Telemedicine project improving health in rural Cambodia
Paul Heinzelman, MD MPH, Operation Village Health
Project Leader, Partners Telemedicine
leverage a growing Internet infrastructure for health purposes within rural
Cambodia, an email-based medical consultation program called Operation
Village Health was established in 2001 by Partners Telemedicine. Since then,
Harvard-affiliated physicians have been providing clinical recommendations
to Cambodian health workers caring for patients at a health centre in
Rovieng and a referral hospital in Ban Lung.
These consultations are based on text and image-rich clinical documents
composed by Cambodian health workers, which are then emailed to physicians
in Boston and in Phnom Penh. Clinical recommendations are returned to the
health workers within hours of their receipt via email, allowing underserved
villagers to receive better care, and providing local clinicians the
opportunity to strengthen their knowledge. Since its inception,
approximately 700 telemedicine-supported patient encounters have been
completed. Operation Village Health is the 2006 winner of the international
Stockholm Challenge in the category of Health.
Recent studies demonstrate a diminishing rate of referral to facilities
outside the village and a decrease in the duration of chronic medical
problems among villagers. A randomized survey of patients demonstrated that
they are satisfied with the telemedicine service and that most are willing
to pay an average of $0.63 per visit. Overall, this initiative seeks to
provide more effective and more affordable local care for these underserved
villagers, and serve as a sustainable model of telemedicine-supported
healthcare. The integration of new mobile technology (digital pen) and the
use of web-based clinical data storage are part of future goals.
Cambodia ranks among the lowest of countries on the human development
index and among the highest in terms of poverty. Disparities in health care
access are great – particularly in rural areas where approximately 40% live
below the poverty threshold and health worker shortages prevail. The
prevalence of infectious diseases and the growing problem of chronic disease
are forcing Cambodia to face a significant health burden in the future.
Since 1992, American Assistance for Cambodia has been working to revitalize
this country after the reign of the Khmer Rouge in the late 1970s that
resulted in the death of approximately two million people. Through these
efforts, a growing Internet infrastructure is accompanying the broad
construction of elementary schools throughout the rural countryside.
Project design and Implementation
Operation Village Health represents a health application for a larger
initiative known as Village Leap, a program established by Japan Relief for
Cambodia / American Assistance for Cambodia, a non-governmental organization
devoted to fostering development by bringing technology to rural Cambodia.
The mission of the organization is to rehabilitate Cambodia in the aftermath
of the Khmer Rouge reign and the Vietnam War.
Village Leap has been responsible for providing Internet access in
nearly one third of the school facilities, using solar and generator-powered
satellite dishes, wireless technology and mobile systems that receive and
In the Ratanakiri province for example, the network relies on an
Internet access hub in the capital Banlung, wireless solar-powered
computers, and motorcycles equipped with a data storage device, a wireless
transmitter card, and an antenna. Each morning five motorcycle couriers
known as ‘motomen,’ download email in Banlung addressed to villagers across
the province. Travelling over rutted, red dirt roads they deliver the mail
using their wireless transmitters to connect with the solar-powered
computers in the small village schools. Simultaneously, the transmitters
upload the outgoing mail for transmission later in the day from Banlung.
Using the connectivity and network built by Village Leap, Operation
Village Health has integrated technology into local healthcare delivery by
supporting village health workers, building local capacity and providing
care to people who otherwise would not have access to medical expertise.
Rural health centre
To leverage this growing Internet infrastructure for health purposes, an
email-based telemedicine program was established in 2001. Through this
program established by Partners Telemedicine, Harvard-affiliated physicians
provide clinical recommendations to Cambodian health workers caring for
patients at a health centre in the village of Rovieng and a referral
hospital in the town of Banlung. These consultations rely on image-rich
clinical documents composed by Cambodian physicians and nurses that are
emailed to physicians in Boston and in Phnom Penh for review. These
consultant physicians are specialists in a variety of fields of medicine who
voluntarily review the cases and return them to the health workers within
hours, allowing underserved villagers to receive improved care while
educating the local clinicians in appropriate medical practice.
Progress and Impact
Through telemedicine links, Operation Village Health
bridges the cultural and digital divide allowing healthcare to make its way
to rural Cambodia through a simple application of technology. Since 2001,
Operation Village Health telemedicine clinics have made substantial progress
in their intended mission of delivering high quality health care to local
villagers in the Rovieng village in the Preah Vihear province, (N Cambodia),
and in the town of Banlung in Ratanakiri province (NE Cambodia). Since its
inception, approximately 700 telemedicine-supported patient encounters have
A retrospective case review studying the first 28
months of consultations documented significant transformation in local
health care access. When the telemedicine clinics began seeing patients, the
average duration of chief complaints at initial patient visits was 37
months, reflecting scarce access to health care in the area. By the end of
the second year of operation, average chief complaint duration decreased
from 37 months to 8 months, a significant reduction. Referrals to hospitals
outside of the village also decreased over the 28 month study period, due to
improvements in local health care worker’s skills and management techniques
as well as the development of enhanced clinic capabilities that made it
unnecessary for patients to travel to the distant hospital for certain basic
tests. Overall, the percent of transfers to facilities out of the village
dropped by 51% per year of clinical presence.
Importantly, a randomized survey of patients revealed each was “very
satisfied” or “satisfied” with the care they received. None reported being
“neither satisfied nor dissatisfied,” “dissatisfied,” or “very
dissatisfied.” Seventy-eight percent of the patients reported they would be
willing to pay for a visit at the clinic, further indicating satisfaction
with the care delivered.
In another retrospective case review currently underway, data from the
past one and a half years will be used to guide further improvements in
services provided to local villagers. The feasibility of important public
health initiatives such as preventive health services and screening for
prevalent diseases is also being investigated as a critical future step.
A major obstacle to smooth exchange of information between the US and
Cambodia is the collection, transcription and completeness of clinical data.
A focus group of participating Operation Village Health Cambodian physicians
identified time-intensive keyboard transcription for the creation of English
language documents as a significant interruption to the usual clinical
workflow that required 50% of the total time devoted to the
telemedicine-supported encounters. Additionally, feedback from US consulting
specialists noted that incomplete clinical documentation by local health
workers was limiting their ability to respond with definitive
recommendations. These obstacles, amplified by cultural and language
differences, inhibit broader adoption among Cambodian health workers and
threaten the ultimate sustainability and scalability of this otherwise
In response to these challenges, a number of technologies and clinical
tools were reviewed and assessed for applicability to the Operation Village
Health model. Digital pen technology, in conjunction with pro-forma clinical
templates, was proposed as a cost-effective model with low cost of
implementation and adoption, which will be easily integrated into the
workflow of the program. Advantages of the digital pen technology solution
Allows users to employ pen strokes to normalize data and easily
create structured documents in a non-native language, eliminating the
time-intensive keyboard transcription.
The digital pen looks and writes like a standard ballpoint pen, and
requires minimal training for proficient use among providers across
cultures and healthcare settings.
Supports clinical documentation at the point of care.
It is easily integrated into existing workflows, and provides an
ideal solution for capturing routine encounter data and making data
available in an electronic, structured format.
Automatic capture and transfer of data and information occurs, thus
obviating or diminishing the need for keyboard transcription.
Data is immediately available to consulting physicians through a
Through assessment of the existing program, we have
identified future targets for improving current operations and initiating
new clinical sites. Program improvements have already included the
introduction of a basic point-of-care laboratory and the development of
simple clinical guidelines for the ten most commonly encountered medical
problems, allowing local clinicians to manage their patients more
confidently and independently. Digitally-enhanced pen and paper clinical
forms are now being piloted for their potential to standardize the
locally-created clinical documents, and improve efficiency of this program.
In addition, direct integration of these clinical documents into an existing
Partners HealthCare web portal and database will allow more effective
tracking of the health status of these communities.
To date, this project has been financially supported by donations made
from corporations, foundations and individuals. Future plans for this
project rely on the donations from these sources. Consulting physicians at
Partners HealthCare provide their time on a voluntary basis.
Overall, Operation Village Health seeks to establish a platform for
effective and affordable local care for underserved villagers and emphasizes
self-sufficiency. Over the next three years we aim to validate its value by
demonstrating that it is not only feasible, but sustainable and scalable as
well. Our belief is that this program may ultimately serve as a model for
cross-cultural telemedicine initiatives in other remote settings of the