The Prof. Dr. Juan Pedro Garrahan Pediatric Hospital in Argentina, is a high complexity medical institution that, since 1997 has been developing the first telemedicine program in the country.
The project, called Referencia-Contrarrefencia (Reference-Counterreference), promotes healthcare nexuses at provincial and regional level and seeks to achieve equality of access to specialized medical consults.
The pediatrician Joaquín Héctor Gonzalez is the head of the Remote Communication Department at the hospital and for the last 25 years he has been working as a doctor in the communications office of the hospital. In this interview he explains how the inter-provincial program began, what it consists of and how it works.
How did the idea of implementing telemedicine at the Garrahan Hospital arise?
The program started at the Day Hospital in 1997; improved internet service in the country allowed us to work from point to point at hospitals. Since its implementation, it has dealt with around 50 thousand consults and 80% of patients did not need to go to a hospital in the city of Buenos Aires.
What were the motives behind the project?
There were several: we had kids travelling a long way with a disease that was aggravated by the trip; we admitted children who arrived without clinical information and once the treatment was over we didn’t have anyone to send it to because we didn’t know who their head doctor was; we treated patients who could have been treated perfectly well where they lived; the list goes on…
How does the appointment administration system work?
There are scheduled appointments, this allows a patient in the interior of the country who arrives in the morning to be admitted at a certain hour to do the tests and consults they need. Within 8 hours, they will get a summary of the examination or a conclusion, we try to do everything within 24/48 hours. In fact the appointments are scheduled taking into account that the patient will be in the hospital for two days.
Furthermore, after scheduling the appointment, we get in contact with the place where the child is usually treated and, through social services, and arrange for the transfer, bearing in mind that they’re going to be in Buenos Aires for less than a day. Then we decide where they’re going to spend the night, be it in Casa Garrahan or an external lodging.
Do you only work with public hospitals?
It’s difficult to combine work with public and private hospitals. For now, we only work with public hospitals because we don’t do any for-profit work, although every now and again we make an exception.
We are well enough equipped that we don’t need the services of private hospitals, but they make a profit by billing for services we provide for free.
In any case, in the province agreements are being signed with the private sphere; especially those with health insurance in the province, who are considered public patients but in fact aren’t.
What plans are being developed at the national level?
There is a subsidy from the International Development Bank (IBD) to the Ministry of Science and Technology to equip 140 hospitals with videoconferencing apparatus, an IP telephone network and a website.
All the equipment will be sent to leading hospitals and the 23 Health Ministries and used for teaching and consults between centers. A new project was also added by the Ministry of Planning through the Ministry of Science and Technology after an agreement with the Ministry of Health, which will include videoconferencing equipment for other hospitals to create a network for pre-natal and adult care.
This network would be implemented in 90% of cases at the same healthcare institutions with which we are working because most of them are not exclusively for children: we work in the network focusing on pediatric issues, which is our field of expertise, but we are planning to make use of the same offices, infrastructure and contact links as the pediatric network to create a network for adults and pre- and post natal care.
How do you work with the provinces?
The system we used with hospitals from other provinces up until 2001/2002 created a breach with the local system. For example, to take the case of Neuquen: we realized that we were working with the Zapala Hospital, which is mid-level in terms of complexity, and the doctors, instead of consulting with the central hospital in the province, consulted us. They ended up sending patients to us when they should have been moved within the province to make the system more efficient: they came to Buenos Aires for things that could have been resolved there.
Then we changed our objective and decided to set up a network of leading pediatric hospitals in each province and also to allow each province to generate its own internal network.
In Neuquén there’s one central nexus but, for example in Rio Negro there are four units of the same complexity: Bariloche, General Roca, Cipolletti and Viedma. The province does not have a central nexus where everyone goes, rather public health is distributed across four poles. We respect that local reference, we try to interact with them and work on the understanding that they are developing four nexus and emphasizing that the network is set up for and by the province.
How are local networks being set up in the provinces?
We still need to set up regional links between the provinces. The telemedicine system that we are developing seeks to improve the capacity for cases to be resolved locally.
In my opinion, telemedicine can be divided into two systems:
1. A health network: a bus goes from the Garrahan to a province with specialists and equipment, patients are treated, the bus leaves and nothing is left behind.
2. A Reference-Counterreference Program, which is what we’re developing. This is a collaborative strategy; via remote communication tools, links are made that allow specialists to be trained at a local level. For example, a province finds that it needs neurologists and they have someone who wants to work as a neurologist in the hospital. Let’s suppose that they’ve already done their residency and that they are the right age for training, there’s an entrance exam for a grant to study at the Garrahan and train as a specialist.
Does the Garrahan treat everyone who comes to the hospital or does it divert patients that are not highly complex cases?
Lots of patients come with respiratory pathologies that aren’t highly complex but seasonal and there are a lot of hospitals that can treat them. In any case, if someone comes to the hospital they’re treated. The cases that aren’t very complex, that don’t require intensive therapy, receive outpatient treatment.
Doesn’t this system overwhelm the Hospital?
This is a hospital that was planned to treat highly complex cases, but it is also open: people can come from anywhere for treatment. When a patient arrives, they are met by a doctor to guide them. We need to make sure that the patients who can’t be treated anywhere else are attended to.
What role does the Electronic Health Record (EHR) play in the telehealth program?
The EHR is implemented in very few countries, there are several projects being debated, but so far none has been implemented. Thus far the system works via fax, which is what we had when we began. We added an email system to send images that we previously needed to post.
What is the national and continental outlook for telehealth?
We are seeing progress. Our program is part of a collaboration with the Ministry and the opportunity to implement a fiber option network as part of the Argentina Connected plan is very promising.
We could take advantage of that network to connect videoconferences and create a very important platform to link all the hospitals in the network.
Brazil, for example, has a fairly significant telemedicine network. From what we’ve seen, they have a program based around a university center for general medical consults to treat groups in rural areas. What they don’t do, in comparison to our program, is manage information there and back again.
They consult the university center about a patient, offer an opinion about the procedure to carry out or whether they need to be admitted and then the general practitioner in the rural area needs to find out where to send them. The videoconference functions as an online consult about what needs to be done and the doctor must continue with what the patient requires, they haven’t integrated the system with a program of what to do next.
The Pan American Health Organization (PAHO) is working on a program, like a virtual clinic, that failed due to connectivity problems. A pilot program was tried in Jujuy but it was delayed by connectivity problems. The health network issue, a network designed as an integrated health service network, is on the WHO’s agenda.
