Using telemedicine to strengthen medical systems in limited-resource countries

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Figure 1: IBOT strategy for establishing telemedicine in developing countries

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The TMPK consists of the Telemedicine Centre of Kosova (TCK) and six regional telemedicine centers. 1. Kosova map (for orientation see number 3). 2. Dr. Ismet Lecaj, Director of TCK (in white coat), demonstrating a telemedicine consultation unit. 3. Regional map of Europe and the Balkans. 4. Many operations are broadcast to an electronic auditorium both from local operating rooms and from abroad. 5. Flamur Bekteshi, IT Engineer, Technical Director, demonstrates telemedicine equipment to physicians in regional telemedicine in Gjakova. Dr. Dashurije Koshi, director of the regional telemedicine, is seated center in white coat. 6. Christina Miner from the U.S. State Department with the staff of the TMPK. 7. The TCK sign.

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In the telemedicine program of Albania, each center has a consultation room, a conference room equipped with a state-of-the-art videoconference system, a smaller “board” room and electronic library, and other premises for research, development, and administration. Currently there are nine functional centers in six cities. 1. Map of Albania. 2. Telemedicine consultation unit. 3. Telemedicine leadership training program. Leadership of hospitals of Albania in Arizona were led by Professor Pellumb Pipero, Ministry of Health of Albania—first row, sitting between Dr. Ronald Weinstein (left) Director of Arizona Telemedicine Program and Dr. Latifi (right). 4. Dr. Erion Dasho, ophthalmologist and coordinator of the telemedicine program of Albania, lecturing at a regional hospital of Albania. 5. Conference room with modern videoconferencing equipment. 6. Medical staff of Korça, a southern city of Albania. 7. An electronic library.

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A virtual educational program—one of the most important parts of a telemedicine program. Main photo: medical students from the Medical Faculty of Prishtina and from the University of Arizona (UA) discussing a research paper. Inset: Dr. Witty, professor of surgery at UA, and Dr. Latifi participating in the discussion of the papers.

Without question, surgical volunteerism has produced great results for thousands of patients. However, the real, long-term effects of surgical volunteerism, especially as a method of sustainably improving medical systems, is unclear.

At the University of Arizona, Tucson, we have created an international telemedicine program that spans several countries in the developing world. Program organizers anticipate that this program will be useful in developing a sustainable form of surgical volunteerism. More specifically, this program is proving useful in the creation of a technical infrastructure for telemedicine and an e-health application that will become part of the fabric of the local medical systems.

Telemedicine’s role in global outreach

Telemedicine has played a key role in expanding health care access in many developing countries and remote areas around the world. However, real concerns remain that the full potential of telemedicine has yet to be realized.1

In 2002, Dr. Latifi, the author of this article, and his collaborators established the first telemedicine center in the Balkans, the Telemedicine Centre of Kosova (TCK), as part of the International Virtual e-Hospital (IVeH) concept, which has significantly advanced telemedicine and e-health services in that region. Establishment of the center was an important step toward improving the quality and availability of medical services in a region where the health care infrastructure and resources had been decimated by war, neglect, lack of funding, and mismanagement.2 The success of the IVeH in Kosova has led to the development of similar programs in other Balkan countries and developing nations.

This article describes the strategy that we have implemented in the Balkans. This strategy could be used as a model for a new sustainable form of surgical volunteerism or high-tech volunteerism.

Four-phase strategy

Program organizers at the University of Arizona have created a comprehensive, four-phase strategy—Initiate-Build-Operate-Transfer (IBOT)—to establish telemedicine and e-health educational services in developing countries (see Figure 1).3,4 The individual phases may be described as follows:

Initiating phase: Assess the local context and collaborate
This first phase in the IBOT strategy is structured to provide the nation’s leadership with a broader understanding of telemedicine and the necessity of establishing such a program. It starts with an assessment of the utility of instituting a telemedicine program based on the answers to the following questions:

  • What is the level of need for a telemedicine program in the country or region?
  • Does the political support exist for such a program? Will local officials, physicians, and the Ministry of Health support and endorse the program?
  • Does the nation or region have the technical infrastructure in place to support the program?
  • Are the people of the country or region interested in receiving training in telemedicine and, in the future, independently running the program?
  • What types of clinical services and educational programs are needed?

However, the overarching question of this assessment process is:

  • Once established, usually by external donors, will the telemedicine program be sustainable?

If suitable answers are determined for these questions, then the IVeH will look for funding, often in collaboration with, and/or on behalf of, the country. The IVeH will write a grant proposal and search for financing, usually from external sources. Once financial support for the project has been secured, the group presents intensive telemedicine and e-health seminars on such topics as telecommunication, clinical applications, and services that may be implemented through telemedicine, data security, virtual educational programs, planning and implementing electronic libraries, and related business and financial issues.5 Bringing together the relevant local stakeholders, including key politicians and other government officials, these prestigious and informative seminars, conducted by world-renowned telemedicine experts, show how different governmental agencies and universities can collaborate to provide care to patients and support to clinicians. Most of the seminars share the same basic content and usually are conducted by more than one group of experts, but the initial seminars in particular are often tailored to the unique medical needs of a specific country or region.

To date, more than 1,500 medical, technical, administrative, and military professionals from various countries have attended our seminars in Kosova (2002), Albania (2007), Macedonia (2009), and Montenegro (2010).6,7 The seminars have served as galvanizing events, enabling a large number of health professionals to develop new capabilities. Physicians, nurses, students, information technology personnel, hospital administrators, government officials, politicians, and numerous others have actively participated in these presentations.1

Building phase: Create a robust infrastructure
The details of the building phase are based on the initial technical assessment and on the goals of the project. The four main steps of this phase are as follows:

  • Build the network
  • Develop the main physical telemedicine center with the necessary space for an electronic auditorium, training areas, servers, administrative offices, and, ideally, additional resource or educational rooms
  • Establish the electronic medical library
  • Produce training and educational opportunities so that local personnel can independently run the program and effectively offer clinical and educational services in the future

The backbone of any telemedicine program is its network infrastructure and available bandwidth with optimal configuration and hardware. In each country, we require the establishment of a virtual private network that connects the national telemedicine center (usually based at the country’s university clinical center) with regional telemedicine centers (RTCs) based at major hospitals in the area. This connectivity is based on fiber-optic lines provided by the local telecommunications company or on some other form of Internet communications technology, including 3G, 4G, and so on. Regardless of what type of connection is established, it should be dedicated, secure, and compliant with the Health Insurance and Portability Act’s privacy rules, due to the fact that most of the funding has come from various organizations in the U.S. It also needs to be managed locally.

In IVeH’s current programs, communications are supported by a Polycom VSX 7000 view station for point-to-point and multipoint communications via a Polycom MGC-25 Multiconferencing Unit or via some other product or technology. All communications should be capable of recording and streaming live on the Internet for educational purposes. In addition, our telemedicine program uses a redundant technological system for educational programs, the electronic library, and teleconsultations. In each emergency room of every hospital involved in the program, we use a MedVizer clinical telemedicine consultation unit that is independent of the electronic library and of the educational videoconferencing system.

In addition, a physical space that will serve as the main center of operations must be established. It is from this site that content will be dispersed and communication among the regional centers will be coordinated. This control center should house an electronic auditorium, training areas, servers, and administrative offices. Additional resource or educational rooms, such as simulation laboratories and smaller video-enabled conference rooms, provide additional flexibility and are highly advisable and encouraged. Such amenities add a special character and depth to the center, empowering leaders to undertake new, smaller-scale projects. Sophisticated computerized classrooms will facilitate the diffusion of the latest information to medical personnel. The main center should be connected to the local institution’s operating rooms and other auditoriums and classrooms, fostering integration of telemedicine into overall medical operations and thus avoiding the perception of the telemedicine center as an isolated place within the institution and the country.

Because universities and medical schools in developing countries cannot afford subscriptions to expensive medical scientific journals, they rely on written manuscripts from professors and other faculty members. Yet, the cost of even those print materials often is prohibitive. Creation of an electronic medical library, using the World Health Organization’s (WHO’s) Health Internetwork Access to Research Initiative (HINARI) and other resources, such as Landes Bioscience, or other open resources, has been extremely beneficial in supporting the cognitive needs of the medical community. In 2009, at the TCK, approximately 2,000 continuing medical education (CME) certificates were awarded to physicians and nurses in Kosova, 18 international teleconsultations were conducted, 138 videoconferences, lectures, and seminars were held, and more than 9,000 individuals visited the TCK e-library. These data show that the Telemedicine Program of Kosova (TMPK) has been an efficient mechanism for CME and a sustainable model for rebuilding the medical system. TMPK has been successful in offering physicians, nurses, and other medical professionals access to electronic information. The library benefits all health care workers, medical students, residents, other trainees, and, ultimately, patients.

Established in 2002, HINARI is a cooperative program comprising WHO, publishers, and various national medical libraries. This program provides online access to 7,000 biomedical journals, and offers robust search engine functionality. Physicians, nurses, students, and other library users have constant, password-protected access to HINARI, even from their homes. Each telemedicine center can modify access to library materials as it deems appropriate. Conveniently offering remote access to the latest in evidence-based medicine, the electronic library is one of the most important segments of an integrated telemedicine and e-health educational program for developing countries.

The operating phase is likely the most challenging phase of the IBOT strategy. As the capacity-building phase, this part of the process focuses on creating telemedicine experts, ambassadors, and champions. In developing countries, new institutions or new concepts are sometimes met with hesitation from those who will benefit the most—medical professionals. Without health care professionals on board who are able and willing to lead the program, it cannot be sustained. Therefore, for the first two to three years of each telemedicine program that we help launch, we pay special attention to training and educating staff who can independently run the program—including technical, educational, library, clinical, research, development, financial, and managerial staff. This all-inclusive concept is of the utmost importance. No matter what their area of specialization, all staff members are the future leaders of the program.

Transferring phase: Turn the program over to a local institution
Ideally, in this fourth and final phase of IBOT, the completed telemedicine program is turned over to the local public institution that it primarily serves. The Ministry of Health of that country becomes the official “owner” of the telemedicine center and equipment. Institutionalization of telemedicine is vital for sustainability; it must become an integral, long-term part of standard protocols and procedures.

The IBOT strategy has now been adopted by a number of the world’s developing countries. IVeH has found that full incorporation of the four-phase implementation process is dependent on the following elements: flexibility in the architectural design of the network and infrastructure; multidisciplinary and functional interoperability of well-trained, actively participating individuals and teams; delivery of effective consultative clinical services; locally relevant, structured educational content through discipline-specific seminars and leadership courses; professional dedication; strategic flexibility; continuous advocacy; and development of specific indicators that go beyond creating a program or center.10
Successful implementation

Using the IBOT strategy, the IVeH has now established the telemedicine program in Kosova (2002–2007) and in Albania (2008–2011). Each of those programs consists of a national telemedicine center in the nation’s capital, Prishtina and Tirana, respectively, as well as an array of RTCs in the Kosovo communities of Gjilan, Prizren, Gjakove, Peja, Mitrovica, and Skenderaj (see Figure 2) and in the Albanian towns of Shkodra, Kukesi, Durresi, Vlora, and Korqa (see Figure 3.) In addition, Albania has two additional hospitals participating in Tirana, a gynecology and maternity hospital, and a regional autism center. Both of the national telemedicine centers and all of the RTCs have the capability to provide clinical services, virtual educational programs, an electronic library, and technical support. Since the inception of these two programs, 16 hospitals have maintained a functional telemedicine network, with effective local leadership in place for the long term.

Using the same IBOT strategy that has worked so well in Kosova and Albania, the IVeH has initiated the development and/or implementation of national telemedicine programs in Macedonia, Montenegro, Moldova, Gaza, Palestine, Cape Verde, Tanzania, Nigeria, and Southeast Asia. Each of these newer programs is supported by the local Ministry of Health but funded by different organizations that play crucial roles in the region in both health care and education. For example, the U.S. Agency for International Development—also known as USAID—in Albania and the U.S. Army Corps of Engineers have both supported the program development and reconstruction of telemedicine centers in Albania.

The IVeH has received three significant awards for its efforts to promote telemedicine and e-health. In June 2011, the Computerworld Honors Program awarded to the IVeH the prestigious 21st Century Achievement Award in the Health category. The award recognizes the utility of the IBOT strategy and its successful implementation in Kosova and Albania. Then, in December 2011, the Utilization Review Accreditation Commission and the Care Continuum Alliance awarded the 2011 International Health Promotion Award in the International Community Health category to the IVeH. Most recently, the IVeH and the seven telemedicine centers in Kosova received the 2011 Visual Communications User Application Healthcare Award at the Telepresence and Videoconferencing Editor’s Choice Awards ceremony.

More work to do

Overall, telemedicine has made great strides, from both a research standpoint and an organizational standpoint. We do need, however, to harness new and innovative concepts, such as smartphone health apps, as long as they are clinically sound, secured, and deployable. We also need to further test their potential effectiveness as principal components of the existing infrastructure.

IVeH previously published data on the cost-effectiveness of the telemedicine program of Kosova.9 Yet clearly, more vigorous analysis of these programs is needed. We await research by other, impartial investigators to demonstrate the strengths and weaknesses of the IBOT strategy in other parts of the world.

It goes without saying that just like in any other surgical mission, the implementation of telemedicine programs in developing nations requires the involvement of people who are passionate about their work and are willing to make personal and professional sacrifices. The intellectual and emotional satisfaction resulting from working with these programs, however, is enormous and most fulfilling, particularly when one considers the sustainable potential impact on patient care in developing countries. Moreover, for those of us who have moved to the U.S. and made it our home, these programs make virtual return possible anytime, anywhere.

The author wishes to thank all the members of the International Virtual e-Hospital Foundation, the leadership of Telemedicine Centers in Kosova and in Albania, and in particular Ronald C. Merrell, MD, FACS, mentor and friend, for his encouragement, support, and help throughout this process.

Editor’s note
This article was presented as an oral presentation at the 96th Clinical Congress of American College of Surgeons, San Francisco, CA, October 2011.


  1. Latifi R, ed. Establishing Telemedicine in Developing Countries: From Inception to Implementation. Amsterdam: IOS Press; 2004.
  2. Latifi R. International virtual e-hospital: The Balkans journey. Stud Health Technol Inform. 2008;131:3-20.
  3. Latifi R, Muja S, Bekteshi F, Merrell RC. The role of telemedicine and information technology in the redevelopment of medical systems: The case of Kosova. Telemed J E Health. 2006;12(3):332-340.
  4. Latifi R, Merrell RC, Doarn CR, Bekteshi F, Lecaj I, Hadeed G, Boucha K, Hajdari F, Hoxha A, Koshi D, de Leonni Stanonik M, Berisha B, Novoberdaliu K, Imeri A, Weinstein RS. “Initiate-Build-Operate-Transfer”—A Strategy for Establishing Sustainable Telemedicine Programs in Developing Countries: Initial Lessons from the Balkans. Telemed J E Health. 2009:15(10):956-969.
  5. Latifi R. Initiate-Build-Operate-Transfer—a strategy for establishing sustainable telemedicine programs not only in the developing countries. Stud Health Technol Inform. 2011;165:3-10.
  6. International Virtual e-Hospital Foundation. Available at: Accessed March 6, 2012.
  7. Doarn CR, Latifi R. Abstracts from the Third Intensive Balkan Telemedicine and e-Health Seminar, Skopje, Macedonia—Introduction. Telemed J E Health. 2008;15(4):387-396.
  8. Latifi R, Merrell RC, Doarn CR, Poropatich R, Latifi Q. Abstracts from the Second Intensive Balkan Telemedicine and e-Health Seminar—Introduction. Telemed J E Health. 2008;14(1):88-106.
  9. Latifi K, Lecaj I, Bekteshi F, Doarn CR, Merrell RC, Latifi R. Cost-benefit analysis of the telemedicine program of Kosova—A sustainable and efficient model to rebuild medical aystems in developing countries. Telemed J E Health. 2011;17(10):757-762.
  10. Latifi R, Dasho E, Lecaj I, Latifi K, Bekteshi F, Hadeed M, Doarn RC, Merrell RC. Beyond initiate-build-operate-transfer strategy for creating sustainable telemedicine programs: Lesson from the first decade. Telemed J E Health. 2012;18(5):388-390. Epub April 23, 2012.

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