Ebook: Current Principles and Practices of Telemedicine and e-Health

This book represents the most current developments in the rapidly expanding and changing field of telemedicine and e-health, especially in the developing countries. Much has changed since the publication of the first book in 2004 (Establishing Telemedicine in Developing Countries: From Inception to Implementation). Telemedicine has become more popular, and continues to grow. Over the last three years, I have received many requests for copies of the book from all over the world. While there are many good books and materials on telemedicine, my hope is that this one will become a useful reference for all of those practicing telemedicine and e-health, particularly in developing countries. It is dedicated to all future generations of telemedicine and e-health students, including health care practitioners, administrators, policy makers, technical professionals and others.

Having in mind this vision for the book, I have asked some of the best and the brightest in telemedicine to help me put together this volume, which should be understandable, informative, and un-ambiguous. I am grateful to every one who has contributed to this and to the first edition of this book.

If you want to go anywhere in world, there are maps (although in some parts of the world maps are changing rapidly); if you want to build a motorcycle, a boat or perform a complex surgical procedure, chances are you can find instructions on the internet on how to do it. Well, this is not the case if you require information on how to establish telemedicine and e-health system and programs, not only in the developing countries, but even in your own town, or own country in the developed world.

I hope that this book will be the guide we all wanted to have and will reflect the current status of telemedicine. Perhaps someone else will take over and name this “Telemedicine for Dummies”. Maybe we should have called this book exactly that: “Telemedicine and E-Health for Dummies”.

Rifat Latifi, MD, FACS

Professor of Clinical Surgery, Trauma, Surgical Critical Care and Emergency General Surgery, Department of Surgery, The University of Arizona, Tucson, Arizona, USA; Associate Director of Arizona Telemedicine Program, Telesurgery and International Affairs; President, International Virtual e-Hospital Foundation; Director, Telemedicine Program of Kosova

What started in Berlin in May of 2000 as an idea to create the telemedicine program of Kosova in order to help the country rebuild the broken medical system and change the miserable face of medicine, has now spread to other countries in the Balkans. Today, June 29, 2007, as I am rewriting this chapter, ten doctors and engineers from Kosova, Montenegro and Macedonia graduated from a three weeks intensive course on telemedicine, e-health and medical electronic library. This international telemedicine fellowship is organized by the very entity that was created in Berlin 7 years ago: The International Virtual e-Hospital (IVEH). This time, however they are part of a project called “Improving Health Care in the Balkans Using Telemedicine, Advanced Technologies and Cultural Exchange Programs as a Platform” funded by the Bureau of Education and Cultural Exchange of the State department of USA, and is being implemented in collaboration with Arizona Telemedicine Program and University of Arizona Health Science Center Library, as well as Alaska Telemedicine program in Anchorage. The goal of the program is to create the medical and technical leadership that will significantly enhance health care access and quality in the region. This program is creating a powerful international medical education network in the Balkans for further collaboration and development. As part of the project, 48 physicians, nurses and engineers from Kosova, Montenegro, Macedonia and Albania are being trained in telemedicine, e-health, electronic library management, trauma and surgical critical care. A group of experts in these same medical disciplines will conduct workshops, seminars and other cultural and educational activities in the Balkan region. We can say now with certainty that the Telemedicine Program of Kosova is having an impact in the region that goes far beyond telemedicine applications and advanced technologies in the Balkans. It is creating leadership that will take the future in their own hands, as they become the true champions of telemedicine and rebuilding the dream of advancing the health care in their own countries. As we say at IVEH, it is “one country at a time.” In October, we will inaugurate the Second Phase of the Telemedicine Program of Kosova. On October 21–23, in Tirana, Albania, we will organize the Second Intensive Balkan Telemedicine and e-health seminar, a three-day workshop on current principles and practices of telemedicine, e-health, and medical informatics. The journey that started in Berlin is continuing. Soon we will be traveling to Atalaya, Peru and other communities of Amazon River, then Africa. We will not stop. One country at a time!

Telemedicine and telehealth programs are inherently complex compared with their traditional on-site health care delivery counterparts. Relatively few organizations have developed sustainable, multi-specialty telemedicine programs, although single service programs, such as teleradiology and telepsychiatry programs, are common. A number of factors are barriers to the development of sustainable telemedicine and telehealth programs. First, starting programs is often challenging since relatively few organizations have, in house, a critical mass of individuals with the skill sets required to organize and manage a telemedicine program. Therefore, it is necessary to “boot strap” many of the start-up activities using available personnel. Another challenge is to assemble a management team that has time to champion telemedicine and telehealth while dealing with the broad range of issues that often confront telemedicine programs. Telemedicine programs housed within a single health care delivery system have advantages over programs that serve as umbrella telehealth organizations for multiple health care systems. Planning a telemedicine program can involve developing a shared vision among the participants, including the parent organizations, management, customers and the public. Developing shared visions can be a time-consuming, iterative process. Part of planning includes having the partnering organizations and their management teams reach a consensus on the initial program goals, priorities, strategies, and implementation plans. Staffing requirements of telemedicine and telehealth programs may be met by sharing existent resources, hiring additional personnel, or outsourcing activities. Business models, such as the Application Service Provider (ASP) model used by the Arizona Telemedicine Program, are designed to provide staffing flexibility by offering a combination of in-house and out-sourced services, depending on the needs of the individual participating health care organizations. Telemedicine programs should perform ongoing assessments of activities, ranging from service usage to quality of service assessments, to ongoing analyses of financial performance. The financial assessments should include evaluations of costs and benefits, coding issues, reimbursement, account receivables, bad debt and network utilization. Long-range strategic planning for a telemedicine and telehealth program should be carried out on an on-going basis and should include the program's governing board. This planning process should include goal setting and the periodic updating of the program's vision and mission statements. There can be additional special issues for multi-organization telemedicine and telehealth programs. For example, authority management can require the use of innovative approaches tailored to the realities of the organizational structures of the participating members. Inter-institutional relations may introduce additional issues when competing health care organizations are utilizing shared resources. Branding issues are preferably addressed during the initial planning of a multi-organizational telemedicine and telehealth program. Ideally, public policy regarding telemedicine and telehealth within a service region will complement the objectives of telemedicine and telehealth programs within that service area.

One may face obstacles in implementing technological advances in our environment or exporting technology and knowledge by disseminating telemedicine and e-health in the rural areas or to the developing countries, or just by simply trying to advance already established medical systems. Dr. Weinstein et al have eloquently put all you need to know it order “to put it all together,” however I wanted to alert you to few other issues may become important as you proceed. So let's talk first about obstacles as they vary. They may be as simple as ignorance, or as complex as political or national lack of vision, and leadership. Frankly, there are no obstacles that cannot be overcome, and there are no valid reasons that will justify failure to start and failure to succeed. We need to adopt the slogan “Failure is not an option.” Determination to succeed is often associated with serious difficulties and growing pain, but that is not a good reason why you should stop.

Over the past several decades the concept of telemedicine has evolved to be more commonplace with many unique applications. These applications have been made possible by overcoming challenges and barriers that have been present for most of telemedicine's development. The application of telemedicine continues to undergo growth and scrutiny. However, the rapid infusion of technology continues to serve as a catalyst for adoption and validation. Looking into the future requires a review of the past. Overcoming barriers and challenges has not been easy. Many have been minimized, in part because of technologies rapid flow and diffusion. Yet there are still significant challenges that must be overcome. In many parts of the world, healthcare and education are limited because of access. This has been driven by many influences, which continue to have an impact, albeit in many cases, minimal. Future generations of telemedicine users will look back at this period as one of transition. The first 30 years or so of telemedicine implementation were fraught with barriers and challenges. The next 30 years will see and entirely different paradigm of practicing medicine, including consumerism and smart systems.

Implementing a telehealth program from the technical standpoint can be an engineering and financial challenge due to associated costs such as hardware, software, networking, administration and human expertise. To maximize potential and minimize costs, it makes sense to leverage existing telecommunications infrastructures and tailor the program based on what is available. This is especially critical in developing nations where funding is often limited.

Over the last decade various international Information and Communications Technology networks have been created for a global access to high-level medical care. OP 2000 has designed and validated the high-end interactive video communication system WinVicos especially for telemedical applications, training of the physician in a distributed environment, teleconsultation and second opinion. WinVicos is operated on a workstation (WoTeSa) using standard hardware components and offers a superior image quality at a moderate transmission bandwidth of up to 2 Mbps. WoTeSa / WinVicos have been applied for IP-based communication in different satellite-based telemedical networks. In the DELTASS-project a disaster scenario was analysed and an appropriate telecommunication system for effective rescue measures for the victims was set up and evaluated. In the MEDASHIP project an integrated system for telemedical services (teleconsultation, teleelectro-cardiography, telesonography) on board of cruise ships and ferries has been set up. EMISPHER offers an equal access for most of the countries of the Euro-Mediterranean area to on-line services for health care in the required quality of service. E-learning applications, real-time telemedicine and shared management of medical assistance have been realized. The innovative developments in ICT with the aim of realizing a ubiquitous access to medical resources for everyone at any time and anywhere (u-Health) bear the risk of creating and amplifying a digital divide in the world. Therefore we have analyzed how the objective needs of the heterogeneous partners can be joined with the result that there is a need for real integration of the various platforms and services. A virtual combination of applications serves as the basic idea for the Virtual Hospital. The development of virtual hospitals and digital medicine helps to bridge the digital divide between different regions of the world and enables equal access to high-level medical care. Pre-operative planning, intra-operative navigation and minimally-invasive surgery require a digital and virtual environment supporting the perception of the physician. As data and computing resources in a virtual hospital are distributed over many sites the concept of the Grid should be integrated with other communication networks and platforms.

To decide to change from paper to a paperless hospital, one decides to go on a journey. This chapter will outline the destination, the reasons to make the journey and describe the best route to the destination. Becoming paperless is the route taken to the destination.

Telemedicine has developed around certain assumptions about connectivity and format. From the pioneer work of Kenneth Bird in the 1970's medical events separated by distance were connected for videoconference interaction [1]. The connection implied well developed telecommunications tools at both ends of the interaction. Telemedicine in its most common manifestations relies upon electronic and professional familiarity plus training with proper technical support. This is true even with Internet telemedicine at the low end of bandwidth. A workable Internet service provider and intact telecommunication services are required at both ends. The assumption of intact, robust telecommunications fails when there is any significant disruption of services, power, or trained people to initiate a telemedicine request. The very nature of disasters whether made by nature, made by fellow humans or in war declarations implies a rupture of the social fabric, a failure of infrastructure. This loss of infrastructure and connection happens at a cruel time when the need for services in health matters is generally very much exacerbated. Extreme remote sites have never had infrastructure and therefore fit into this chapter. Is telemedicine incompatible with support and relief in disasters of remote places? Certainly not. However, telemedicine must adapt to the situation in ways not generally associated with standard telemedicine. New solutions can meet the expectation of being wherever services are need whenever the need arises. This chapter looks at the experiences, successes and failures of telemedicine in natural disaster, war, and extreme remote sites. The presentation is concluded with recommendations to make telemedicine integral to any disaster response and a natural tool for any human endeavor that requires sending people to remote and hostile environments.

While telemedicine is now well established in many areas of medical practice, it is only beginning to create impact in some of the more complex medical applications such as critical care. New systems based on advanced technologies such as the Virtual Critical Care Unit and the eICU have recently successfully demonstrated the provision of critical care services from a distance in emergency and intensive care respectively. These specialties make particular demands on a telemedicine system, and studies in computer supported collaborative work as well as studies of work practices suggest that there is a minimum threshold of technology complexity for supporting such applications. The eICU relies mainly on transmitting a rich data space to a remotely located specialist, while ViCCU^® relies on creating a sense of presence. Other systems rely on complex physiological models. These approaches exemplify two trends in telemedicine systems of the future, with enhanced immersiveness creating a high sense of presence, and ready access to structured patient-specific data providing assistance to decision support. The future of telemedicine technology may see a convergence of these two trends.

Historically, telemedicine has focused on the application of traditional physician-to-patient (and physician-to-physician) interactions enhanced by two-way video and audio capability. This “one-on-one” interaction via a telemedicine link can dramatically extend a physician's or other caregiver's geographic range and availability. However, this same telemedicine model is most often implemented “on-demand” for a specified time-limited encounter. The remote Intensive Care Unit (ICU) model to be described similarly expands the geographic range of ICU physicians, but also allows a single specialist to simultaneously monitor multiple patients on a continuous basis by leveraging computerized “intelligent” algorithms and an electronic medical record interface. This new application of telemedicine wedded to computer technology facilitates maximum leveraging of specialists' cognitive skills but also mandates significant process changes in how ICU services are provided. In short, the remote ICU represents a “re-engineering” of how ICU care is delivered and establishes a new paradigm for the field of telemedicine, expanding the reach, scope and availability of intensivist specialty expertise.

The re-engineering occurs through a number of ways. First, the telemedicine connection is continuously available in a pro-active fashion that can be provided 24 hours a day, 7 days a week (24/7). Secondly, the system utilizes computerized clinical intelligence algorithms with direct electronic links to physiologic, laboratory and lab/pharmacy data as well as patient diagnoses to focus attention on potential adverse outcomes or trends in individual patients and notify caregivers before trends manifest as adverse outcomes. Third, the traditional physician, nurse, and patient relationship is substantially augmented when there is an ICU physician immediately available to address issues in patient care, particularly at night when physicians are less likely to be present at the bedside. The current preliminary data suggest that this system can be quite effective in improving ICU quality of care, thus leading to reductions in the cost of ICU care, ICU patient mortality, ICU patient outliers, and ICU length of stay (LOS).

Given the extensive data showing improved ICU outcomes with daily ICU physician participation in care of critically ill patients, and the national shortage of ICU physicians, nurses, and ancillary staff; the electronic ICU system is gaining popularity as an alternative paradigm for the expansion of an ICU team's expertise in the care of the severely ill. Interestingly, internal Quality Improvement (QI) data from several healthcare systems have shown that improved outcomes occur even when remote ICU telemedicine is applied to a pre-existing 24/7 in-house intensivist care model. The reasons for this remain speculative at this point, but pro-active and hourly remote “virtual rounds” on the most critically-ill patients, and use of computerized algorithms in triaging ICU physicians' attention may contribute to the success of this system. Also, we will show how the system supports key elements of error reduction theory even in well-staffed critical care units.

Multiple challenges remain before remote ICU systems become more broadly accepted and applied. These include cost of implementation of the system, resistance to the system by ICU physicians and nurses, and integration of data systems and clinical information into the remote electronic ICU model. In this chapter, we will provide background information on error reduction theory and the role of the remote ICU model, review current data supporting use of the remote ICU system, address the current obstacles to effective implementation, and look to the future of the field for solutions to these challenges.

It is well known that in most countries, there is a perennial shortage of specialists in neurosciences. Even the few available neurologists and neurosurgeons are clustered in the metros and urban areas. Those living in suburban and rural areas have limited or no access to neurological care. At the same time there has been an unprecedented growth in ICT (Information and Communication Technology). In this article, the authors review the increasing use of telemedicine in neurosciences.

Here, the possibilities to build integrated primary health care telemedicine services are presented accompanied with available epistemic criteria for quality evaluation purposes. Given that the cost of sanitary care is increasing continuously the telemedicine approach is a challenge for providing quality care and at low cost to the rural citizens.

This chapter will review the current state-of-the-art of home health services in the telemedicine environment. Two aspects in particular will be discussed that reflect where most of the efforts in home telehealth care are being directed. The first aspect is the more traditional implementation in which the healthcare practitioner “visits” the patient (typically chronically ill or at home recovering from a hospital visit) virtually at a distance using telemedicine technologies to assess their health status, obtain a select set of vital signs (e.g., blood pressure), and converse with them about how they feel and so on. The second application is the growing field of distance monitoring, especially as it pertains to prevention and health maintenance. In this application, the users may be patients with chronic conditions such as asthma or diabetes that require regular monitoring to achieve or maintain healthy functioning, but they are typically not in an acute phase. More and more often, however, the users of distance monitoring technologies are relatively healthy people looking to enhance their health awareness and healthy status by monitoring various vital signs to alert them of any potential changes in their health status that would require actual medical attention.

Telerehabilitation in which rehabilitation services are provided at a distance using communication technologies is a new and developing field of telehealth. Primarily developed to provide equitable access to individuals who are geographically remote and to those who are physically and economically disadvantaged, telerehabilitation also has the capacity to improve the quality of rehabilitation health care. Online delivery of rehabilitation enables the rehabilitation therapist to optimize the timing, intensity and duration of therapy that is often not possible within the constraints of face-to-face treatment protocols in current health systems. This chapter outlines the advances made to date in telerehabilitation applications in the fields of physiotherapy, speech-language pathology, occupational therapy, and biomedical engineering and provides evidence for the success of these applications. Applications to date encompass systems ranging from low-bandwidth low-cost videophones, to highly expensive, fully immersive virtual reality systems with haptic interfaces. A number of barriers to the establishment and advancement of telerehabilitation within health care systems have been outlined and include professional issues relating to the inherent hands-on approach of some treatments, licensure laws, professional skill development, patient disability, reimbursement, and the paucity of online assessment and treatment tools and outcomes data. In response, possible solutions to these barriers such as the development and validation of alternative assessment and treatment procedures, involvement in the international policy debate, as well as the resolution of national professional policies which hinder the wider uptake of telerehabilitation technologies, have been outlined. The future of telerehabilitation is promising as a new, yet complex form of telehealth with the capacity to provide a wide range of services specifically designed to suit the needs of the individual.

Although wound care has been practiced for centuries, telewound care is a relatively new concept. Currently, only a few pilot programs are in existence. Telewound care has yet to achieve the popularity and recognition of its other telemedicine predecessors amongst members of the health care industry and public alike. The tremendous potential of incorporating the technology of telemedicine into wound care needs to be realized. Wound care is a representation of the care of chronic and debilitating conditions that require long-term specialized care. We have seen the positive effects of improved living conditions and advances in health care globally. The result: people are now living longer. Every day a small piece is added to the pie: the percentage of worlds' elderly and those with chronic medical conditions that would require medical attention is rising. With the escalating costs of health care, and the push of the industry towards outpatient care, this is a part of the health care crisis that is demanding our immediate attention. We have seen positive outcomes in the care of other chronic medial conditions using telemedicine such as home telecare programs. In addition, the effectiveness of several programs using available advances in technology such as the field of radiology has been established. Wound care can build on success created in these fields to create an effective and useful method of care.

The aim of this chapter is to recognize the impact of this problem, to introduce several pilot programs in several different aspects of wound care and to build on current resources in order to achieve a novel method of wound care. The goal would be to create a technologically advanced, cost-effective and user-friendly program, and be able to bridge the gap between the sick and available specialized care. Both store-and-forward technology and televideo have a role to play in telewound care, the latter greater in the role of home telecare and teleconsultation, and the former in post-operative patients and the follow-up of chronic wounds. Either way, both have been underutilized and underdeveloped. With the advances in the field of telecommunications in connecting people across distances at a fraction of the time and costs, improved outcomes reported in other fields of telemedicine and positive legislative changes, there is an enormous potential in this field. We now have the ability, knowledge and resources to develop telewound care programs, which can provide high quality patient care in a more concise and cost-effective way. It is certainly a welcoming relief to a field that has traditionally been known to pose an emotional, physical and financial drain to all those involved.

Telemedicine for pathology, this is pathology in which the specimen is digitally transmitted and examined by a pathologist at a distance. In another words, telemedicine for pathology, or simply telepathology, is a branch of telemedicine and pathology that consists in the exchange of pathology images through telecommunication with the purposes of diagnosis, consultation, research and/or education. The use of telepathology is of great importance in management of patients since it allows fast diagnosis and inter-consultations among specialist pathologists located in every part of the world.

Australia is a large country with a small and scattered population. Specialist dermatology services are concentrated in the capital cities and larger urban centers on the coast. This has meant access to these services for Australians in rural and remote areas has been limited to those able to travel the often long distances to their nearest dermatologist. Due to a considerable shortage of dermatologists, waiting times to see one are more than six months.

The challenge was to provide a dermatology service that overcame these twin obstacles of distance and demand. Telecommunication infrastructure in Australia is good and most towns have at least one general practitioner. More than 75% of all general practices are equipped with computers and have broadband internet access.

Dermatology is a specialty with few life threatening disorders. However short delays in diagnosis and management of a skin condition rarely have any serious impact on a patient's long-term health. At the same time many skin problems are distressing, and difficult to diagnose and treat. Many skin conditions last for considerable periods of time and patients need ongoing care. Due to the highly visual nature of the specialty, most skin conditions can be diagnosed from an image especially if there is some history available. This often requires a trained specialist. Paradoxically, any needed investigations such as skin biopsy or blood tests can be performed by any qualified doctor. Dermatological treatments can be instituted and monitored by these same practitioners without any specialist training. These factors make tele-medicine an ideal solution to the problems of isolation from and excess demand for specialist dermatological services.

In 2004 the Australian College of Rural and Remote Medicine (ACRRM) in a joint initiative with Queensland Divisions of General Practice (QDGP) set up Tele-Derm with funding from the Commonwealth Department of Health and Ageing under the Medical Specialist Outreach Assistance Program (MSOAP).

Tele-Derm was set up as an online consultation service combined with a central portal for online dermatology education, resources, links, discussions and professional development activities. It was set up with the belief that a teledermatolgy service must offer ongoing education as well as a specific case consultation service. If the remote doctor does not have the skills to perform required procedures such as biopsy and excision then the patient will still need to travel.

The common misconception about tele-dermatology is that this form of consultation is not as good as a face-to-face one with a dermatologist. But, in the majority of cases it is [1]. In any event Tele-Derm is not trying to provide a service that is necessarily better then the traditional mode of delivery. It wishes to provide a service where none currently exists. To this end, Tele-Derm provides teleconsultation and online education in dermatology to doctors Australia wide.

Telemedicine in oncology or teleoncology integrates many so far well-known telemedicine elements such as teleconsultation, telesupport, telesurgery and telerobotics, teleeducation, and many others and is integral part of many disciplines such as internal medicine, surgery, dermatology, but also dentistry and psychooncology/psychiatry. Changes in ICT, new developments in oncology, the need to think and work interdisciplinarily, geographic and economic challenges as well as the transgression of sectoral boundaries as elements of modern teleoncology. Whereas the northern parts of Europe show a well-developed telemedicine infrastructure with a growing tendency to incorporate teleoncology for documentation, data analysis and quality assurance, in more southern countries this process is still underway and often marked by project status. Modern technology using xDSL and other terrestrial network lines but also satellite connectivity is at hand to cover a wide variety of telemedicine applications and services from which teleoncology benefits. More and more specifically designed software applications can be used to assess the medical workflow of an oncological patient and determine a life-long oncological electronic patient record. The trend, however, goes to the systemic integration of single applications and services into clinical information systems with a telemedicine approach. Although past evaluations of telemedicine applications and services have shown very positive results, only the right financial funding determines their survival and wide-spread usability in daily routine medical use. Formerly identifiable barriers for this use nowadays can be overcome more easily.

Internet use for health information by both practitioners and consumers continues to expand geometrically. The impact of Internet on practice, access and health decisions is considerable and will probably grow to the predominant mode of health information delivery in the coming years. As the growth of this unregulated global bulletin board continues, how do we assure the quality of the information retrieved by professionals and patients? What are the indicators of quality? How should we measure impact? How do authoritative sources get the attention and who should decide? What should practitioners recommend? What should medical teachers advise trainees? This review of Internet content, access and application considers the history, patterns of use, evaluation studies and specialty examples. A few authoritative sources are recommended and that recommendation is justified. Changes in health care delivery must take best advantage of the Internet with least disruption to the important principles of practice and patient relationships. The health community needs effective interaction with medicine's inevitable partner, the Internet.