International Telepharmacy Education: Another Venue to Improve Cancer Care in the Developing World

Abstract

In developed countries, pharmacists play a crucial role in designing and implementing cancer treatments as part of a multidisciplinary oncology team. However, developing countries have a shortage of pharmacists, and their role is generally limited to dispensing and selling drugs. The aim of this study was to investigate the feasibility of providing clinical pharmacy educational activities via international teleconferencing to improve cancer care in developing countries.
Meticulous preparation and intense promotion of the workshop were done in Egypt before the telepharmacy conferences began. Multiple connectivity tests were performed to resolve technical problems. Nine telepharmacy conferences were delivered during 3-h sessions that were held on three consecutive days. Talks were subsequently made available via Web streaming. Attendees were requested to complete a survey to measure their satisfaction with the sessions.
The teleconference was attended by a total of 345 persons, and it was subsequently reviewed online via 456 log-in sessions from 10 countries. Technical issues (e.g., poor auditory quality) were resolved on the first day of the event. The rate of attendees' responses on the survey was 30.1%, and satisfaction with the event was generally good.
Telecommunication is a relatively inexpensive approach that may improve pharmacy practices, especially those used to treat patients with cancer in developing countries. Special attention to patient-based telepharmacy education, including the use of cost-effective technology, should be considered.

Full text

Brief Communication
International Telepharmacy Education: Another Venue
to Improve Cancer Care in the Developing World
Ahmad S. AlFaar, M.B.B.Ch.,
1
Sherif Kamal, Pharm.D.,
2
Sherif AbouElnaga, M.D.,
3
William L. Greene, Pharm.D.,
4,5
Yuri Quintana, Ph.D.,
6
Raul C. Ribeiro, M.D.,
6,7
and Ibrahim A. Qaddoumi, M.D., M.S.
6,7
Departments of
1
Research,
2
Pharmaceutical Services,
and
3
Academic Affairs Research and Outreach,
Children’s Cancer Hospital, Cairo, Egypt.
Departments of
4
Pharmacy,
5
Pharmaceutical Sciences,
and
7
Oncology and
6
International Outreach Program,
St. Jude Children’s Research Hospital, Memphis, Tennessee.
Abstract
Objective: In developed countries, pharmacists play a crucial role
in designing and implementing cancer treatments as part of a
multidisciplinary oncology team. However, developing countries
have a shortage of pharmacists, and their role is generally
limited to dispensing and selling drugs. The aim of this study
was to investigate the feasibility of providing clinical pharmacy
educational activities via international teleconferencing to im-
prove cancer care in developing countries. Materials and Meth-
ods: Meticulous preparation and intense promotion of the workshop
were done in Egypt before the telepharmacy conferences began.
Multiple connectivity tests were performed to resolve technical
problems. Nine telepharmacy conferences were delivered during 3-h
sessions that were held on three consecutive days. Talks were sub-
sequently made available via Web streaming. Attendees were re-
quested to complete a survey to measure their satisfaction with the
sessions. Results: The teleconference was attended by a total of 345
persons, and it was subsequently reviewed online via 456 log-in
sessions from 10 countries. Technical issues (e.g., poor auditory
quality) were resolved on the first day of the event. The rate of
attendees’ responses on the survey was 30.1%, and satisfaction with
the event was generally good. Conclusions: Telecommunication is a
relatively inexpensive approach that may improve pharmacy prac-
tices, especially those used to treat patients with cancer in devel-
oping countries. Special attention to patient-based telepharmacy
education, including the use of cost-effective technology, should be
considered.
Key words: pharmacy, distance learning, telemedicine
Introduction
Pharmacists play a major role in improving healthcare and
patient safety while reducing cost, especially for oncology
patients.
1,2
The role of pharmacists as part of the treating
team is well established in the developed world.
3
However,
there is a general shortage of pharmacists in developed countries that
is the most critical in rural areas.
4,5
This shortage has prompted New
Zealand to explore compulsory externships in which all pharmacy
students would be required to complete part of their training in rural
areas.
6
In the United States, Wisconsin has created new laws that
allow the use of telepharmacy for practice as a solution to the
pharmacist shortage in that state.
7
In the developing world, the
shortage of clinical pharmacists is even worse, partially because their
role is marginalized and their activities are predominantly those of
medication dispensers or entrepreneurs.
3,8
Oncology is a multidisciplinary field in which pharmacists play an
integral role in treatment design and implementation, side effect
management, patient safety, supportive care, and patient educa-
tion.
1,7,9–11
In addition, the cost of antineoplastic and supportive care
drugs is rising. Pharmacists can be gatekeepers and help control that
cost while improving efficiency.
2,7
This is most important in developing
countries, where drug costs constitute 25–66% of healthcare expenses;
drugs constitute only 10% of healthcare in developed countries.
3
The Children’s Cancer Hospital 57357 Egypt (CCHE), which opened
its doors in Cairo in July 2007, is considered one of the largest pe-
diatric cancer centers in the world; 950 new cases are accepted each
year. The CCHE Pharmacy is dedicated to improving care, promoting
research, and cutting cost. The International Outreach Program and
Pharmaceutical Services at St. Jude Children’s Research Hospital
(Memphis, TN) agreed to facilitate telepharmacy educational activi-
ties to CCHE via videoconferencing. Here we report our experience
with emphasis on the quality of the telepharmacy sessions, the per-
ception of the participants, and the savings in cost and time that this
event allowed.
Materials and Methods
TELECONFERENCE PREPARATIONS
Before the teleconference, issues such as scheduling, duration of
the sessions, and topics were negotiated between the teams at CCHE
and St. Jude. Because of the 8-h time difference between Memphis
and Cairo, three daily 3-h sessions were more practical than a single
9-h workshop. The agreed-upon time was 5:00 to 8:00 p.m. (Cairo
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time), which was 9:00 a.m. to 12:00 p.m. ( Memphis time). Topics to be
discussed were suggested by the CCHE team with some minor mod-
ifications suggested by the St. Jude team. The learning objectives for
each topic were determined by the respective speakers (
T1 Table 1).
Finally, permission was obtained from speakers to film their lecture
for Web streaming.
Connectivity and other technical issues were tested prior to the
conference. The first test with high bandwidth was performed 9 days
before the conference. After addressing some of the recognized
technical problems, we performed another test 2 days before the
conference. A final test was done 30 min before the first tele-
pharmacy session started. The conference was publicized in Egypt
and around the world via personal communications (e.g., e-mails),
printed material, and online. Talks were available via synchronous
and recorded Web streaming.
CONNECTIVITY AND EQUIPMENT
The connection used at CCHE was a symmetric digital subscriber
line with 25 megabits per second (Mbps). The videoconference unit
used was a Tandberg (now part of Cisco) MXP 6400. The CCHE au-
ditorium has a capacity of 208 attendees and is covered by two
cameras, in addition to a unit-attached camera that was used for
preparing the connections before the sessions started. Images from
the auditorium cameras were collected and mixed by a video mixer.
The video mixer chooses the source and destination screen of the
video. Then the mixer provides the videoconference unit with the
video source. An audio mixer provided the audio to the videocon-
ference unit. Questions from the local conference attendees were
collected using wireless microphones.
Output from the videoconference unit was transferred to the dig-
ital versatile disc recorder (DVR) with an internal hard disc drive. The
DVR recorded and bypassed the audio/video signals to the previously
mentioned video mixer, which transferred the audio and video feeds
from the videoconference unit to conference displays, which con-
sisted of two 42-inch plasma screens and one auditorium projector.
Another projector was secured to avoid any main projector failures.
Video/audio was provided to the streamer/broadcaster (VBrick
Systems, Wallingford, CT) through the video mixer, and sessions
Table 1. Telepharmacy Topics, Learning Objectives, and Attendance
DAY TOPIC LEARNING OBJECTIVES
ATTENDEES
(TOTAL)
1 Research List two examples of pharmacokinetic or pharmacodynamic objectives that may be studied
in a clinical trial
Give an example of a drug with a known relationship between genetic variation and toxicity
140
Pharmacy dashboard Review the rationale for and process used to assemble a ‘‘living’’ data dashboard for use by health system
pharmacy leaders at St. Jude
Safety List key milestones in medication safety
Describe the features of a high-reliability organization
Discuss methods for applying these principles in practice
2 Order evaluation Review the many elements of proper pharmacy processing of an order for chemotherapy
Emphasize the important safety steps that should be adhered to for optimal handling of these orders
105
Hyperglycemia Evaluate the literature on hyperglycemia in the hospital setting
Discuss the sequelae associated with transient hyperglycemia in oncology patients
Identify patients at risk for transient hyperglycemia
Review insulin preparations and activity profile
Status epilepticus in neutropenia Describe the adequate drug selection in status epilepticus
Describe the challenges of home management of status epilepticus in neutropenic patients
Discuss the use of buccal midazolam for seizure control
3 Fever and neutropenia guidelines Provide an overview on practice guidelines currently published in the United States
Review key points of drug therapy related to preventing and treating infection in the neutropenic patient
with cancer
100
Zygomycosis treatment Review the current treatment of zygomycosis and the spectrum of activity and pharmacokinetic properties
of posaconazole
Describe the application of this treatment approach to a patient case
Voriconazole Review the basic principles of TDM
Review published data on the use of TDM for voriconazole for efficacy
Discuss the importance of TDM in the prevention of voriconazole-induced toxicities
Discuss the results of a pharmacokinetic review of voriconazole in pediatric patients
TDM, therapeutic drug monitoring.
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were broadcast directly over the conference Web site and recorded on
the streamer’s hard disk drive.
RCA cables were used. Videoconference units at both sides were
connected at a speed of 4,200 kilobits per second to accommodate the
available bandwidth. The connection was interrupted twice on Day 1,
once on Day 2, and twice on Day 3. Interruptions did not exceed 15 s
in duration. Connection was resumed each time without any conse-
quences or changes in the configuration. During discussions, the
picture-in-picture view was used, with the presenting side shown in
the maximized view.
SURVEY
A questionnaire was developed based on modified online surveys
from the Cure4Kids.org Web site,
12
and other questions were added
based on previous telemedicine experiences
13
and eLearningGuild
.com synchronous learning evaluation surveys. The online survey
was implemented using the open-source survey management ap-
plication Lime Survey (www.limesurvey.org), after its style was
modified for the hospital’s corporate identity. The survey was hosted
on a Web site prepared for the event. On Day 1, answering all of the
survey questions was not mandatory, so some questions were left
unanswered. On Day 2, all questions, except the responder’s name,
were programmed to be obligatory to answer for an attendee to be
able to complete the survey. However, it was not mandatory for
attendees to take the survey. Browser cookies and Internet protocol
(IP) addresses were used to track the respondents. Because the Lime
Survey system provides an IP-tracking module, each respondent’s IP
was tracked to ensure that attendees answered for themselves and
that all duplicate responses from anonymous users were removed.
The survey consisted of 19 questions that addressed the following
topics: session quality (topic, presenter, audiovisual, equipment, and
technical support), impact on practice, general satisfaction, request
for general suggestions, and miscellaneous (e.g., session name, per-
sonal name, and whether the person would recommend or participate
in such activities again in the future). The survey was done elec-
tronically and was available for 2 weeks after the last session.
Results
ATTENDANCE AND RESPONSES
In total, 106 surveys were completed. Of these, two were excluded
because no information was provided, so 104 surveys were evalu-
able. We also documented a total of 456 online log-ins from 10
countries to review the sessions. Most of the responses (84 [80.8%])
were completed within 3 days of the last session, and the rest (20
[19.2%]) were completed within the following 11 days. It should be
noted that the percentages were calculated for each day separately
(
T2 Table 2).
EFFECTIVENESS OF THE SESSIONS
The majority of attendee responses indicated that the sessions will
influence their practice (n=93), will improve their patient care
(n=82), will improve treatment outcomes (n=91), met their educa-
tional needs (n=78), reinforced their current practice (n=87), and
met the stated objectives (n=85). Most attendees indicated no evident
commercial bias and/or influence (n=59), but some were uncertain
(n=29). When asked about their commitment to making changes in
their practices, many were committed to implementing these changes
(n=74). Some reported a desire to change for their practice but
cannot because of various limitations, including administrative is-
sues (n=26), practice issues (n=30), lack of resource issues (n=10),
policy issues (n=3), or financial reasons (n=15).
EFFECTIVENESS OF THE PRESENTERS
Most attendees were satisfied with the presenters’ knowledge of
the subject (n=95), meeting the stated learning objectives (n=91),
and method of presenting information (n=88). There were many
attendees who had never participated in telepharmacy sessions
(n=87). Many indicated satisfaction with the presenter who led the
discussion (n=85) and with their opportunity to ask questions
(n=82).
PREPARATION AND MATERIAL QUALITY
Most attendees were satisfied with the information they received
prior the videoconference (n=90), the video quality (n=85), and the
audio quality (n=64). Some attendees were not satisfied with the
audio quality (n=17), while some were not sure (n=22). Satisfaction
with equipment was good (n=82), as well as that with the room
(n=94) and technical support (n=95). Nearly a third (28.9%) of the
attendees reported dissatisfaction with the background noise that
occurred on Day 1 (discussed below).
ATTENDEES’ SUGGESTIONS
Some attendees suggested allowing more time for questions
(n=21), showing more visual examples (n=19), and allowing more
interaction between the presenter and attendees (n=19).
MARKETING SUCCESS
When asked how they learned about the teleconference, the
attendees responded as follows: word of mouth (n=28), printed
material (n=22), e-mail (n=14), and Internet search (n=13).
Table 2. Attendance and Survey Response Rates
NUMBER OF
DAY
LOCAL
ATTENDEES
ONLINE LOG-IN
SESSIONS
SURVEYS
COMPLETED (%)
a
1 140 126 38 (27.1)
2 105 203 36 (34.3)
3 100 127 30 (30.0)
Total 345 456 104 (30.1)
a
Surveys were completed by local attendees only, and 80.8% were completed
within 3 days of the last telepharmacy session.
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TECHNICAL PROBLEMS
Two weeks prior to the workshop, we identified interference with
Internet functions requiring bandwidth caused by e-mails, broad-
casting, and regular Internet browsing. To overcome this interfer-
ence, the Internet bandwidth at CCHE was increased from 10 to
25 Mbps. Another problem faced during the testing was that any
changes in the St. Jude real IP of the videoconference machine
or gateway required that CCHE register the new IP addresses at
their firewall to accept the connection and route it to their video-
conference unit.
On Day 1, the level of background noise was very high. Different
methods of noise reduction were attempted using an auditorium-
equalizer facility with little improvement, and the problem persisted
throughout the session. On Day 2, we discovered that the source of
the background noise was the echo-reduction option on the CCHE
videoconference unit. When this option was turned off, the audio
became very clear. However, the microphone at CCHE had to be
turned off during the presentation to avoid the echo. Thus, when an
attendee at CCHE posed a question, that microphone was switched on,
and the microphone at St. Jude had to be turned off. Attendees’
satisfaction with the audio quality was preserved throughout the rest
of the workshop.
Discussion
Knowledge sharing using advanced telecommunication strategies
has been successful in accomplishing diverse educational and eco-
nomic activities, including adult and pediatric oncology. Applied to
oncology, it has improved cancer care in the developing world. To
date, most of these teleinteractions have involved diagnostic and
therapeutic procedures but not pharmacy practices.
14
To our
knowledge, this is the first reported experience of an international
telepharmacy educational symposium in pediatric oncology. Most
cancer burden in the future will be in developing countries
14
; thus,
integrating pharmacy activities into oncology practices will improve
care and decrease cost.
2,7
This goal is crucial in developing countries
because drugs constitute a significant portion of the healthcare cost
there.
3
Telemedicine has the potential of saving money and time by de-
creasing the need to travel.
15
The airfare for one speaker to travel
from Memphis to Cairo during the period of the teleconference was
approximately $3,000 (U.S.), and the cost of hotel accommodation in
Cairo for 3 nights would have been about $570 (U.S.). By using
videoconferencing, CCHE saved nearly $25,000 (U.S.). This amount
does not include the honorarium usually paid to speakers by the
hosting institute or the number of working days saved by St. Jude.
Round-trip travel from Memphis to Cairo is approximately 42 h; thus,
the seven St. Jude speakers saved in total 294 h of travel time.
Our study provides evidence of the success of an international
experience of telepharmacy. This success is evident in the attendance
and number of times the programs were reviewed online. Such at-
tendance was made possible because of the dynamic marketing of the
telepharmacy workshop via different methods such as e-mails, online
announcements, printed material, and word of mouth. Except for
poor audio quality on the first day, the attendees were generally
satisfied with the content, preparation, and technical support. This
success was due to the meticulous preparation and multiple technical
tests done prior to the telepharmacy sessions. This technical success
would not have been possible without the human factor and local
institutional support that are crucial for any telemedicine activity to
thrive.
14
Many CCHE pharmacy colleagues and those from other CCHE
departments, including two of the co-authors (S.K. and S.A.), have
visited St. Jude since the establishment of our International Outreach
Program partnership with their institution. Thus, to establish a sus-
tainable telepharmacy program, it is best to incorporate it as part of a
larger twinning/collaboration initiative.
We must note that the general satisfaction reported in the survey
could be overestimated because of the low response rate of around
30%. Attendees who had positive feedback to offer responded, and
those who were dissatisfied may have elected to not fill out a survey.
Many of the suggestions offered by attendees focused on allowing
more time for interaction with the speaker and more time for ques-
tions. These suggestions will be considered in the planning of future
telepharmacy activities to alleviate the anxiety of the attendees and
compensate for the lack of the speaker’s physical presence.
Finally, we must emphasize that we are not proposing that tele-
pharmacy is the solution for all pharmacy problems and deficits in
developing countries or underserved populations in the developed
world, but rather we suggest that it is a method to be explored in a
systemic approach. Providing seminars may not necessarily improve
patient care, but a patient-focused approach complements the
knowledge gained during the telepharmacy sessions and may benefit
patients in real time.
16
Also, other methods of telemedicine that are
less expensive than videoconferencing (e.g., www.Cure4Kids.org or
Skype) should also be considered, if they can achieve the defined
goals.
To improve patient care, the pharmacy teams from CCHE and St.
Jude have started holding regularly scheduled online meetings
that are mainly dedicated to actual cases at CCHE. The teams are
conducting these meetings via the Cure4kids Web site (www
.Cure4Kids.org). The meetings may facilitate the application of
knowledge gained during these interactions into clinical practice.
Further follow-up work could include surveying the CCHE attendees
to learn whether they have implemented changes or improved their
practice based on the telepharmacy symposium and online follow-up
meetings.
Acknowledgments
The authors would like to acknowledge the internet company
TEDATA in Egypt for upgrading the bandwidth speed at CCHE, the
Egyptian National Science and Technology Information Network for
donating the Tandberg MXP 6400 videoconference unit to CCHE,
Mdm. Ola Laurence for logistical support, and Cornelius Johnson for
technical support. We also thank the St. Jude speakers who partici-
pated in the telepharmacy sessions: William Greene, Cyrine Haidar,
ALFAAR ET AL.
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4 TELEMEDICINE and e-HEALTH JULY/AUGUST 2012

Kristine Crews, James Hoffman, Sara Jane Faro, Rong Wang, and
Jennifer Pauley. Finally, the authors acknowledge Angela McArthur
for scientific editing of this manuscript. This work was supported, in
part, by the American Lebanese Syrian Associated Charities.
Disclosure Statement
A.S.A. is the owner of an e-learning company called Moriat for
eSolutions, e-Learning, which did not contribute to this work. S.K.,
S.A., W.L.G., Y.Q., R.C.R., and I.A.Q. declare no competing financial
interests.
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Address correspondence to:
Ibrahim A. Qaddoumi, M.D., M.S.
MS 260, St. Jude Children’s Research Hospital
262 Danny Thomas Place
Memphis, TN 38105-3678
E-mail: ibrahim.qaddoumi@stjude.org
Received: August 31, 2011
Revised: November 28, 2011
Accepted: November 29, 2011
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