Ebook: Benchmarking Telemedicine: Improving Health Security in the Balkans

Telemedicine has the potential to completely change how healthcare is delivered around the world. From its initial use of providing medical care to military personnel, space explorers, and civilians living in remote areas, telemedicine has developed to the point where its use may become ubiquitous. What has made that possible are concurrent advances and price reductions in telecommunications, computer, and medical equipment, technology. Medical trade shows and exhibitions are filled with all types of imaging equipment, patient monitoring devices, computers, and software. Each has the potential to help the hospital, clinic or individual practitioner provide better, faster and less expensive medical care to their patients. Already, telemedicine devices such as personal fitness trackers and Bluetooth-enabled scales are available in any consumer electronics store or webpage catalogue. What a cornucopia of choices!

Two years ago, members of the Organizing Committee thought about this and asked, “what are the implications of using telemedicine to improve health security in Southeast Europe?” As they talked, they realized that technology was the easiest problem to solve. Health security is dependent on a host of other factors such as individual government policies and regulations, financing, management systems, the collection, analysis and use and protection of data, and coordination of care to prevent duplication of efforts. Unfortunately, there were no venues at that time bringing people from widely varying sectors of the telemedicine community together with NATO Member and Partner countries to share information and develop solutions to these issues. The NATO Science for Peace and Security Programme Advanced Research Workshop, Benchmarking Telemedicine: Improving Health Security in the Balkans, was developed to be that venue.

Participants were representatives of, or responsible for, implementing telemedicine within the context of their positions in the military or civilian governmental structure, or as healthcare, educational, medical equipment or ICT/telecommunications providers and integrators. The emphasis for our workshop was information sharing since too often, information is siloed, either within a country or telemedicine subsector.

The Workshop included speakers, panel discussions, demonstrations of telemedicine technology, and real-time web-casting and social media. Using telecommunications media, our Forum expanded the numbers of people who could join the discussion or receive information immediately as it was being shared in the Workshop, or by downloading the stored online discussions.

Panels addressed significant issues such as cyber security for the implementation of telemedicine; healthcare capabilities of deployed and local medical equipment; learning methods; information sharing among local professionals; prevention and control of infectious diseases; best practices of telemedicine among NATO member and partner countries; integration of telemedicine across regions and borders; telemedicine implementation. In addition, the workshop included demonstrations of new technology for telemedicine that addresses NATO concerns.

The Workshop presented a single forum of discussion; all attendees could attend all panels as there were no concurrent panels or seminars. This was designed to increase communication across the different telemedicine sectors and give attendees a common framework, with a common language, with which to discuss issues. The publication of these Proceedings will allow others to become part of the conversation.

Carla Sydney STONE

Editor

Wilmington, Delaware, U.S.A.

31 July 2017

Many existing telemedical projects are being put into practice for civilian use. The telemedical systems can be divided into two main groups regarding their functionality: real time telemedical systems versus store and forward telemedical systems. Another division is based on intention of the communicating parties. There are patient–doctor; healthcare provider–expert (doctor); and patient–patient telemedical systems. Our proposed system is classified as a “store and forward” telemedical system for health care provider-expert communication. The two years of project realization has given us a solution, ready to put in test to prove the concept of the SIARS project.

Background: Establishment of telemedicine programs as tool to help restructuring healthcare system in post-conflict countries as well other developing countries in a sustainable fashion, and to rebuild their health care systems to meet the needs of citizens. Establishing sustainable telemedicine has become a goal of many developing countries around the world. Yet, despite initiatives from a select few individuals and on occasion from various governments, often these initiatives never mature to become sustainable programs.

Methods: A program known as “Initiate-Build-Operate-Transfer” (IBOT), is a comprehensive, four-pronged strategy that allows for development and implementation of successful sustainable telemedicine system not only in post conflict countries but countries in transition and developing countries.

Results: Using IBOT strategy, we have built three national programs (Kosovo, Albania and Cabo Verde) in all 46 hospitals of these three countries. Currently we have partnered to build telemedicine in Vietnam building telemedicine.

Conclusion: IBOT includes assessment of healthcare needs of each country, the development of a curriculum and education program, the establishment of a nationwide telemedicine network, and the integration of the telemedicine program into the healthcare infrastructure.

Turkey is a secular, democratic and constitutional republic with a diverse cultural heritage. It is an important player regionally and globally, a member of the NATO, OECD, a candidate for European Union accession, and chair of the 2015 G20. As of May 2016, Turkey's Ministry of Health has about 900 hospitals and more than 7,000 health centers, about twice as many as a decade ago. Today there is a limited amount of telemedicine in Turkey but those numbers are expected to increase. Telemedicine is on the duty-supervised urgent e-change action plan of Turkey. Tele-radiology and tele-pathology are a current focus of the ministry of health as there are inadequate numbers of medical imaging specialists. Unlike these two areas, tele dentistry is newly developing in Turkey. Out of all of them government decided to prepare a project of 15 city hospitals or digital hospital in 15 Metropolitans in Turkey in 2013. Digital hospital will be a hospital model in which information systems work integrated, all kinds of medical device can send data to the information management's system through networks and sensors, the information in the system can be accessed from hospital and distantly in the limits of personnel's' and patience's authorization and approval. It is know that telemedicine can save time, money and reduce costs for the medical practices in the world.

Prevention is crucial in the management of chronic respiratory diseases, especially in the prevention of asthma and chronic obstructive pulmonary disease (COPD), the most common chronic diseases in respiratory pathology. Information and communication technologies (ICT) have great potential to support organizational changes for enhancing chronic care management. Currently, many patients with severe and very severe stages of COPD are unable to live a normal life. Helping people decrease their risk for chronic diseases and improving a patient's ability to live with chronic conditions, are international concerns. The increasing incidence of chronic conditions is approaching epidemic levels and finding evidence-based and effective strategies to promote health and prevent and manage these conditions is essential. Prevention of these diseases is also important as a way of reducing for healthcare system costs.

Telemedicine has gained a stable place among the vast varieties of medical branches in contemporary health care services. Clinical Genetics, on the other hand, has always been a cornerstone for high-quality medical practice especially with the evidenced possibilities of the specialized genetic counselling. It is of general public interest the information about the current developments in the field of Genetics and Epigenetics to be properly managed. One of the main issues in this regard is the information about newly evolving epigenetic therapies to be correctly and timely transferred from the research laboratories and clinical physicians to the social workers and patients. The possibilities of Telemedicine could be exploited in an approach which can be termed Tele-epigenetics. As a relatively new field of human knowledge epigenetic principles and mechanisms will require specific tasks to be fulfilled for the creation of Tele-epigenetics. Generally, like in Telemedicine the field of Tele-epigenetics could include fast and short online consultations on epigenetic therapies, treatments and possibilities via consultation through electronic and mobile devices.

Telemedicine approaches are relevant to genetic services. Current developments in genetic services allow the fast accumulation of massive genetic data bases, most of which grant free access to both medical specialists and private individuals. Figuratively, we are talking about an ocean of genetic data which has the potential to transform modern medicine into a more precise and personalized field. Personalized medicine in the age of genomics and epigenomics literally means that we are living in a time when anyone can very easily obtain information about his own genetics, about a predisposition to a certain deadly disease, or about the presence of mutations which could potentially be transferred to one's offspring. Genetic screening produces massive amounts of data, which increases every day. Patients and medical specialists face serious challenges in dealing with this. Special genetic services and counseling is not easy to find, especially in rural and distant places which are sometimes referred to as “genetic deserts.” These locations may reach out for solutions to fill the gap between modern health care services and the proper understanding of, and use of, genetic data. Genetic counselling via the internet and mobile devices already occasionally takes place, but is not regulated. The topic needs attention by specialists, politicians, and decision makers in the field of healthcare and medicine. Videoconferencing for genetic consultation is becoming a logical extension of what people already do with their webcams and smartphones. Telemedicine is a good solution as it saves patients' time, the cost and burden of transportation and, oftentimes, the need to find day care or take time off from work. This opens a new field of providing genetic counselling using videoconferencing and other and other forms of media, allowing specialists and patients to benefit from genetic data.

Medicine is one of the few domains where innovation has proven an unacceptably, very low rate of diffusion. Comparing with new born industries (like aviation) or with ones in which one witnesses an extremely high rate of diversity (in terms of electronic tools, services and resources) such as banking, medicine still operates with the same ages old business model self-designed, following the “try & error” model.

Health care services had been supported in the last 100 years as governments, societies and patients created nationwide systems based on success and failures of the welfare state models. Is there a limit of technology in changing the paradigm of health care services delivery? If the answer to this question is affirmative, where does telemedicine fit into the new born business model in healthcare?

Over two decades Finland has had a national information strategy within the area of healthcare, which has created the basic principles how safe information management, information share and capacity building of healthcare staff should be realised, for instance. The renovation of social and healthcare services will constitute a coherent system that increases equality in access to services, and will give citizen's freedom of choosing services. The developments of cloud computing, Internet of things (IoT) and other digitalised health applications is fast-paced and the amount of personal data is growing. The legislation has not kept up with the technology, leaving significant gaps in privacy and data protection. This means that development of data security and privacy protection is lagging behind digitization.

Telemedicine is rapidly developing today and we can already actively use current information technologies in healthcare. In Ukraine, monitoring of patients from a distance is especially important in remote areas that lack qualified specialists and new equipment. In this article, we analyze providing highly qualified complex consultative medical assistance to the population through the application of telemedical technologies, and the development, testing and implementation activities for advaninge telemedicine in Ukraine.

Within the objectives of the Digital Agenda for Europe, the European Commission has co-funded flagship projects, in order to pilot test and evaluate the deployment of large scale telemedicine projects (United4Health and Renewing Health) in every day e-health and e-care services practice. The Region of Central Greece participated in these large scale EU co-funded projects in order to permit a comprehensive approach in the assessment methodology within the national health care services, providing also sufficient to draw valid conclusions on the effectiveness of the installed telemedicine services. Future telehealth services in Central Greece will be upgraded via Internet of Things technology, implementing large scale IoT e-health and e-care services via the ACTIVAGE EU co-funded project.

Disasters occur when we least expect and when we are often not prepared. There are many differences across the globe on the ability to respond and these differences are based almost entirely on socioeconomic conditions in the affected society or region. A highly developed nation has a lower risk of catastrophic destruction and death as compared to a developing nation. Nevertheless, healthcare in the immediate and post or chronic phase of a disaster is vital to recovery, stability and security. Over the past 5–6 decades, telemedicine has been integrated successfully in disasters and has been shown to be effective. This chapter summarizes this previous work and highlights the NATO-developed Multinational Telemedicine Systems for Disasters. It lays out the award winning strategy of Initiate, Build, Operate, and Transfer, developed by the International Virtual e-Hospital and implemented across several Balkans countries. It provides a summary of the challenges telemedicine faces in the integration of healthcare. The chapter closes out with a summary of the many resources that are available for using telemedicine in disasters.

This article is focused on the Bulgarian tendencies and initiatives in the development and application of telemedicine and the importance of implementing evidence-based practice. The paper presents separate descriptive modules, including academic education and experience in telemedicine, the healthcare system in Bulgaria itself and the authors experience in telemedical solutions and implementations.

The aim of this article is to present the key achievements in the implementation of the Integrated Telemedicine and e-Health program in Albania, supported by US government agencies, implemented by International Virtual e-Hospital Foundation in partnership with Albanian Ministry of Health. The IBOT (initiate–build–operate–transfer") strategy was used by IVeH to establish an effective telemedicine system in Albania that includes the National Telemedicine Center and 5 university, 11 regional and 3 municipal hospital telemedicine centers throughout the country. This nationwide telemedicine network has several active clinical programs, virtual educational programs, and an electronic library. Experiences in Albania show that the application of sustainable and low-cost telemedicine programs not only improves access to health care but can overcome the existing unmet needs, thus significantly improving health services throughout the country. The IVeH telemedicine network in Albania provides a solid experience that can be expanded in countries with limited financial and technical capacities, as a model to build on to improve access to quality of health care in professional and timely manner.

This article presents Croatian Institute of Telemedicine, telemedicine services and technical solutions used within the national telemedicine network.

Scaling-up a telemedicine service involves careful preparation and planning for managing change. Telemedicine “doers” worked together actively in Momentum, a co-financed European Commission project, on how to manage changes to telemedicine services. In 2015, they came up with 18 critical success factors that are best used to deploy a telemedicine service, looking specifically at the importance of change management. Translated into a workshop and accompanying survey, now called the Momentum process, the European Health Telematics Association (EHTEL) offers training in these success factors. The factors have already been used by several sites in Europe to move telemedicine services forward in a practical way. This workshop, can help telemedicine practioners, in Europe and globally, make progress on the expansion of this useful technology.

In the early stages of an emerging technology, such as telemedicine, there is no single universal model of service. Benchmarking the use of telemedicine within a country, a region or in a variety of locations is valuable as usage is guided by local conditions. Benchmarked results can be used to establish commonalities of practice, to improve the monitoring and evaluation of individual practices, to reduce risk, and to improve system sustainability. The key to measuring actionable information is the development of appropriate metrics. This chapter proposes a set of metrics that can be used in benchmarking the analytics so they can be used to build a sustainable telemedicine system measured in improved patient outcomes.