Ebook: Global Telehealth

Telehealth – in the context of the delivery of health services and clinical information across a distance – has “come of age” over the last decade, with the advent of consumer videoconferencing, mobile telecommunications devices, high bandwidth ubiquitous connectivity infrastructure, and close range wireless sensor networks. New specialised clinical applications and markets have also emerged, including tele-homecare, tele-rehabilitation, tele-emergency care, tele-surveillance and tele-disaster response. Futuristic advances such as tele-procedures and tele-surgery are regarded as now being “around the corner” and offering unforeseen potential to contribute in the health reform agenda.

Regrettably, two aspects which contribute to telehealth deployment remain elusive: the volume of widely accepted evidence for clinical and economic benefits of telehealth, and the development of policy and business modeling drivers that will speed their adoption. These factors block not only the uptake of telehealth solutions in developed countries, but also in the emerging world. Progress in these two areas depends very strongly on increasing the number and scope of studies such as many of those presented in this book.

The Global Telehealth 2010 conference (GT2010) was convened with this purpose in mind. The theme for the meeting was “Telehealth for every nation, community and home” and papers were solicited internationally to cover a broad spectrum from successfully completed projects to work in progress. This book contains selected contributions of papers deemed to have lasting value and which capture the international diversity and variations of scope of contemporary telehealth developments, in keeping with this theme.

GT2010 was supported by the International Society for Telemedicine and eHealth (ISfTeH) and hosted by the Australasian Telehealth Society (ATHS), an organisation formed in 2008 to promote the growth of telehealth in all aspects, through Australian and New Zealand. The event would not have been possible without generous primary sponsorship by CSIRO, and the support of several companies and agencies involved with telehealth and eHealth. Endorsement of the event by numerous professional societies and promotion of it to their membership was also very much appreciated.

Reviewing of all papers submitted for publication in this book was undertaken by an international panel of independent expert reviewers, who are listed elsewhere. Approximately 70% of those papers submitted for review were accepted. The editors wish to record their grateful acknowledgement of the efforts of the reviewers who conducted detailed appraisals of the papers and provided valuable feedback leading to the high standard of work appearing in this publication.

Anthony C. Smith,

The University of Queensland, Centre for Online Health, Australia

Anthony J. Maeder,

University of Western Sydney, School of Computing and Mathematics, Australia

Telemedicine may have a useful role in neonatal care, particularly in regionalised health care systems where there may be impediments to access. Following the development of a system for neonatal teleconsultation, we assessed its efficacy, usability and preliminary effectiveness. While results were positive, uptake in routine clinical use was less than expected. The study described in this paper examined aspects of clinicians' perceptions of telemedicine in neonatal care. Overall, clinicians had positive perceptions of telemedicine. Further work is required to understand the negative perceived usefulness of telemedicine held by some clinicians and to determine whether this may be overcome.

Children with life limiting conditions require intensive, complex management of the physical, psychosocial and spiritual issues that evolve for the child and their family as the focus of care moves from curative treatment to palliation. Optimal palliative care for children can be limited by the lack of health professionals with the necessary skills and experience to confidently and competently manage the care of both the child and the family. The University of Queensland's Centre for Online Health has been working closely with the Paediatric Palliative Care Service (PPCS) at the Royal Children's Hospital (RCH) in Brisbane, Australia, to investigate the potential of telemedicine for the delivery of specialist support in the home or local community. Research conducted in Queensland has shown how telemedicine can be effectively used to link the specialist paediatric palliative care team into the home of families caring for a child receiving palliative care, regardless of their physical distance from the RCH. This qualitative report describes two case studies, each illustrating the value of home telemedicine for families at this vulnerable and distressing time. This work should provide a useful insight for other specialty disciplines contemplating home telemedicine applications.

A structured analysis of peer-reviewed literature about the delivery of health services by email was undertaken for this review. A total of 185 articles were included in the analysis. These articles were thematically categorised for medical specialty, participants, sub-topic, study design and service-delivery application.

It was shown that email-based telemedicine can be practiced in a large number of medical specialties and has application in primary consultation, second opinion consultation, telediagnosis and administrative roles (e.g. e-referral). Email has niche applications in low-bandwidth, image-based specialties (e.g. dermatology, pathology, wound care and ophthalmology) where attached digital camera images were used for telediagnosis. Diagnostic accuracy of these images was the predominant topic of research and results show email as a valid means of delivering these medical services. Email is also often used in general practice as an adjunct for face-to-face consultation. Further, a number of organisations have significantly improved the efficiency of their outpatient services when using email as a triage or e-referral system.

Email-based telemedicine provides specialist medical opinion in the majority of reviewed services and is most likely to be instigated by the patient's primary care giver. However, email-consultations between patient and primary care and patient and secondary care are not uncommon.

Most email services are implemented using ordinary email. However, a number of organisations have developed purpose-written email applications to support their telemedicine service due to impediments of using ordinary email. These impediments include lack of management tools for: the allocation and auditing of cases for a timely response and the co-ordination of effort in a multi-clinician, multi-disciplinary service. The ability to encrypt ordinary email thereby securing patient confidentiality is also regarded as difficult when using ordinary email. Hence, alternative web-based email applications where the encryption can be implemented using the more user-friendly HTTPS have become popular.

Much of the reviewed literature is descriptive or anecdotal and hence, suffers from lack of conclusive results regarding positive patient outcomes. This may account for email-based telemedicine generally being regarded as underutilised. However, the potential is well recognised.

Encryption is used to convert an email message to an unreadable format thereby securing patient privacy during the transmission of the message across the Internet. Two available means of encryption are: public key infrastructure (PKI) used in conjunction with ordinary email and secure hypertext transfer protocol (HTTPS) used by secure web-mail applications. Both of these approaches have advantages and disadvantages in terms of viability, cost, usability and compliance. The aim of this study was develop an instrument to identify the most appropriate means of encrypting email communication for telemedicine. A multi-method approach was used to construct the instrument. Technical assessment and existing bodies of knowledge regarding the utility of PKI were analyzed, along with survey results from users of Queensland Health's Child and Youth Mental Health Service secure web-mail service. The resultant decision support model identified that the following conditions affect the choice of encryption technology: correspondent's risk perception, correspondent's identification to the security afforded by encryption, email-client used by correspondents, the tolerance to human error and the availability of technical resources. A decision support model is presented as a flow chart to identify the most appropriate encryption for a specific email-based telemedicine service.

Nurses represent the largest group of healthcare professionals; and their role in healthcare is diverse. The lack of nurses in the workforce and the increasing demand of care continues to challenge health systems across the globe. Telehealth has been identified as a potential alternative method for delivering health services. Evidence is emerging that the use of telehealth by nurses results in efficiency gains and cost effective health care delivery. Regardless of growing evidence, the use of telehealth in nursing practice is still very limited. The lack of systematic education programs in telehealth and the lack of resilience in regards to organisational change remain significant barriers for the uptake of telehealth for nurses.

Cost reduction has become the primary theme of healthcare reforms globally. More providers are moving towards remote patient monitoring, which reduces the length of hospital stays and frees up their physicians and nurses for acute cases and helps them to tackle staff shortages. Physiological sensors are commonly used in many human specialties e.g. electrocardiogram (ECG) electrodes, for monitoring heart signals, and electroencephalogram (EEG) electrodes, for sensing the electrical activity of the brain, are the most well-known applications. Consequently there is a substantial unmet need for physiological sensors that can be simply and easily applied by the patient or primary carer, are comfortable to wear, can accurately sense parameters over long periods of time and can be connected to data recording systems using Bluetooth technology. We have developed a small, battery powered, user customizable portable monitor. This prototype is capable of recording three-axial body acceleration, skin temperature, and has up to four bio analogical front ends. Moreover, it is also able of continuous wireless transmission to any Bluetooth device including a PDA or a cellular phone. The bio-front end can use long-lasting dry electrodes or novel textile electrodes that can be embedded in clothes. The device can be powered by a standard mobile phone which has a Ni-MH 3.6V battery, to sustain more than seven days continuous functioning when using the Bluetooth Sniff mode to reduce TX power. In this paper, we present some of the evaluation experiments of our wearable personal monitor device with a focus on ECG applications.

We tried to monitor stress by using a wearable one channel ECG device that can send ECG signals through Bluetooth wireless communication. Noxious physical and mental arithmetic stress was given three times repeatedly to healthy adults, and cortisol and catecholamines were measured serially from peripheral blood. At the same time, time domain and frequency domain parameters of heart rate variability (HRV) were calculated by taking precordial electrocardiogram. The intensity of correlation between subjective visual analogue scale (VAS) and catecholamine, cortisol, and HRV parameters according to stress was analyzed by using concordance correlation coefficients. The HRV triangular index and LF/HF ratio had high concordance correlation with the degree of stress in the physical stress model. In mental arithmetic stress model, the HRV triangular index and LF/HF ratio had weak concordance correlation with the degree of stress, and it had lower predictability than epinephrine. In both models, cortisol had some correlation with catecholamine, but it had little correlation with HRV parameters. HRV parameters using wearable one channel ECG device can be useful in predicting acute stress and also in many other areas.

e-Health projects are being implemented globally in low-income countries as a response to the identified inequality and inequity of access to health services for poor populations with a great burden of disease. These projects are seen to offer solutions that provide quality care at a low cost. Limited research is done on the sustainability of these projects. Even less addresses the socio-cultural impact on the host communities. Based on experience of living with a remote community in Ghana, this paper explores the needs of one community, and how e-Health has the ability to meet those needs using different solutions. Also examined are the potential positive and negative impacts that e-Health might yield on the people and their surroundings were e-health solutions to be introduced.

Anticoagulation is necessary for many patients after implantation of mechanical heart valves. In order to reduce the number of visits to a physician for the review of INR values, we propose a telemedicine system based on mobile phones for patients and physicians. Physicians are furthermore supported by a decision support system offering recommendations for therapy adjustments.

Malaysia's national health statistics for the last half century show a remarkable improvement in the nation's health status. One important factor for this improvement is the Malaysian government's proactive intervention in the health sector. Among others, e-health has played a vital role in delivering and managing healthcare services in Malaysia. While the Government has integrated telehealth in its national digital infrastructure re-design, it has heavily invested in telehealth. The enactment of new laws to facilitate telehealth practices can also be noted as an important measure.

The Royal Institute for Deaf and Blind Children (RIDBC) in Sydney, Australia has demonstrated an ongoing commitment to innovation in the field of hearing impairment. RIDBC has created a unique program known as RIDBC Teleschool which successfully utilises videoconferencing technology to provide specialist hearing support and associated therapies to children living in rural and remote areas of Australia, including children in Indigenous communities. The high rate of hearing loss in Indigenous communities has led to the implementation of hearing screening programs in many areas of Australia. However, access to therapy support after screening is a critical intervention component which is often lacking in screening programs. RIDBC Teleschool uses a telehealth model to address this unmet need.

Teleconsultation in Neurosurgery was introduced in Malaysia in 2006 with the aims of enhancing quality services in the field of Neurosurgery. The present teleconsultation system is equipped with user friendly features which allow physicians to send and neurosurgeons to gain access to patient data in a swift and effective manner. In the past, teleconsultation in neurosurgery was tied with teleradiology, however we have now developed a multimodality system to cater specifically for neurosurgery. In Malaysia, the teleconsultation service is gaining momentum as evidenced by the large volume of cases channeled through this system. 944 cases within a span of 4 months were recorded on the system. 54.5% of the cases were trauma, 33.2% stroke, 6.1% intracranial tumours, 2% of cases were of spinal pathology, 2% pediatric anomalies and 2.2% intracranial infections. 50.2% of the referrals were after regular working hours reflecting the need for dedicated teleneurosurgery consultative services and the ability to review referrals outside of hospitals. Only 36% of cases needed emergency transfers and 9.9% of the cases were managed remotely at distant hospitals. Another 9.4% of the cases were either transferred electively or brought to the clinic for consultation. The above findings emphasise the importance of teleconsultation as a means to provide wide medical coverage within the region.

The “Foundations in Global e-Health” is a capacity building initiative designed for providers, managers, and ICT professionals in the healthcare sector. Currently being trialled through PANACeA (a pan-Asian e-health research network) it is intended to offer the course in other developing regions from 2011. Using adult education principles, this on-line, self-paced course is offered in a modular fashion comprising 12 modules; the workload of each module is in the range of 20-24 hrs, with modules 2 to 12 requiring 1 month for completion. The evidence-based curriculum is designed to provide an introduction to e-Health such that graduates of the program have a solid and standardised baseline awareness and understanding – a common foundation – from which they are better able to collaboratively communicate and independently develop and assess e-Health initiatives within their respective settings and countries.

The Environmental e-Health Research and Training Program has completed its scoping study to understand the breadth of a new field of research: Environmental e-Health. Nearly every aspect of modern life is associated, directly or indirectly, with application of technology, from a cup of coffee, through transportation to and from work, to appliances in the home and industrial activities. In recent decades the rapidly increasing application of information and communications technologies (ICT) has added to the cacophony of technological ‘noise’ around us. Research has shown that technology use, including ICTs, has impact upon the environment. Studying environmental impact in such a complex global setting is daunting. e-Health is now being used as a convenient microcosm of ICT application within which to study these impacts, and is particularly poignant given that e-Health's environmental harms conflict with its noble goals of ‘doing no harm’. The study has identified impacts, both benefits and harms in all three life-cycle phases for e-Health: up-stream (materials extraction, manufacturing, packaging, distribution), mid-stream (use period), and down-stream (end-of-life processes – disposal, recycling). In addition the literature shows that a holistic ‘Life Cycle Assessment’ approach is essential to understand the complexity of the setting, and determine the true balance between total harms and total benefits, and for whom.

Information and communication technologies may be used to provide health care services to people living at home. The term “home telecare” has been coined for this service. The elderly and patients with chronic pulmonary conditions, heart disease and diabetes have been thought to be obvious beneficiaries. The evidence base supporting home telecare is growing; however, there is a need for studies of long-term deployment and integration with existing health system processes. We discuss the experiences gained from one such pilot conducted in the Sydney West Area Health Service, which examines the integration of home telecare within the framework of an existing respiratory ambulatory care service. Interim results demonstrate high levels of reliability and positive patient attitude towards use of home monitoring. Clinical staff acceptance levels appeared lower. Effects on health burden, such as hospital admissions and nurse workload, were not significantly altered. The study results have been essential in developing local telecare knowledge within the health care community.

In Queensland, the majority of rural hospitals and some regional hospitals lack paediatricians or paediatric sub-specialists. Many specialist referrals result in a transfer to a tertiary paediatric hospital in Brisbane – up to 3000 km away. Travel is difficult, time-consuming and expensive, especially from rural and remote areas in Queensland. The telepaediatric service managed by the Centre for Online Health (COH) at the Royal Children's Hospital (RCH) in Brisbane, delivers general and specialist paediatric support directly into selected neonatal and paediatric wards in a convenient and child-friendly manner. We conducted a review of telepaediatric service records to determine which clinical and educational services had been delivered through the mobile videoconference systems. Telepaediatric service activity records for all consultations conducted between January 2005 and July 2010 were summarised.Since 2005, seven mobile telepaediatric systems have been established in selected regional hospitals throughout Queensland. For some hospitals, the service was used mainly for consultations with specialists based at the RCH or at The Townsville Hospital (TTH) in north Queensland. During a 67 month period, a total of 966 consultations were conducted during 465 videoconference sessions, totaling about 228 hours of activity. In addition, 39 education sessions were delivered to regional staff through the mobile robot systems by specialists based at the RCH in Brisbane. The telepaediatric robots have proven useful for general paediatric support for hospitals without a local paediatrician; sub-specialist paediatric support and professional education and support for regional clinicians. Our service model provided a streamlined method of delivering specialist health services to children and families living in rural and remote regions of Queensland.

As globalisation advances, patients in many nations increasingly access diverse medical systems including Western medicine, Traditional Chinese Medicine, Homeopathy and Ayervedic medicine. The trend toward co-existence of medical systems presents challenges for health informatics including the need to develop standards that can encompass the diversity required, the need to develop software applications that effectively inter-operate across diverse systems and the need to support patients when evaluating competing systems. This article advances the notion that the challenges can most effectively be met with the development of informatics approaches that do not assume the superiority of one medical system over another. Argument visualization to support patient decision making in selecting an appropriate medical system is presented as an application that exemplifies this stance.

Physiological vital signs are important factors for clinical processes like tele-assessment, tele-monitoring and tele-treatment of patients. Records of patient vital signs over time are complex to understand without proper visualisation and data analysis aids. We present a model for interactively visualising vital signs in patient data histories, as used for remote chronic disease management. Our model allows simultaneous access to all vital signs records for the patient along a time-based axis. Clinicians and other health carers can then apply generalisation and refinement ‘lenses’ in a multi-layering visualisation mechanism to examine records further over single or multiple time sessions. The model also includes rule-based decisions for issuing notifications, when expected limits are exceeded.

Human health is inextricably linked to animal health and production, particularly in developing regions of the world where animals play an important role in communities by providing transportation and food. Many deaths occur each year from a number of well-known and preventable animal diseases that are transmitted to humans, especially in developing countries, due to a lack of early detection and preventative measures. Despite the link between human health and animal health, veterinary telehealth has not attracted much attention from researchers in the medical health community. This paper describes a case study exploring the use of mobile phones for rapid reporting of zoonotic diseases in South Africa. It outlines an SMS-based mobile service to enable community members to report suspected cases of diseases. This service aims to increase the number and density of traditional reporting sources to facilitate near real-time reporting and consequently more rapid response to zoonoses outbreaks. The initial phases of this system design are described in addition to future directions.

The uptake of telehealth into the ongoing and routine operations of healthcare has been slow, uneven and fragmented. Research has focused on the initial adoption and diffusion of telehealth, with much less known about sustainability. This study made a qualitative inquiry into the sustainability of a diverse sample of ceased and continuing telehealth services in Australia, asking why services ceased, and how continuing services were either vulnerable or sustainable. Fifty four Australian telehealth services were identified in the academic literature over a ten year period between 1998 and 2007. A sample of these was chosen for maximum variation, and 36 semi-structured interviews were conducted concerning 35 telehealth services. Of these services, 8 had ceased, 14 were vulnerable, 10 sustainable, and 3 could not be classified. The major theme from ceased services was lack of support and insufficient demand from participating sites. Vulnerabilities identified from operating sites were reliance on a single person, low levels of interest, short-term funding, and difficulties making the transition from research to service. Sustainable services had two main models of functioning: to reach a sufficient size and flow of referrals to justify dedicated staffing, coordination and infrastructure; or, to fit a lower level of telehealth activity into an existing clinical setting. Sustainability of telehealth services can be enhanced by choosing an operating model appropriate to the size of the service, meeting the needs of and developing good relationships with referring services, raising awareness, and succession planning.