MEDICAL INTERNET PROJECT

IMPLEMENTATION in SLOVAKIA

Proposal for OSI, NY January, 1997 Drafted by

Martin Rusnak, MD, PhD, Dr. Katarina Liptakova

OSF Bratislava Dr. Alena Panikova, Executive Director

CONTENTS

1. STATEMENT OF THE PROBLEM
2. PROJECT GOALS for SLOVAKIA
3. IMPLEMENTATION AND PROJECT MANAGEMENT
4. TECHNICAL RESOURCES
5. EXPANSION OF THE HEALTHNET NETWORK
6. INTERNET GRANT PROGRAM
7. ELECTRONIC DISCUSSION GROUPS
8. THE ANTICIPATED IMPACT OF THE PROJECT AND HOW WILL IT BE ASSESSED
9. PROJECT TIME-TABLE

STATEMENT OF THE PROBLEM

a. GENERAL SITUATION in SLOVAK HEALTH CARE

The goals of the public health community are to understand the nature of the health problem, the scope of the health burden, the personal, social, and environmental factors associated with the development of chronic illness, and then find ways to prevent or effectively treat these illnesses. The goals also imply that the interest is oriented toward the way how the care is provided for the community and the quality of the care. Information support possesses crucial position through this process. Health care in SLOVAKIA faces rapid and complicated phase of restructuralization and privatization. The relatively poor state of services could be traced to scarce resources for upgrading medical technologies as well as to limited access to information. Therefore the libraries in hospitals, individual physicians, nurses, managers, they all have rather limited access to literature, information and even communication opportunities. After two years of implementing the HealthNet-SR Project we could see the need for expanding its potential for gradual increase of knowledge capabilities and skills of Slovak physicians and students of medicine and nursing. At the same time, unrestricted access to information represents one of the cornerstones of democracy. This particular issue is addressed through the HealthNet project, being developed in Slovakia during the last two years. New technologies of computer communications and networking has led OSF to offer Internet capabilities to wide range of physicians, nurses and other health professionals. The experiences gained throughout the project run has naturally resulted in many new issues to be developed further on. The most important one is a question how to offer the technology to maximum number of potential users with maximizing information flow within the country as well as between individuals in different countries. One step in this direction is represented as the MEDICAL INTERNET PROJECT implemented in Slovakia.

b. HEALTHET PROJECT in SLOVAKIA

The HealthNet project's objective is to establish an electronic network for use by Slovak health care organizations. In the same dimension to create conditions for sustained information support of health care system in Slovakia through the electronic networking with incrementally increased proportion of financial participation from users. The network is built up incrementally over several years. The secondary objectives are:

• i.select and train users;
• ii.develop a technical project;
• iii.install equipment;
• iv.contract for services;
• v.develop and start operations of a center with the WWW site;
• vi.start distribution of documents;
• vii.evaluate the performance.

c. MEMBERS of HEALTHNET PROJECT

The project in spite of difficulties is successful in general. It has generated substantial interest in Slovak health professionals and started to fulfil the main goal: to connect health professionals. Until now, there are following institutions connected to Internet based on the HealthNet / OSF grant:

• Faculty Hospital of L. Pasteura, Kosice - one of the major hospitals in Eastern Slovakia, with teaching and research responsibilities;
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• Trnava University, Faculty of Nursing, Trnava - newly established institution with teaching assignments;
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• Institute of Preventive and Clinical Medicine, Bratislava - major research institute;
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• Hospital with Polyclinics in Poprad - hospital with many activities in health care reform;
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• Hospital with Polyclinics in Levoca - institution active in quality and cost - effectiveness of care;
• State Health Institute in Povazska Bystrica - institution active in public health research;
• Hospital with Polyclinics in Ruzomberok - active in Hospital Association activities;
• Hospital with Polyclinics in Sahy - active in third sector;
• Hospital with Polyclinics in Trencin - various activities in quality of care;
• Faculty Hospital in Bratislava - major hospital with many educational and research activities;
• Health Management School - nongovernmental school of management, influential in health care reform process;
• Slovak Medical Library, Bratislava - an important resource of health and medicine related information;
• Slovak Chamber of Physicians, Bratislava - important for the reform development;
• National Institute of Tuberculosis and Respiratory Diseases, Podunajske Biskupice - major hospital with many educational and research activities;
• Institute of Tuberculosis and Respiratory Diseases, Vysne Hagy - specialized institution active in research;
• Psychiatry Hospital of Philipp Pinel, Pezinok - specialized institution active in research;
• National Center for Health Promotion, Bratislava - leading institution in health policy development.

There are more institutions collaborating with the project. The collaboration is based on mutual interchange of information and share of experiences. Among them Faculty Hospital in Martin, Specialized State Health Institute in Banska Bystrica are those with the most visible activities.

d. HEALTHNET WEB SITE

Close cooperation was developed with Health Care Weekly, journal covering health care issues within Slovakia. Slowly growing area of data on Slovak health care is limited by the supply of data, which will be hopefully solved in the nearest future. Apart from two exhaustive papers and a small survey provided, the journal offers the most of its information for publishing in Internet through the HealthNet. The aim of HealthNet authors is to distribute relevant information for health care professionals. Therefore in cooperation with editors of MEDICINMAN, booklet with addresses of all health care providers (central health institutions, hospitals, polyclinics, private practitioners, other health related institutions) the addresses were displayed on Web. To facilitate orientation of users in wide area of health on Internet, materials of AIHA (American International Health Alliance) were translated to Slovak language and displayed along with new results of our own searches. The most of currently available search machines with a description of pros and cons are accessible through a separate page. A database from Slovak Medical Library with all journals available is displayed along with other sources of information from the library.

e. TRAINING of USERS and PUBLIC RELATIONS

Activities of HealthNet are not exclusively oriented to developing knowledge base or information base for Slovak and foreign health professionals. One of the most prominent targets is to increase number of people using this facility to support their daily activities. Therefore public campaign is carried on to market potential of Internet for medical people. HealthNet has been demonstrated several times during medical conferences, seminars, workshops. Short course on HealthNet is provided regularly during education activities in the Institute for Medical Postgraduate Studies, School of Public Health in Trnava University, Medical School in Martin, Health Management School in Bratislava. More than 150 health professionals, mostly physicians, were trained during the courses. In order to increase participation we have recently announced a competition for individuals and institutions with a reward of a year of Internet connectivity.

f. HARDWARE/SOFTWARE CONFIGURATION

The substructure supporting those activities is based on the HealthNet server and the network of Internet providers in Slovakia (PubNet for members in Bratislava and Kosice, SANET for users from other localities). This configuration is important from the point of view of implications for development of Medical Internet Project, since PubNet has its two centers in Bratislava and Kosice, where the project is focused to as well as HealthNet will provide infrastructure for developing the new project.

PROJECT GOALS for SLOVAKIA

a. MISSION

The mission for the project could be defined as follows:
To facilitate access for health care professionals and students of medicine to Internet sources.

As it has been stated during the above description of the HealthNet project in Slovakia, in it is not enough for securing adequate use of Internet to create technical structures. Much more emphasis should be given to provide relevant, useful, up-to-date information at minimal costs. However, costs are understand not necessarily as economic value, but as an amount of time and personal involvement invested to master the Internet skills (this term however vague deals with a knowledge on how and where to look for specific information, rather than how to use a computer). In Slovakia both costs are quite high: the costs of telecommunication services, Internet, computers, software, etc. are still limiting the access to information for relatively low payed health care professionals. Accessibility of the technical resources is becoming more feasible for professionals in university hospitals and state run central health institutions compared with those active in smaller, local or rural areas. However, the aim is to provide information for those who need it when, where and how they need it. So we speak of current health care professionals and future health care professional: students. Both of those groups should get:

• (1) basic experience what is Internet and what benefits they could get from it for their own decisions related to Internet usage made later on;
• (2) an access to vast information and knowledge base currently available in the Internet space for individual use in practice or during studies;
• (3) used to open communication among themselves or with colleagues abroad (since ability to understand and/or speak English posses significant limitations to extensive use of Internet one has to rely on an expert estimate on number of English speaking people in Slovakia to be about 10%. It could be assumed that with increasing emphasis on teaching English to university students, that this number could be much higher in this community).

b. OBJECTIVES

HealthNet over two years of its existence proved significant interest in this issue. In order to fulfill the mission stated above, the principal objectives of this project for 1997 and subsequent years could be stated as follows:

• i. to create Resource Centers;
• ii. to run them;
• iii. to provide information for the users how to use it for maximum benefit gained;
• iv. to prepare for sustainable activities after the project will be concluded.

c. RESOURCE CENTERS

Creation of two Resource Centers in Slovakia should facilitate an access to Internet resources for medical public. In order to cover the territory of Slovakia two principle sites were selected: Bratislava (West of Slovakia) and Kosice (East part). Particular hosts of the project which will be selected. The selection process will be based on following criteria:

• criterion of compliance: the selected site has to be willing to support the development of open society in Slovak Republic in terms of increasing quality of care, participation of patients (patient rights, satisfaction), increased knowledge of ethical principles, strengthening of links with community served, support of independence of health care professionals and institutions. Selected institution will be willing to provide room and other resources not mentioned in the budget (furniture, copiers, ...) for the center.
• criterion of education: the staff of the selected site has to provide some educational capacities and/or make the resources available for providing training by other institutions.
• criterion on accessibility: the site has to be opened for users and easily accessible. The location of the site within a city should stimulate access. Therefore the optimal site has to be situated somewhere where there already is significant concentration of health professionals and students.
• criterion of maximal benefit: This criterion expects achieving maximum effect with minimal resources. Financial resources will be used as seeds to start and support organizations or institutions which possess a potential to be self supportive after the initial phase.

The selection of sites will be decided by the OSF Medical Board, serving for other health care projects. The selection will be navigated based on the criteria listed above. The members of the Board will evaluate received applications. It is envisaged to start announcing the project through media right after the project is approved for funding. When the selection is made contracts will be signed between the Open Society Fund and an institution selected for the implementation. The selection of this institution will be based on managerial and technical qualities of an institution and a project manager offered. That decision will be made by the Executive Director of Open Society Fund after consultations with the Foundation Board.

As it could be seen from the time-table of the project implementation and the foreseen budget that each of the Resource Centers will be equipped with 12 computers each connected through LAN and leased line to the Internet. HealthNet-SR Web Site will serve as the principal gateway to medial and health resources in the Internet world. User Manual development represents an integral part of the training provided for staff and users of the center. Evaluation of the performance is planned to provide insights into quality of services provided as well as into effectivity of usage of the equipment. Seminars are planned to inform medical public of the opportunities and new services offered. After the project will be finished after three years of operations the institutions hosting the project should be able to sustain provision of the services from their own resources.

d. EDUCATION

There is no doubt, that extensive education of professional public in this particular field is needed. Therefore the selection process will reflect feasibility of using the centers for education and teaching. Therefore the institutions selected has to provide some education activities or have to be opened to provide capacities for educational institutions. Specifically we have in mind institutions like:

• i. Medical School, with target audience of students, but not excluding teachers;
• ii. Institute for Continuing Education of Physicians, with target audience of physicians taking courses;
• iii. Health Management School, with target audience of participants;
• iv. Medical Library, with target audience on students and health professionals.

We do not exclude hospitals and other health institutions, however, the four types of institutions listed are among the most likely candidates, since their orientation is close to the mission of the project. All four institutions have their offices both in Bratislava and Kosice.

The education will be oriented toward obtaining and strengthening skills in Internet technologies and information retrieval primarily for health professionals and students. It is envisaged, that among the topics will be:

• i. Basic skills in retrieving information from Internet resources;
• ii. Special interest areas (cardiology, oncology, ...) information sources in the Internet;
• iii. Internet for general practitioners;
• iv. Introduction to medical library resources in Internet;
• v. Introduction to creation and maintenance of Web sites;
• vi. Internet for health managers;

Naturally, number of topics will increase along with positive experiences from previous courses. The form of courses, curricula and more detailed information on educational activities will be a part of the project development. When the critical amount of dedicated users among students and educators will be reached then the distance training will be implemented based on the resource centers availability.

Certain educational impact will be reached through discussion groups, too.

As it could be seen from the budget, each center will be equipped with 12 computers (PC type), out of them 1 will be used as the server, 1 as development tool and 10 will be in a class. The class will be used according to fixed schedule for:

• i. teaching of regular courses;
• ii. teaching and training in irregular activities (seminars, workshops, demonstrations);
• iii. individual work for individuals (students, course participants, professional public);
• iv. distance learning courses.

The organization of access will be determined as a part of the project activities.

3. IMPLEMENTATION AND PROJECT MANAGEMENT
The project will be implemented by the Open Society Fund in Bratislava through the Foundation for Prevention of Communicable Diseases (the institution which has developed the HealthNet-SR). The project development will be supervised by the OSF Executive Director Dr. Alena Panikova, Medical Officer Martin Rusnak, MD, PhD and Internet officer Dr. Katarina Liptakova. The key decisions (as selections of participants, selection of sites) will be provided by the OSF Medical Board, serving for other health care projects. The list of members of the Board is in the table 1.

The management of the project will be based on harmonized action with OSI Project management and participants of the entire multinational project. It is understood that regular meetings of all project managers will be facilitated by the OSI in New York. Extensive use of Internet connectivity media will facilitate the implementation of the project as well as real collaboration of all participants.

4. TECHNICAL RESOURCES
The technical concept for each of the Resource Center is quite straightforward:

A. Hardware: the 12 computers will be interconnected with LAN, using a network repeater (the price for cabling is included). The connection to Internet is provided by a leased line to local Internet provider. The costs for Internet connectivity is still significantly higher in Europe and even in Slovakia, than it is common in USA currently. Prices for modems went relatively down for lower end modems. However, it has to be encountered, that the quality of telephone lines is not sufficient to support high speed connectivity and therefore at least for the beginning the project will start with slower lines (Internet costs are lower, too). UPS has to be provided to prevent the WWW server go down. SYQUEST is needed to keep copies of the system installed as well as WWW pages developed. The Ink Jet printer will be used as a network printer. A scanner will be used for WWW pages development.

It is anticipated, that furniture, room renovation, duplicating equipment and supplies as well as related infrastructure will be contributed by the selected institutions.

CONTINGENCY: if the overall budget of the regional project will allow, a video projector will be useful to support education in centers. The Slovak Library of Medicine offered entire database of library resources to be published on the Internet. Because of the extent of the database it was estimated, that the database should be kept on a separate server connected to the Internet. There was some discussion to install an OVID full text journal source in Slovakia. Such a step would require a disk of 8 Gb.

A. Software: The centers will be running on Windows NT servers with workstations running Windows 95 or Windows for Workstation software. Office software will be used to support users. Netscape offers free software for WWW creation, maintenance and other Internet activities free of charge for educational non for profit organizations.

5. EXPANSION OF THE HEALTHNET NETWORK
The management of HealthNet is prepared to aggressively pursue expansion of the network to include 15 to 25 more recipients, which will receive sponsored connectivity, training and e-mail services, but will have to own a PC and modem in order to benefit from the in-kind grant. Other criteria will apply and the recipients will be designated after an call for applications and committee review. The network will be expanded according to the criteria previously established.

6. INTERNET GRANT PROGRAM
A grant program is being established which will reward on a proposal submission basis interesting Internet-based projects with one year of free connection to the Internet. This grant program will vary from the above in that it will reward specific projects, rather than a demonstrated institutional need for access to health information. The goal is to promote a more active approach to the Internet among users. Selected applicants will receive training in html and website administration, moderation of discussion groups, and related subjects.

The grant has been already announced in newspapers. The OSF Medical Board will select those proposals, which provide firm guarantee of creation useful WWW pages on their own, or provide useful information for Slovak health professional in close collaboration with HealthNet team. Special consideration will be focused on those proposals, which are compliant with criteria described in Chapter 2c. It is envisaged, that up to 10 grants will be awarded in next few months.

7. ELECTRONIC DISCUSSION GROUPS
The project HealthNet with its growing impact on information distribution among local medical society achieved a threshold, when enough users received a training as well as practical skills in everyday usage of its facilities. Therefore it has been felt, that it seems to be the right time to start discussing the role of Internet for medical society. The discussion will hopefully lead to increased communication of people with different backgrounds. It also implies that it would help to overcome communication barriers still existing in closed society of Slovakia. Therefore an invitation for joining the discussions was distributed to all known health professionals (physicians, nurses, other health care professionals, students of medicine, nursing, public health, and others) with an access to e_mail. Following topics were offered for the kick off:

• What further orientation should the HealthNet Project implement;
• New, interesting websites were visited;
• New information, problems, software is available on the web.

As this is a kick off activity, it has been decided to make it as simple as possible: the e_mail server's service FORWARD on the following account: healthnet.diskusia@healthnet.sk
The discussion will not be moderated. The invitation for joining the discussion group has just been distributed.

8. THE ANTICIPATED IMPACT OF THE PROJECT AND HOW WILL IT BE ASSESSED
The project of this extent would require several different types of evaluation.

• Accountability Evaluation: to determine the extent to which the program has been implemented correctly, is reaching its intended targets, and is having the desired effects, as well as the extent to which the program's funds are being expended properly. Indicators:
• compliance with the project: how many modifications the program implementation required, unit %;
• effects: how many individuals used the services, unit man-days, dimension months;
• expenditures: how were the funds spent: expenditures versus the budget, unit US $.
• Cost-Effectiveness Analyses: the relationship between project costs and outcomes, with both costs and outcomes expressed in monetary terms.

Indicators:

• number of users per day/week/month; unit: number;
• number of people enrolled into discussions; unit: number;
• number of literature searches per day/week/months; unit: number;
• number of trainings and/or other educational activities provided; unit: number;
• cost per user; unit US $;
• cost per literature search; unit US $;
• cost per training/education activity; unit US $.
• Impact Evaluations: Evaluation of whether and to what extent a program causes changes in the desired direction among a target population.

Indicators:

• number of media reviews; unit number;
• number of conferences attended; unit number;
• number of requests for enhancing HealthNet; unit number;
• number of new web pages in health care; unit number.

The evaluation will require significant efforts to be allocated to follow up the project development. Much of the work will be done by technicians, who will be responsible for monitoring activities at sites.

9. PROJECT TIME-TABLE
The dates will be adjusted according to the real beginning of the project.