1. From Cambridge to Cambodia: Experience with a telemedicine project in the developing world Joseph C. Kvedar, MD Director, Partners Telemedicine Vice Chair, Department of Dermatology Harvard Medical School

2. www.villageleap.com

3. Three Components of Development Health Health Education Education Economic stability Economic stability

4. Snapshot of Robib Population, 900 Population, 900 Per capita income, $40/year Per capita income, $40/year With the web site Villageleap.com, villagers have made over $6,000 in With the web site Villageleap.com, villagers have made over $6,000 in ~1 year, selling crafts via e commerce. ~1 year, selling crafts via e commerce.

5. Village Leap Project Individual donor funded schools Individual donor funded schools Each equipped with a solar panel Each equipped with a solar panel 60 complete 60 complete 70 planned 70 planned At present, only one has Internet connectivity At present, only one has Internet connectivity

6. Telemedicine in Robib Simple store and forward email solution. Simple store and forward email solution. Evolved from the posting of general health questions to specific case presentations. Evolved from the posting of general health questions to specific case presentations. Nurse from Pnom Penh travels monthly. Nurse from Pnom Penh travels monthly. Information includes history, nurses PE and some digital images. Information includes history, nurses PE and some digital images.

7. Work Flow Pnom Penh Boston Robib

8. Case Mix Cardiovascular8 Cardiovascular8 Endocrine5 Endocrine5 Musculoskelatal4 Musculoskelatal4 Pulmonary2 Pulmonary2 Infectious diseases2 Infectious diseases2 Eye2 Eye2 Others (DERM, GI, GU, GYN)5 Others (DERM, GI, GU, GYN)5 Total 28 Total 28

9. Chief complaint: mother says child has mild fever and dry cough since birth Chief complaint: mother says child has mild fever and dry cough since birth Abdominal distension observed Abdominal distension observed pulse 145, resp. 40, temp. 37.9, 5 KG pulse 145, resp. 40, temp. 37.9, 5 KG Lungs crackle all lobes, heart normal but tachycardia, abdomen is tender, Positive hepatosplenomegaly, positive bowel sound, skin mild pale Lungs crackle all lobes, heart normal but tachycardia, abdomen is tender, Positive hepatosplenomegaly, positive bowel sound, skin mild pale

10. Patient #1: Som Tol, male, 48 years old Chief complaint: Feel burning on both soles and palms, palpitation, frequency of urination, blurred vision. Last 6 months chest pain. BP: 100/60 Pulse: 104 Resp.: 20 Temp. : 37.0 Past history: not significant Lungs: clear both sides Heart: regular rhythm, no murmur Abdomen: soft, flat, not tender Bowel sound: positive Skin: warm to touch, no edema Limbs: numbness and feel burning in all limbs Urinalysis: Glucose: ++++, Ketone: +, Protein: + The most likely diagnosis is peripheral neuropathy due to uncontrolled diabetes. Better glucose control with insulin or oral agents has been associated with less neuropathy. Unlikely to reverse the symptoms but better control may prevent worsening. An EMG and NCS would be most definitive in establishing the diagnosis. Infrequently a demyelinating component can be seen which responds to IV gammaglobulins.

11. Concerns/next steps Incomplete medical data Incomplete medical data –Easy to capture more data System to implement advice needs thought System to implement advice needs thought –Supplies –Human resources –Local expertise

12. Contributors (incomplete list) Partners Telemedicine Partners Telemedicine –Kathleen Kelleher, Remote Consultation Coordinator –Countless physicians Sihanouk Hospital Center for Hope Sihanouk Hospital Center for Hope –Graham Gumley, MD –Maetha, RN Project Villageleap Project Villageleap –Bernie Krisher –David Robertson