Ebook: Global Telehealth 2012

Globally, health systems are under increasing pressure to deliver health services in a fair and cost-effective manner. Geography, workforce and the increasing prevalence of chronic disease are contributing factors. Telehealth – or the delivery of health services at a distance – has an important role to play.

With communication technologies becoming more readily accessible and affordable – we are now seeing an array of telehealth applications emerging with potential benefit for patients and clinicians – particularly where health services are traditionally limited or non-existent – or difficult to access. The Global Telehealth 2012 conference (GT2012) was convened with this in mind.

The theme for the meeting was “Delivering Quality Healthcare Anywhere Through Telehealth” and papers were solicited internationally to cover a broad spectrum from ‘work in progress’ laboratory studies to successfully established clinical services. 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.

GT2012 was the 2nd International Conference 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 sponsorship by the Australian Government – Department of Health and Ageing, the University of Western Sydney and The University of Queensland; 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 was undertaken by an international panel of 35 independent expert reviewers, who are listed further on. Approximately 58% 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

Nigel R. Armfield

The University of Queensland, Centre for Online Health, Australia

Robert H. Eikelboom

The University of Western Australia, Ear Science Institute, Perth, Australia

In medicine, the advancement of new technologies creates challenges to providers both in learning and in maintaining competency in required skills. For those medical providers located in remote environments, access to learning can be even more formidable. This work describes a collaboration created to facilitate the use of new communication technologies in providing distance training and support to health care personnel deployed in remote areas.

Ubiquitous personal health records, which can accompany a person everywhere, are a necessary requirement for ubiquitous healthcare. Contextual information related to health events is important for the diagnosis and treatment of disease and for the maintenance of good health, yet it is seldom recorded in a health record. We describe a dual cellphone-and-Web-based personal health record system which can include ‘external’ contextual information. Much contextual information is available on the Internet and we can use ontologies to help identify relevant sites and information. But a search engine is required to retrieve information from the Web and developing a customized search engine is beyond our scope, so we can use Google Custom Search API Web service to get contextual data. In this paper we describe a framework which combines a health-and-environment ‘knowledge base’ or ontology with the Google Custom Search API to retrieve relevant contextual information related to entries in a ubiquitous personal health record.

Rural Health Facility Management Training is a training program developed by the National Department of Health in collaboration with AUSAID through the office of the Capacity Building Service Centre. The purpose of the training is to train officers-in-charge who did not acquire knowledge and skills of managing a health facility. As part of this study, it is essential to assess whether the cell phone is a better mode of communication between the participants and the facilitators compared with other modes of communication from a distance. The study used the cross-sectional method to collect 160 samples from 12 provinces and the statistical software Stata (version 8) was used to analyse the data. The results showed that mobile coverage is not very effective in most rural areas, though, it is efficient and accessible. Furthermore, it is expensive to make a call compared with sending text massages. In spite of the high cost involved, most health managers prefer to use the cell phone compared to normal post, email, or fax. This clearly shows that the mobile phone is a better device for distant learning in rural Papua New Guinea compared to other modes of communication.

The telemedicine approach is a very much relevant and effective strategy for the Mongolian context of a huge geographical area with a sparse population and huge disparities in quality and access to health services. Through this initiative, it was possible to strengthen the capacity of service providers to provide timely and appropriate care, especially to mothers with pregnancy and childbirth complications. All the way through this network, health staff had easy access to information and support from experts; this improved access to knowledge is a positive benefit of the program. The early detection of pregnancy complications and timely management with the distance consultation of an expert team had contributed significantly to the reduction of maternal and newborn morbidity and mortality in project-selected provinces compared to non-project areas. The effective use of a modern telemedicine approach has been demonstrated as being effective in addressing the remoteness and rural-urban discrepancy in the quality of health care in Mongolia.

Background: Periodic limb movements (PLMs) are repetitive, stereotypical and unconscious movements, typically of the legs, that occur in sleep and are associated with several sleep disorders. The gold standard for detecting PLMs is overnight electromyography which, although highly sensitive and specific, is time and labour consuming. The current generation of smart phones is equipped with tri-axial accelerometers that record movement. Aim: To develop a smart phone application that can detect PLMs remotely. Method: A leg movement sensing application (LMSA) was programmed in iOS 5x and incorporated into an iPhone 4S (Apple INC.). A healthy adult male subject underwent simultaneous EMG and LMSA measurements of voluntary stereotypical leg movements. The mean number of leg movements recorded by EMG and by the LMSA was compared. Results: A total of 403 leg movements were scored by EMG of which the LMSA recorded 392 (97%). There was no statistical difference in mean number of leg movements recorded between the two modalities (p = 0.3). Conclusion: These preliminary results indicate that a smart phone application is able to accurately detect leg movements outside of the hospital environment and may be a useful tool for screening and follow up of patients with PLMs.

Type 2 diabetes is a leading cause of death and morbidity and is a health priority in Australia. This randomised controlled trial will explore whether remote access to clinical care, supported by telehealth technologies over high speed broadband, leads to improved diabetes control in a way that benefits patients, carers and clinicians and improves the overall health system. People in the intervention arm of the trial will receive additional diabetes care from a care coordinator nurse via an in-home broadband communication device that can capture clinical measures, provide regular health assessments and videoconference with other health professionals when required. Patients in the control arm of the trial will receive usual care from their GP and participate in the clinical measurement and quality of life components of the evaluation. The trial evaluation will include biomedical, psychological, self-management and quality of life measures. Data on utilisation rates and satisfaction with the technology will be collected and cost -effectiveness analyses undertaken. The role of this technology in health care reform will be explored.

Non-attendance represents a significant cost to many health systems, resulting in inefficiency, wasted resources, poorer service delivery and lengthened waiting queues. Past studies have considered extensively the reasons for non-attendance and have generally concluded that the use of reminder systems is effective. Despite this, there will always be a certain level of non-attendance arising from unforeseeable and unpreventable circumstances, such as illness or accidents, leading to unfilled appointments. This paper reviews current approaches to the non-attendance problem, and presents a high-level approach to fill last minute appointments arising out of unforeseeable non-attendance. However, no single approach will work for all clinics and implementation of these ideas must occur at a local level. These approaches include use of social networks, such as Twitter and Facebook, as a communication tool in order to notify prospective patients when last-minute appointments become available. In addition, teleconsultation using video-conferencing technologies would be suitable for certain last-minute appointments where travel time would otherwise be inhibiting. Developments of new and innovative technologies and the increasing power of social media, means that zero non-attendance is now an achievable target. We hope that this will lead to more evidence-based evaluations from the implementation of these strategies in various settings at a local level.

This paper presents the ongoing development of a community based, self-management system for diabetes mellitus, which incorporates web-based, SMS and mobile-terminal functionalities. SMS represents the first stage of our system development as it is widely available on all mobile phones, convenient and becoming increasingly popular. We discuss past findings and the need for such a system, as well as design, implementation and system architecture. Poor self-management of diabetes is associated with progression into more complex health issues, manifesting as a significant public health burden and impacting negatively on an individual's quality of life. This approach recognizes that telehealth systems will play an increasingly pertinent role in health systems worldwide.

The history of telemedicine is at times presented to commence in the 20^th century. Events in Central Australia in 1874 show that the history goes further back, when the newly constructed telegraph played an important telemedicine role not only in enabling care for a wounded person, but also in uniting a dying man with his wife 2000 kilometres away. Innovation with the tools at hand has proven to be effective to bridge the tyranny of distance in the delivery of health care.

This paper identifies ways technology, including telehealth, can be utilised to reduce health delivery costs whilst providing the highest possible standard of care.

Healthcare for elderly people has become a vital issue. The Wearable Health Monitoring System (WHMS) is used to manage and monitor chronic disease in elderly people, postoperative rehabilitation patients and persons with special needs. Location-aware healthcare is achievable as positioning systems and telecommunications have been developed and have fulfilled the technology needed for this kind of healthcare system. In this paper, the researchers propose a Location-Based Mobile Cardiac Emergency System (LMCES) to track the patient's current location when Emergency Medical Services (EMS) has been activated as well as to locate the nearest healthcare unit for the ambulance service. The location coordinates of the patients can be retrieved by GPS and sent to the healthcare centre using GPRS. The location of the patient, cell ID information will also be transmitted to the LMCES server in order to retrieve the nearest health care unit. For the LMCES, we use Dijkstra's algorithm for selecting the shortest path between the nearest healthcare unit and the patient location in order to facilitate the ambulance's path under critical conditions.

Half of the pregnancies in the United States are unplanned and the highest rate of these unplanned pregnancies occurs in young women aged 18–24y. Serious birth defects, such as those that affect the neural tube, occur early in pregnancy, most of the time before a woman knows she is pregnant. These neural tube defects can be reduced by 50–72% with an adequate daily intake of folic acid. In continuing the research on how to effectively communicate the important benefits of folic acid to young women, this study sought to investigate the use of social media as a tool for health promotion. Young women are considered the ‘power users’ of social media and the current study uses Twitter as a vehicle for multivitamin promotion messages due to the ability to quickly share content and the potential to attract viral attention through re-tweets.

Body sensor networks can be used for health monitoring of patients by expert medical doctors, in remote locations like rural areas in developing countries, and can also be used to provide medical aid to areas affected by natural disasters in any part of the world. An important issue to be addressed, when the number of patients is large, is to reliably maintain the patient records and have simple automated mobile applications for healthcare helpers to use. We propose an automated healthcare architecture using NFC-enabled mobile phones and patients having their patient ID on RFID tags. It utilizes NFC-enabled mobile phones to read the patient ID, followed by automated gathering of healthcare vital parameters from body sensors using Bluetooth, analyses the information and transmits it to a medical server for expert feedback. With limited hospital resources and less training requirement for healthcare helpers through simpler applications, this automation of healthcare processing can provide time effective and reliable mass health consultation from medical experts in remote locations.

In June 2008 the Congressionally Directed Medical Research Program provided a grant to the Research Foundation at the James A Haley Veterans Hospital in Tampa, Florida to provide care for wounded veterans from Operation Enduring Freedom (Afghanistan) and Operation Iraqi Freedom (OEF/OIF). The telerehabilitation for OEF/OIF returnees with mild or moderate combat related Traumatic Brain Injury (TBI) has as its objectives 1) care coordination for wounded veterans using distance technology via the internet and 2) monitoring of physical and mental health outcomes using a variety of instruments. A total of 75 veterans were enrolled in the study. Our initial findings indicate that 1) Functional capabilities measured by locomotion and mobility appear to have stabilized among our cohort of veterans while deficiencies in cognition (memory, problem solving), psychosocial adjustment (anger, emotional status) and problems in integrating into society pose challenges 2) Those with comorbid PTSD appear to linger in employability and ultimate integration into society as compared to those without the diagnosis 3) Individualized treatment pathways are needed for rehabilitation and ultimate integration into society.

A target of telehealth is to maintain or improve the health of people outside the normal healthcare infrastructure. A modern paradigm in healthcare, and one which fits perfectly with telehealth, is “person self-monitoring”, and this fits with the concept of “personal health record” (PHR). One factor in maintaining health is to monitor physiological parameters; this is of course especially important in people with chronic maladies such as diabetes or heart disease. Parameters to be monitored include blood pressure, pulse rate, temperature, weight, blood glucose, oxygen saturation, electrocardiogram (ECG), etc. So one task within telehealth would be to help monitor an individual's physiological parameters outside of healthcare institutions and store the results in a PHR in a way which is available, comprehensible and beneficial to the individual concerned and to healthcare providers. To date many approaches to this problem have been fragmented – emphasizing only part of the problem – or proprietary and not freely verifiable. We describe a framework to approach this task; it emphasizes the implementation of standards for data acquisition, storage and transmission in order to maximize the compatibility among disparate components, e.g. various PHR systems. Data from mobile biosensors is collected on a smartphone using the IEEE 11073 standard where possible; the data can be stored in a PHR on the phone (using standard formats) or can be converted in real-time into more useful information in the PHR, which is based on the International Classification for Primary Care (ICPC2e). The phone PHR data or information can be uploaded to a central online PHR using either the Wi-Fi or GSM transmission protocol together with the Continuity of Care Record message format (CCR, ASTM E2369).

Evidence from the literature indicates that the degree of immersion often referred to as the “sense of being there” experienced by clinicians and patients is a factor in the success of tele-health installations. High definition and 3D telemedicine offers a compelling mechanism to achieve a sense of immersion and contribute to an enhanced quality of use. This article surveys HD3D trials in tele-health and concludes that the way HD3D is integrated into telemedicine depends on the clinical, organisational and technological context. In some settings real time HD3D is not so desirable whereas asynchronous transmission of HD3D images and videos is highly desirable.

Health care aides (HCAs) are the backbone of the home care system and provide a range of services to people who, for various reasons related to chronic conditions and aging, are not able to take care of themselves independently. The demand for HCA services will increase and the current HCA supply will likely not keep up with this increasing demand without fundamental changes in the current environment. Information and communication technology (ICT) can address some of the workflow challenges HCAs face. In this project, we conducted an ethnographic study to document and analyse HCAs' workflows and team interactions. Based on our findings, we designed an ICT tool suite, integrating easily available existing and newly developed (by our team) technologies to address these issues. Finally, we simulated the deployment of our technologies, to assess the potential impact of these technological solutions on the workflow and productivity of HCAs, their healthcare teams and client care.

Health data includes all content related to health in all data formats, document types, information systems, publication media and languages from all specialties, organisations, regions, states and countries. Capabilities to share, integrate and compare these data contents, clinical trial results and other evaluation outcomes together with telehealth applications for data processing are critical to accelerate discovery and its diffusion to clinical practice. However, the same ethical and legal frameworks that protect privacy hinder this open data and open-source code approach and the issues accumulate if moving data across national, regional or organisational borders. This can be seen as one of the reasons why many telehealth applications and health-research findings tend to be limited to very narrow domains and global results are lacking. The aim of this paper is to take steps towards establishing an international electronic repository and virtual laboratory of open data and open-source code for research purposes by comparing international, Australian and Finnish frameworks. The frameworks seem to be fundamentally similar; they apply the principles of accountability and adequacy to using and disclosing personal data. Their requirements to inform data subjects about the purposes of data collection and use before the dataset is collected, assure that individuals are no longer identifiable and to destruct data when the research activities are finished make sharing data and even secondary data difficult. Using the Internet or cloud services for sharing without proper approvals by ethics committees is technically not allowed if the data are stored in another country. The research community needs to overcome these barriers and develop a virtual laboratory, which operates on distributed data repositories. This empowers the community by enabling systematic evaluations of new technologies and research hypotheses on a rich variety of data and against existing applications, and subsequent tracking of quality improvements in time.

Access to basic healthcare in many parts of Papua New Guinea (PNG) remains a challenge partly because the majority of the population is thinly scattered across a geographically rugged country. The major health problems in PNG pertain to malaria, tuberculosis and diarrheal diseases while HIV has reached epidemic levels. The proliferation of the mobile phone technology in PNG has been unprecedented since the introduction of competition in the sector in July 2007. Users in rural areas now access the mobile phone signal making it their preferred form of modern communications medium. This paper introduces an SMS-based HIV/AIDS education, awareness and information dissemination model for a predominantly rural-based PNG society.

The changing and demanding nature of the mining workforce in rural and remote Australia brings unique challenges to the delivery of healthcare services. In an attempt to control costs whilst delivering cost effective and quality healthcare, new models of delivery must be considered. For a workforce that is fly-in/fly-out, the provision of healthcare is problematic given the lack of consistency in location. A cost-benefit framework is analysed comparing three models of service provision using travel to a major location, locum services and remote health monitoring. Ultimately, new models of care must be considered to address the issues of increasing workforce turnover, to cater for rising healthcare costs, and to improve the health of such communities.

Currently, healthcare costs associated with aging at home can be prohibitive if individuals require continual/periodical supervision and assistance because of Alzheimer's disease. Open-source tools and videoconferencing tools are attracting more significant organizations; it has been observed that another way to reduce medical care costs is to reduce the length of the patient's hospitalization and reinforce home sanitary support by medical professionals with family care givers. Videoconferencing has been around for a while and presently this technology is the leading way in reducing healthcare costs, thus making medical care more available and convenient for both doctors and patients. This article portrays how the videoconferencing tool can be utilized to improve communication practices for patient monitoring using a Robot Companion. SWOT analysis method is also presented in a form of a summary and was utilized to evaluate the user's point of view.

Many patients with major mental illness do not take their medication. This leads to repeated relapses. Some of these patients are managed by clinicians who visit the patient seven days a week long term and supervise their taking of medication. This paper explores the design and implementation of an Android telemonitoring application to supervise patients taking medication in their homes.