Dr. Karl O. Karlsen, author
District Medical Officer
Primary Health Care Clinic of Greenland

Introduction
Medical Services
The Telemedicine Project
Social Benefits

Introduction

Greenland is the largest island in the world. The total area of the island is over 2.1 million square kilometers, of which more than 1.8 million are covered by the inland ice. The latter is over 3000m thick in some places. Greenland's population of approximately 55,000 lives in 18 towns and some 60 settlements, mainly along the ice-free rim of the coastline.

For hundreds of years, the means of transport between settlements was limited to dogsleds and kayaks, as there are no roads or railways connecting the towns and settlements in Greenland. The last decade has seen an increase in the number of airports, and aviation is now an important means of transportation between the main towns. Passenger ships regularly sail along the coast - depending, of course, on the ice situation. North of the Arctic Circle on the West coast, and all the way along the East coast, the sea is frozen all during winter, prohibiting transport by sea. That is when the dogs come in handy. Helicopters used to be the only mean of air transport all over Greenland, but with the growing number of airfields, fixed-wing planes are increasingly used.

Due to the above factors, providing timely and expert medical care to the entire population traditionally has been a challenging task. However, all towns in Greenland and the vast majority of smaller settlements are now linked by telecommunications, either by radio link or by satellite. This has led the government to consider telemedicine as a supplement to personal visits by doctors and specialists to each district.

Medical Services

All medical treatment in Greenland is free, being financed by the public via taxes. The country is divided into 16 health districts, corresponding to the number of municipalities.

Present situation. Each district has a hospital, varying in size, but with basically the same equipment, such as X-ray facilities, operating theatre and laboratory. The hospitals are staffed according to size, employing from one (1) to five or six (5-6) physicians and an adequate number of supporting staff. For specialist treatment the patients have to travel to the capital, Nuuk, or to the University hospital in Copenhagen, Denmark.

An example of traditional medical treatment. Diagnosis and treatment of a health problem, for example an eye disease, can be a prolonged and strenuous experience for a patient who happens to live in a smaller fishing settlement. First, he or she has to wait for the infrequent visit of the district physician, usually a general practitioner (GP). If called for, the GP will refer to an eye specialist who visits the district once or, at the most, twice a year. Sometimes the condition can be dealt with by the specialist at the local district hospital, but just as often the patient will have to be put on the waiting list for examination and treatment in Nuuk or Copenhagen. The same procedure goes for most specialities.

As the GPs cannot have adequate qualifications in all aspects of medicine and surgery, the patients are often referred for examination and treatment to Nuuk or Copenhagen before the visiting specialist arrives, to prevent delay. It often turns out, though, that a great number of the patients could as well have waited. The risk of underestimating the seriousness of the condition is of course also present, sometimes resulting in delays, with negative consequences for the patient outcome.

The costs of patient transport within and outside of Greenland are considerable, as are the negative consequences of a less than optimal course of diagnosis and treatment.

A trial via ISDN. It was on this background that a few enthusiastic physicians in 1996 introduced the suggestion of a telemedicine network in Greenland. The idea was adopted by the politicians, and in a pilot project telemedicine was established between the Primary Care clinic in Nuuk and the nursing station in Qeqertarsuatsiaat, a settlement located approxmately 150 km to the south. Over an ISDN connection (3 basic ISDN lines) weekly tele-consultations were held, including otoscopies and laryngoscopies. A nurse at the nursing station handled the endoscopes, while a physician in Nuuk evaluated the findings in real time.

The bandwidth used was 3x128 kb/s, a total of 384 kb/s. This turned out to be sufficient for its purpose, but ISDN was not as flexible as we could have wanted. Considering the investment necessary to establish a cost-efficient telemedicine network to cover all of Greenland, it was of paramount importance to chose a system which was flexible, reliable and future secured.

A business plan for an operational system. After the trial period expired in 1998, the physicians together with a student of engineering from the Technical Univerity of Denmark, a nurse and a civil servant were asked to present a business plan for the implementation of telemedicine in Greenland. The plan was ready by spring 1999, and immediately adopted by the proper authorities. The conditions were that the evaluation was integrated during the entire implementation period, and that a satisfactory temporary report would be presented by the late spring of 2000 for continued funding.

This report described the introduction of a telemedicine network covering most of Greenland over the period 1999 to 2001. The system would be web-based, and the mode of transmission would be a routernet (private IP network) on the national radio link, or via satellite, as appropriate.

First operational phase. The first phase of the plan would cater for 6 district hospitals and one nursing station in addition to the one mentioned, to be linked up with the Primary Health Care clinic in Nuuk, where the main server was installed. During the last months of 1999 and the first months of 2000 the equipment was installed in six towns along the Greenlandic West coast, all with a 512 kb/s routernet connection. In February 2000, one of the towns at the East coast was connected via satellite, using 64 kb/s, which restricted at least the video conferencing facilities. In this way it was possible to explore the potentials in a narrow-band connection.

Through the planning and implementation phase, TELE Greenland has been an enthusiastic partner, and the company's extensive know-how of telecommunication in extreme environments has contributed invaluably to the almost problem-free task of establishing the network.

The medical areas chosen were video conferencing to allow for live video consultations including psychiatry, dermatology, X-ray and electrocardiogram (ECG) transmission, the latter three as store and forward.

Units Installed. The installed units consist of the following :

- an IBM Intellistation

- one video camera for conferencing

- one video camera for taking pictures of skin conditions

- one Epson A3 flatbed scanner with transparency unit for scanning X-rays

- one 29-inch TV monitor hooked up to the computer monitor, for psychiatry consultations

The network runs on Windows NT. Instead of chosing proprietary programs for transmission, storage and handling of the medical data, programs were written in common web-based languages, or open-source programs were used.

The basic price in Greenland of the system described above is U.S.$13,000. By substituting less expensive equipment, this amount can be reduced by up to 40% without a significant loss in quality. The price to install the first unit costs approximately $2,500, but this decreases at the installation of the following units due to the experience gained. In countries other than Greenland, the total cost of a similar system may well differ from the costs indicated as guidelines in this document.

Implementation. By the end of February 2000 all stations had commenced transmissions. Video conferences and video consultations are held ad hoc, while store and forward transmissions are channelled to a dermatologist in Nuuk. X-rays are scanned and sent for reading to the radiology department at one of the major hospitals in Copenhagen, where we have installed a separate server for the purpose. The main server in Nuuk stores all the data, which can be retrieved as per need by the participating stations. Furthermore the internal medicine department and the orthopaedic surgeon at the hospital in Nuuk (the main hospital in Greenland) are hooked up via LAN for ad hoc clinical emergencies.

Use of e-mail. The integrity of the net is ensured by its intranet structure. E-mail within the net is handled by its own mail server. Mail to and from the domain from the outside goes to TELE Greenland's mail server. A so-called mail-drop service from TELE Greenland, where the server checks for mail every hour, ensures that access to the telemedicine net has to be established from the inside. The transmission of X-rays from Greenland to Denmark is also per e-mail. The data are not encrypted, but the transmissions are pre-edited in Greenland, to ensure that the X-rays cannot be related to the patient by name or birth date.

Internet Protocols. The user interface is a common Internet home page design, with a menu for the various services (see Figure 1). Certain basic patient and anamnestic information has to be filled in, in order to enable transmission. These are, together with the actual medical data, easily retrievable for later review or statistics. The database is common SQL, placed on the central server at the Primary Health Care clinic in Nuuk. At present, all involved districts transmit on a regular basis, and the volume is increasing.

Figure 1: Telemedicine Greenland Home Page

Cardiology. There is also an echocardiography project which is run as a seperate, point to point project from the primary care clinic in Nuuk to the cardiology department at one of the major hospitals in Copenhagen. Weekly live echocardiography sessions are transmitted to the expert cardiology department in Denmark for PC-based echocardiography. Due to insufficient bandwidth on the Internet, the clinic uses 3 basic ISDN lines (a total of 384 kb/s) for these transmissions. On average, each transmission lasts one hour. In the not-too-distant future, TELE Greenland will be able to increase its satellite capacity, which should open the possibility of net-based echocardiography as well.

Present Status and future plans. Although it is too early for a proper evaluation, there are clear indications that the system has been well received by the patients, as well as by the staff, and that it generally raises the quality of medical care in Greenland. Provided continuous funding, the hospitals in all the towns and the nursing stations in the 20 largest settlements willl be connected to the system during years 2001 and 2002.

Today more than 50% of the population of Greenland have access to telemedicine services. This is probably a world record.

Social Benefits

The following improvements have been reported as a result of the telemedicine program:

d) Accessability of specialist care has been greatly improved, especially for dermatology and cardiology, but also regarding radiology. The x-rays are now read by some of the finest specialists in Denmark. The telemedicine equipment is also used ad hoc for obstetrical problems and for traumatology.