Ebook: Handbook of Telemedicine

It is an honour and a pleasure to respond to the kind invitation of the Catai-Telemedicine consortium to present the “Handbook of Telemedicine”. As a physician, a scientist and an educator, keen on the prospects of technological progress and their influence in the training of the young professionals, I am extremely satisfied to see the birth of an informative and comprehensive publication in the new discipline and practice of telemedicine. As a politician and a Member of the European Parliament I am satisfied to see that this book is the result of a broad collaboration bringing together experts and knowledge from all the corners of Europe, from Norway to Spain, and from the United Kingdom to Austria, attaining a quantum leap with the added value that makes the resulting whole bigger that the simple sum of its parts.

On the verge of the 21st Century, and in view of the economic, social, technological and cultural transformations contained in the term “information society”, we shall all -as citizens, professionals, administrators and policy makers- be called on to re-think our views on health matters. The European social protection model has made possible a high degree of coverage of the health needs of the population. Scientific progress, better diagnostic and therapeutic means, as well as healthier life-styles have contributed to “add years to life” and “life to years”. On the other hand, patients are changing from a passive role in respect to their own health problems, and are now better informed and willing to assume more responsibilities for their well being and that of their families. There is also a will to access medical and other services that should be much more easily available, in terms of place and time, bringing care closer to household and communities.

In this context, the advent of telemedicine and telecare could not be more opportune. As we enter an era that has also been described as the society of knowledge, it becomes ever more imperative that medical practitioners and other health professionals offer their clients the best existing information about a particular disease affecting them. Time, distance or physical obstacles can no longer justify placing a barrier between a patient's ailment and the best existing knowledge on how to manage it, wherever in the world it is to be found. And here is where telemedicine can be of higher value, by making it much easier to use expert advice from the hospital specialist to the primary care doctor, or from a doctor to a nurse, or from a world-class specialist to another specialist confronted with particularly complex cases. The ability of telemedicine to offer “just-in-time” help where it is most needed is one of its main assets.

It goes without saying that telemedicine can and should also play an important role there where emergencies, or geographic or other conditions (isolation, bad weather, catastrophes), call for the use of this new model of medical delivery. Another case would be that of underserved populations or regions with a critical shortage of health personnel, as in the case of developing countries.

However, as telemedicine develops, the need for basic accepted principles for its practice becomes evident. Medicine has always been strict in respect to “the practice of the art”, and the same should apply for the new and numerous telemedicine and telecare applications. If we accept that telemedicine should be “medicine at a distance”, it should have the same requirements as plain medicine: use by qualified personnel, an unambiguous legal framework defining the rights and obligations of clients and providers, and well-defined quality standards.

One of our main preoccupations in respect to health informatics and telematics is that the proper protection of patients' health information should be guaranteed at all costs. Confidentiality, integrity and security of medical data affecting the most intimate conditions of a person have to be fully assured, both at the technical and at the legal levels. When travelling through networks, patient information should be made anonymous, and appropriate mechanisms including encryption should be used as required. Medical doctors and other professionals should observe the highest ethical standards in this respect, and a new deontology adapted to the information age might need to be sought.

A major challenge and opportunity opened up by telemedicine is the new vista for training and education. Offering a means to acquire general medical knowledge in itself, telemedicine will also dramatically change the way in which the new generations of doctors, surgeons, and nurses will be trained in the future. The availability of teaching materials, both in traditional support forms like this book, and others in multimedia formats, will be in high demand for that purpose.

In summary, telemedicine and telecare make a reality out of the best promises of information and communication technology for the benefit of patients and citizens. In the era of the massive extension of the Internet they take full advantage of the existing and future connections and tools. It is also the dawn of a golden age of shared knowledge that will be put at the disposal of a much broader base of beneficiaries. If all this can be accomplished with the necessary caution that the introduction of such fantastic changes requires, and with an exacting respect for the person for whom it is intended, it will offer a shining future for the ancient and noble health professions. Let us hope that this book makes a significant contribution in that direction.

Prof. Alain Pompidou

Member of the European Parliament

Chairman of STOA, Scientific and Technological Options Assessment

Strasbourg, June 1998

To be able to evaluate and indicate the MINIMUM REQUIREMENTS that a particular Telemedicine network, service, application or device should fulfil in order to assure a safe and adequate medical support at distance. The health community (users and providers) have to know which of the available technologies is suitable for that purpose and the reasons that justify a particular choice excluding others. An overview of the elements involved in Telemedicine applications is discussed in this chapter.

Telemedicine applications use communication technology for the transmission of various types of data between the different locations of terminals. In this chapter, the technology for both the terminal equipment and the networks connecting these terminals are introduced.

The strict control of Telemedicine trials is a guarantee for acceptance of the technique. This chapter introduces some guidelines on the aspects of quality control and assurance as well as the most common statistical techniques used for analysis

This chapter deals with the type of telemedicine that can be carried out using the widely diffused telecommunication channel of Internet. This is accomplished with an analysis of the advantages and limitations and the communication requirements of the medical professional. Personal collaborations through e-mail, group co-operation through newsgroups and mailing lists, multimedia data sharing through World Wide Web are described, with special attention to security and quality of service. A quick review on forthcoming Internet developments complements the issue. Some examples of the Medical use of Internet are included.

The continous education and diagnostic support is extremely important in public and private medicine. In this chapter, distant teaching and learning new technology developments are discussed. The challenges brought by recent telecommunications, computer hardware and software are examined and the new questions raised on distance education and training in Telemedicine are put forward. Some answers are proposed for future progress.

The present chapter covers one of the most important issues in medical practice related to ethics, privacy and confidentiality of the data held by the Health professionals. Special emphasis is put on the EU directives that regulate those issues and on possible practical solutions for the forthcoming implementation of Telehealth applications.

This chapter will introduce liability and legal aspects not covered in other chapters, and particularly will take into consideration the existing EU norms that may cover those issues. To model the situation the existing contractual scenarios are introduced. The Teleassistance scenario is linked to world emergency situations. The chapter concludes with some legal formulas that may protect the practice of Telemedicine.

The present chapter gives an overview on economically relevant factors to be considered when planning to introduce telemedicine. The chapter covers the aspects of constraints, cost/benefits and possible indications for a widespread telemedicine use based on market demand and user needs as well as a comprehensive model for strategic planning. Failure to design telemedicine policies is an outstanding problem discussed in detail in the sections on re-engineering and hospital management. The rules of strategic planning and the process of formulating strategies and making decisions will be described.

The present chapter contains information on the issues that could affect the implementation of Telemedicine in the everyday work. This is complemented with some definitions on the aspects of transfer technology, innovation and techniques. To finally summarise some possible schemes to overcome those problems.

This chapter introduces some new technological advances and trends on the market that may influence the future Telemedicine applications, including a brief analysis of the agent technology and their possible Telemedicine applications.

The following list of terminology include terms not appearing in the book or new terms that might be of use in some Telemedicine aspects. It is not a complete glossary and only try to help with the numerous abbreviations and new names appearing in the market.

This annex presents complementary information on the aspects related to colour capture and manipulation as well as possible influences that could modify it, in the fields of visual perception, image analysis and densitometry.

This chapter dicusses most of the standard norms that control networks, either ISO or IEEE and introduces some guidelines on the devices required to build a network and on the solutions to segment it.

Previous to introducing innovations, some qualitative parameters should be studied to understand the potential acceptance and impact of the new technology, work patterns and outcomes. This annex contains a model to evaluate user attitudes.

This annex introduces some aspects related with present electronic money and electronic transactions, particularly on the solutions existing at present, especially those that have been standardised. A summary of the levels of protection is also included at the end of this annex.

Reality and subjective perception of the reality are two different issues. The factors that influence the reality have to be taken into account to understand that environment changes require re-training on reality perception.

A more detailed description of the most commonly used image formats such as GIF, TIFF, MPEG2 and PNG is given in this annex. Particular considerations that might be of interest for Telemedicine are mentioned.

The basic concept of computer mathematical operations is introduced in this annex in order to be able to understand the complex operations done in cryptography, which are also summarised.

The present annex deals with the multiconference applications in a broadcast environment, in spite of the fact that this technology is anchored in 1996. The broadcast and multipoint activity that packed switched networks can provide explain the new market trends and MCU functionality implemented in the gateways for compatibility reasons. Quality of Services is the only reason that maintain multimedia multiconferencing devices over ISDN