exchange of medical images and reports through the internet. The tool integrates a medical image management module that permits the upload and review of both radiological (CTs, MRIs) and non-radiological images (anatomic pathology, dermatology, etc).

The strategic objectives of the ISA project are the following:

1. To create a constantly growing international cooperative network of medical, technical, and administrative staff in order to facilitate the exchange of knowledge for the implementation of diagnostic, therapeutic, technological, and management support actions within Peru, Mexico, Kenya, Equatorial Guinea and Sierra Leone. Successful pilot collaborative models validated in these countries shall be exported to other health systems of Latin America and Africa.

2. To encourage investment policies regarding human resources, technology, and infrastructures among local authorities and health organisations in order to transmit a vision of progress, strengthen local commitment, and ensure the sustainability of the intended support actions within the ICPC territories.

3. To implement multinational online CME programs in order to improve medical knowledge, skills, and professional performance. These web-based CME programs shall stimulate interaction among doctors and students of different countries benefiting all the hospitals and universities of the ISA network.

4. To promote the creation of clinical research groups focusing on the occurrence, diagnosis, and treatment of specific pathologies in diverse territorial contexts with particular interest in frequent diseases within the implicated ICPC areas (i.e. cavum carcinoma, AIDS, etc.)

5. To evaluate the technical feasibility and added value of deploying a cost-effective web 2.0 tool (see http://www.ISAplatform.com online) for clinical case exchange incorporating a software module that facilitates the upload and review of both radiological and non-radiological images without the need of costly equipment such as picture archiving computer systems (PACS).

6. To contribute to the implementation of Framework Programmes and the preparation of future European Community research and technological development policies.

Project results:

Period 1: September 2009 to February 2011

The first 18 months of ISA focused on the creation of the ISA workgroup, the presentation and dissemination of the action, the setup and launch of the ISA Platform, initial discussions of clinical cases and the beginning of specific subprojects in some ISA countries.

One of the key achievements of the first period was the creation of a workgroup composed of medical, technical and administrative personnel of each ISA partner. The ISA workgroup includes the ISA executive committee and 9 teams specialised in infectious diseases, paediatric oncology, adult oncology, anatomic pathology, molecular biology, dermatology, information technology, management and administration (65 members in total).

A second major goal during the first three semesters was the presentation and dissemination of the action within the ISA territories and to the public at large. The main promotion tool was the project's site (see http://www.theISAproject.eu online). During the first stage, members of SSIB, IVO, ICS and HSJD visited Sierra Leone, Peru, Mexico and Equatorial Guinea to strengthen collaboration relationships and promote the initiative locally. Preliminary meetings were also held in Kenya before September 2009.

ISA was presented to the public at large at the ISA presentation event celebrated in the University of the Balearic Islands of Palma de Mallorca (26 February 2010). A representative of each ISA partner attended this event along with local authorities.

The ambassadors of Kenya and Equatorial Guinea in Spain, and a minister of Peru were also present. The event was intensively disseminated via the internet, TV and newspapers. In addition, ISA was presented in conferences held in Barcelona, Badajoz and Boston.

During the first semester the clinical and technical teams of ISA defined the requirements of the ISA platform. The application was programmed by SSIBs informatics staff and made available to users by May 2010. The Spanish eHealth SME C2C provided support to integrate a medical image management module to enable web-based exchange of clinical pictures through the platform. These tools were constantly improved in terms of functionalities and usability.

By February 2011, a total of 180 users and 75 organisations of 28 countries worldwide were registered in the ISA platform. Users uploaded and exchanged opinions on 147 clinical cases (69 in infectious diseases, 23 in paediatric oncology, 40 in adult oncology, 11 in dermatology and 4 in primary care).

Subprojects in some ISA countries began such as the creation of the first web-based regional network aimed at improving the management of tuberculosis (TB) patients in La Libertad Region, Northwestern Peru. In this action the Center of Excellence of Pulmonary Health of HRDT acts as centre of reference to provide support to a pilot network of 25 primary care centres in the region. The project counts on the approval of the Telehealth Unit of the Gerencia Regional de Salud La Libertad, as part of the implantation of telemedicine in the regional health system. This experience led to the implementation of the same concept in Kenya, where CMF Maasai Health Ministries work in the creation of an ISA-based network to manage TB patients in Narok district.

ISA also established a teaching program at the Universidad Nacional de Trujillo (UNT) (see http://www.unitru.edu.pe online) as medical students are evaluated according to their comments on ISA platform cases. As of February 2012, 48 UNT students were registered in the platform.

Period 2: March 2011 to February 2012

Consolidation and extension of the ISA platform

During period 2 the deployment of the ISA platform was consolidated and extended. By 30 April 2012, the platform counted a total of 335 users, 119 organisations and 33 countries. Users exchanged opinions on 265 clinical cases (102 in infectious diseases, 24 in paediatric oncology, 75 in adult oncology, 30 in dermatology, 17 in general paediatrics and 17 in primary care). The ISA platform will be used beyond the 30 months of the pilot phase and it will be progressively extended to more users and countries in the years ahead. The platform can operate in a sustainable manner via voluntary contributions of existing and new qualified health specialists. Future basic technical maintenance costs (hosting, support) can be covered by the project coordinator (SSIB).

Strategic medical trainings

In line with ISA teaching goals, strategic medical trainings were carried out at SSIB in cooperation with CMF and HRB. Firstly, a clinical officer of CMF, Leonard Loontaye, completed a three-month training period (January to March 2011) in infectious diseases, microbiology and oncology at SSIB.

Secondly, an internist from HRB, Rosa Nora Mananga, visited SSIB to perform a 45-day training in oncology (November - December 2011). The main goal was to train Rosa Nora in basic oncological diagnostic and therapeutic procedures so that she can start the establishment of a pilot oncology service in HRB (where there are neither diagnosis nor treatments in oncology).

Web-based clinical sessions

In parallel with the asynchronous consultations of the ISA platform, doctors held videoconference-based multipoint clinical sessions in order to review clinical cases in real time. Videoconference activities began in May 2011 and continued to present.

Key meetings

The key meetings celebrated in period 2 were training evaluation meetings with Leonard Loontaye and Rosa Nora Mananga (from CMF and HRB, in March and December 2011 respectively). SSIB infectious diseases specialist Maria Penaranda visited CMF headquarters in Ewaso Ngiro (Kenya) to hold follow-up meetings, promote results and provide support in patient care (April 2011). Mercedes Guibelalde and Angela Tavera, paediatric oncologists of SSIB, carried out follow-up and result presentation actions at HRDT, Hospital Belen, IREN and INEN during May and June 2011. In October 2011, Maria Penaranda presented ISA Platform results at HRB in Equatorial Guinea. A follow-up meeting was celebrated at Hospital Universitari Son Espases (SSIB) in February 2011 to inform about the general progress of the action and main results. In addition, Mercedes Guibelalde presented ISA results at 43rd Congress of the International Society of Paediatric Oncology (SIOP) (October 2011, New Zealand) and HSJD Telemedicine Manager Carlos Fabrega disseminated conclusions at the VIII Forum Iberico de Telemedicina (Alandroal, Portugal) on 18 November 2011. Finally, a technical meeting for the adoption of the ISA platform by the Ministry of Health of Peru was organised on 21 March 2012. Additional dissemination meetings were planned beyond February 2012.

Potential impact:

Potential impact of the ISA platform

The main general outcome obtained by the ISA project was the technical and clinical validation of the ISA platform as an effective sustainable tool to improve healthcare and medical decision making in Latin America and Africa. A key aspect of this validation was the consolidation and proven usefulness of clinical case exchange activities via web among primary care centres, regional hospitals and national centres of expertise in each ISA country. Under a web 2.0 social network approach, third-level ISA hospitals can act as hospitals of reference to provide second opinions to smaller health centres and clinics within their territories, even though these might be located in remote areas. The conclusion is that the ISA platform collaboration model provides an attractive, beneficial and free channel to improve the diagnosis and treatment of patients regardless of their location and resources leading this to increased social equity. Therefore, this simple and free web-based model can be offered widely to other ICPC communities where medical expertise is deeply needed and resources are limited.

Potential impact of ISA-related subprojects and future actions

Along with the validation of the ISA platform, the ISA project led to the definition and initial development of specific subprojects of strategic impact for the participating ICPC communities. In general, the future actions defined require low investments yet their social benefit is considered wide and highly valuable.

The development of ISA national networks in Peru and Mexico, in different medical specialties, is to improve and confirm diagnosis and treatment decisions considerably in critical diseases in which expert knowledge is crucial. These functional national models can be exported to other countries of Latin America.

The specialised trainings of key personnel of Kenya and Equatorial Guinea (continuously supported by ISA specialists of reference) open the door to the provision of oncology services for large regions where no cancer diagnosis or treatments have ever been offered to patients. This is a major national advancement in the case of Equatorial Guinea.

From an academic point of view, the ISA platform is to grow as a valuable teaching tool for medical students worldwide, providing a free knowledge repository of real-life clinical cases. Various universities from different countries are already registered in the ISA platform.

The global sustainability of the ISA actions rests on the voluntary communication of knowledge and experience by committed medical experts, the support of local authorities, the low technical maintenance costs of the platform and simple free technology that facilitates quick adoption and interaction. This approach is to favour fast extension and long term sustainability.

The following actions were initiated within the scope of the ISA project and they will be further developed in months ahead:

1. ISA platform consolidation and extension. To continue using the platform after the pilot phase. To involve more users and institutions. All partners. Interconsultation activities continued with success. More specialists and centers were added. Further deployment of the platform. Promotion of the tool via different means. Introduce the platform in more countries.

2. ISA platform Peru national network. To use the ISA platform at national level. HRDT, Hospital Belen, IREN, INEN, SSIB, MINSA. Technical meetings of HRDT, MINSA and SSIB to plan the nationwide use of the tool in Peru. Preliminary tests. To sign collaboration agreement for national use of the platform. Official launch of the platform by MINSA.

3. Trujillo paediatric palliative care program. To implement a pediatric palliative care program in Trujillo. SSIB, HRDT, Hospital Belen. Presentation of the program. Initial plan for start-up. Additional technical meetings for the launch of the program.

4. ISA platform Mexico national oncology network. To extend the ISA platform to all INC centres. INC, IVO, SSIB. The platform has been used by INC central hospital in Mexico City and Centro de Cancerologia of Colima. To propose the use of the platform by all the INC network (several oncological centres in various regions).

5. Hospital regional de Bata pilot oncology service. To start diagnosis and treatment of cancer patients in Equatorial Guinea. HRB, D2A, SSIB, IVO. Rosa Nora Mananga was trained in basic concepts of tumour diagnosis and treatment (chemoterapy). Some patients have been diagnosed and treated in the distance with SSIB support. To implement a sustainable model to diagnose and treat cancer patients at HRB via close communication with the ISA network.

6. CMF oncology day hospital. To create a day hospital service for cancer patients at CMF Ewaso Ngiro centre. SSIB, CMF, KNH. Leonard Loontaye was trained in basic oncology management (treatment and diagnosis). Plans for chemotherapy treatments at CMF discussed with KNH. To complete the design of the CMF day hospital and start treating patients in cooperation with KNH and SSIB oncologists.

7. CMF nursery training program. To provide support for the training of nurses. SSIB, CMF, KNH. SSIB designed and proposed a nursery training program to CMF managers. To carry out interviews with candidates, select the person to be trained and start training in August 2012.

8. CMF web-based network for TB management in Narok district. To create electronic database for TB patients. CMF, SSIB. CMF launched and developed TB management program. The program is already operative. Data entry fields defined. To develop electronic database and collect and process patient information via the ISA web tool.

9. University of Nairobi lymphoma research project. To define the factors behind heterogeneity of AIDS-associated non-Hodgkin's lymphomas in the era of HAART in Africa. KNH, SSIB, IVO. Project proposal written. Research to be started.

10. Implementation of cost-effective molecular biology techniques. To implement cost-effective techniques in molecular biology at KNH. SSIB, KNH. Implementation goals and requirements were defined (in-house PCR). Setup meeting in July 2012, trainings, and start-up of the techniques.

11. ISA web-based teaching program. To create an international community of medical students for teaching purposes. All partners. HRDT already implemented and validated a teaching network with the Universidad Nacional de Trujillo. To promote the use of the ISA web-based teaching program in more universities worldwide.

12. Kolda-Dantec tele-opthalmology project. To launch tele-ophtalmology network based on ISA platform. HSJD, SSIB, Dantec, Kolda centre. Project proposal written. Technical meetings for start-up with Dantec and Kolda centres (Senegal).

Dissemination activities

Months 1 - 18

Presentation and technical meeting at Saint John of God Hospital, Lunsar, Sierra Leone, 28 October 2009
Presentation meeting at Instituto Nacional de Enfermedades Neoplasicas (INEN), Lima, Peru, 7 January 2010
Presentation and technical meeting at Hospital Regional Docente de Trujillo, Trujillo, Peru, 8 January 2010
Presentation meeting at Facultad de Medicina of Hospital Regional Docente de Trujillo, Trujillo, Peru, 8 January 2010
Presentation meeting at Hospital Belen, Trujillo, Peru, 8 January 2010
Presentation meeting at Instituto Regional de Enfermedades Neoplasicas (IREN), Trujillo, Peru, 8 January 2010
ISA Public Presentation Event University of the Balearic Islands Palma de Mallorca, Spain, 26 February 2010
ISA Technical Meeting for all ISA partners, Palma de Mallorca, Spain, 26 February 2010
Project presentation and technical meeting at Instituto Nacional de Cancerologia de Mexico, Mexico City, Mexico, 19 March 2010
Project presentation and technical meeting at Centro Estatal de Cancerologia de Colima Colima, Mexico, 20 March 2010
Project presentation and technical meeting at Hospital Regional de Bata, Bata, Equatorial Guinea, 2 July 2010
Technical meeting of ISA Information Technology Group at Son Espases Hospital (new Son Dureta), Palma de Mallorca, Spain, January 2011

Months 19 to end

Evaluation meeting for medical collaboration of Maria Penaranda and presentation of ISA platform results and conclusions (SSIB infectious diseases specialist) at CMF Kenya, Ewaso Ngiro, Kenya, 18 April 2011
Medical meeting of Mercedes Guibelalde and Angela Tavera (SSIB pediatric oncologists) and presentation of ISA platform results at Hospital Regional Docente de Trujillo, Trujillo, Peru, 29 May 2011
Medical meeting of Mercedes Guibelalde and Angela Tavera (SSIB paediatric oncologists) and presentation of ISA platform results and conclusions at Hospital Belen, Trujillo, Peru, 29 May 2011
Medical meeting of Mercedes Guibelalde and Angela Tavera (SSIB pediatric oncologists) and presentation of ISA Platform results and conclusions at Instituto Regional de Enfermedades Neoplasicas (IREN), Trujillo, Peru, 30 May 2011
Medical meeting of Mercedes Guibelalde and Angela Tavera (SSIB paediatric oncologists) and presentation of ISA platform results and conclusions at Instituto Nacional de Enfermedades Neoplasicas (INEN), Lima, Peru, 1 June 2011
Presentation of ISA results at 43rd Congress of the International Society of Pediatric Oncology (SIOP) By Mercedes Guibelalde, Auckland, New Zealand, 29 October 2011
Follow-up meeting of the ISA Project at Hospital Regional de Bata and presentation of ISA Platform results (visit of SSIB infectious diseases specialist Maria Penaranda), Bata, Equatorial Guinea, 31 October 2011
Presentation of ISA results at VII Forum Iberico de Telemedicina (by Carlos Fabrega HSJD), Alandroal, Portugal, 18 November 2011
Presentation of ISA Platform results and conclusions at Hospital Universitari Son Espases, Palma de Mallorca, Spain, 15 February 2012
Technical meeting for the adoption of the ISA Platform by the Ministry of Health of Peru and presentation of ISA Platform results, Lima, Peru, 21 March 2012
Presentation of ISA results (poster) at SIOP Africa (International Society of Pediatric Oncology) Mercedes Guibelalde (SSIB), Cape Town, South Africa, 22 March 2012
Presentation of ISA platform results and conclusions at Kenyatta National Hospital and University of Nairobi, Nairobi, Kenya, 18 July 2012
Presentation of ISA platform results and conclusions at 30th Mexican National Congress of Oncology, Guadalajara, Mexico, 25 October 2012

List of websites:
http://www.theisaproject.eu
http://www.isaplatform.com

Related documents