Ebook: The Impact of Telemedicine on Health Care Management

The main objective of G-7/8 Global Healthcare Applications sub-project 4 is to enable an international concerted action on collaboration in telemedicine. To promote and facilitate the implementation of telemedicine or health telematics networks around the world, it was felt necessary to solve certain key issues. Five thematic solution-seeking FORUMS are each addressing a specific item. The first FORUM held in Montréal, Canada on May 28-30 1998 focussed on Interoperability of telemedicine and telehealth systems. Other FORUMS address other themes such as: Impacts of Telemedicine on health care management (Regensburg, Germany, November 21-23 1998); Evaluation and Cost Effectiveness of Telemedicine (Melbourne, Australia, February 19-20 1999); Clinical and technical quality and standards (Washington, USA, April 29-30 1999); Medico-legal aspects of national and international applications (Oxford, UK, fall 1999).

The main objective of these FORUMS is to arrive at best practices through consultation amongst experts who seek together the best solutions to facilitate global international telemedicine networks.

Towards this goal, G-8 sub-project-4 will also conduct the IMPACT (International Multipoint Project of Advanced Communication in Telemedicine) feasibility study which will aim at conducting multipoint exchanges between telemedicine units in the academic centers of the participating G-8 and other countries. More detailed information on this project and summaries of the initial FORUMS are found on our Web site at www.g7sp4.org.

One objective of the growing telehealth and telemedicine literature base is to inform potential adopters and raise their awareness through pilot projects. However, pilot studies often fail to create sustainable solutions because certain conditions are needed for long term success:

(1) matching needs to appropriate solutions: while needs assessment can identify needs, adopters must view, test, and experience potential solutions under a number of circumstances;

(2) change and new technology: technological implementation brings both foreseen and unforeseen changes, difficult to forecast, and pilot projects can create artificial expectations;

(3) diwareness of context: there has been a pervasive tendency to treat telemedicine or telehealth as separate from the context of health care delivery, but telemedicine is only a communication and information tool, and should not be considered as separate from other health care delivery activities; (4) availability of long term funding: while loans, government grants and private sector partnering can bridge gaps temporarily, sustainable solutions require that savings from existing systems can be applied to pay for telehealth and telemedicine installations. This paper makes a case for adopting best practices by proposing that a data base of case studies documenting best practices and success factors be developed and made widely available.

A variety of telehealth applications have been implemented throughout the industrialized world. Given that telehealth has yet to become routine in the practices of physicians, the impact of such applications on health care management remains difficult to identify. Only by becoming integrated into the ‘normal practice’ of clinicians can telehealth facilitate smooth communications in health care delivery processes.

In this paper we demonstrate the importance of developing a ‘theory of use’, describing how clinicians are expected to use teleconsultation in their daily activities. By employing Giddens' Structuration Theory, we can develop a clear vision of the utilization of telehealth, and a better framework with which to assess its added value for health care delivery. We illustrate this claim by referring to our research on the Quebec Inter-Regional Telemedicine Network. In this study we compare the ‘theory of use’ behind the telemedicine network with the perceptions of physicians regarding their needs in terms of communications and access to expert advice. The breach between the theory and the perceptions of physicians may help to explain how the utilization of telehealth could be enhanced, and how new and sustainable routines for its integration into the health care system might be created

Healthcare managers and policy makers will, in the immediate and near future, make major decisions about the allocation of scarce healthcare resources for telehealth ‘solutions’. In our haste to capitalize on what technology can do we may be obscuring discussion and research about what technology should do. For example, currently much attention is being paid to standardization for technological aspects of telehealth. In contrast few efforts have been made to seek standardization in regards to a broad evaluation framework for telehealth. A body of opinion believes that missing in our rush into the on-line world is a systematic approach to research into the human, social, cultural, economic, and political factors associated with healthcare. As a result we lack the tools and experience necessary to assess the true value and implications of telehealth ‘solutions’. Developing general guidelines for an evaluation framework, from needs assessment through integrated research to post-study assessment, would greatly enhance the quality of decision making by healthcare managers and policy makers. We propose a model - the Telehealth Integrated Research Model (TIRM) - as the first step in encouraging discussion and development of an internationally accepted standardized telehealth evaluation framework.

Telemedicine is undoubtedly one of the most dynamic developing fields of IT-technologies in health care. From research and development to routine clinical use of telemedicine applications, decision-makers demand information on the impact that widespread use will have on structures and processes in health care.

To date published evaluations have mostly focused on technical core functions. Future evaluation concepts have to consider side-effects the use of telematic systems in health care might have. The report of effects should consider the 4 major interest groups: patients, providers, third-party payers, and society.

Learning from experiences in other IT-fields, system developers can avoid pitfalls that might lead to a poor acceptance of their systems or the discontinuation of their R&D project at an immature stage.

We can trace 229 telemedicine trials in Japan. Of these, 150 were active in 1998, including 73 in radiology, 24 in home care, 22 in medical imaging, 20 in pathology, 5 in ophthalmology, and 3 in dentistry. Some of them have been reformed into practical daily activities. However, activities using the same method work in some local areas but not in others. Typical successful cases will be presented and discussed.

We are constructing Japan-Canada cooperation in numerous areas using several communicative methods: ordinary telephone, ordinary Internet, ISDN (2B/6B), and an offline network using optical memory cards (which patients carry). We have introduced successful domestic cases into global cooperation. Some of them will be useful for exchanging medical information among developing countries.

One of the results of the 49^th Bavarian Physician’s Conference was that in 1996 the Bavarian Statutory Health Care Administration (Kassenärztliche Vereinigung Bayerns, KVB) and the Bavarian Medical Association (Bayerische Landesärztekammer, BLÄK) jointly suggested a project for the development and verification of a security infrastructure for the online transmission of medical patient data. This Project, the so-called “Health Care Professionals Protocol” (HCP-Protokoll), was designed to establish the first consensus standard for a secure and provably open system to be used in the health care system operating under the constraints of the diverse and heterogeneous IT-infrastructure in Bavaria, with a view towards utilization in all of Germany.

In January 1997, the HCP-Protocol was accepted as the strategic mainline project for telematics applications in medicine by the State of Bavaria and endowed with more than 1.3 million DM in the framework of “Bavaria Online II”.

In the meantime, various national organizations of the German medical community as well as important industrial partners have expressed support for this initiative. Mention in the Roland-Berger study “Telematics in Health Care, Perspectives of Telemedicine in Germany”, designation as an “exemplary scenario” in the final report of the Working Group 7 of the Forum Info 2000 “Telematics Applications in Health Care”, as well as integration of the new German health professional card, make the HCP-Protocol the most promising candidate for a de facto standard in the security infrastructure for all participants in health care telecommunication in Germany.

Since the middle of 1998, an expert group under the guidance of the joint “Projektbüro Telemedizin” of the KVB and BLÄK has been working on the definition of this protocol, taking into consideration the current legal framework of the German medical profession (Berufsordnung), the German signature law (SigG), and the national data security laws (BDSG), as well as today's technical possibilities and existing components.

The results of this definition will be published at the first opportunity (sometime during the first half of 1999) and then placed into public domain, so that any solution provider can reference this source to create secure and mutually interoperable application programs for health care professionals in Germany.

Based on the work of the ISHTAR, the TRUSTHEALTH1, the EUROMED- ETS and the MEDSEC project funded by the European Commission, the synergetic results of these different projects in providing a security infrastructure for the test environment of an oncological network will be demonstrated.

The ISHTAR project investigated security issues in Health Care Establishments (HCE). It provides guidance for threat and risk analysis, and defines a schema for specification and implementation of appropriate security services and mechanisms to respond to the HCE security requirements of both communication and application security concepts.

The TRUSTHEALTH 1 project dealt with specification and test implementation of basic security services and mechanisms based on Health Professional Cards (HPC) and Trusted Third Party (TTP) services.

Within the EUROMED-ETS project, the security solution has been extended to the Internet environment and WWW tools, successfully creating an Internet-based international TTP structure between the universities of Athens, Calabria, and Magdeburg.

Finally, in the MEDSEC project the specification and implementation of a generic EDI security solution has been delivered to provide secure communication between applications and sites.

In the ongoing TRUSTHEALTH2 project, the results of all these projects will be implemented in a real environment of cancer care.

Experiencing communication problems in our emergency services, we developed an innovative communication network and system (NOAH, which stands for Notfall-Organisations-und Arbeitshilfe, or Emergency-Organisation Active Aide System). In contrast with the currently established emergency services communication in Germany by radio wave, data is transferred from the scene in the form of an electronic record on a notepad-computer by means of the wireless data communication network Modacom ($\underline{Mo}$bile $\underbar{D}$ata $\underline{Com}$munication), which is provided by German Telekom. It is received at the dispatch-centre in mentioned format and transferred to the admitting hospital without any loss of data.

In a prospective study, the technical and conceptual suitability of this system was investigated. It was shown that an admitting hospital was informed more than 20 minutes in advance about the admittance of a patient. To assure the quality of transferred data, information was ranked by different criteria. This further demonstrated that much more precise information about a patient's condition was already available upon admittance to the hospital.

The practical needs of the medical professional faced with critical care or emergency situations differ from those working in many environments where telemedicine and mobile computing have been introduced and tested. One constructive criticism of the telemedicine initiative has been to question what positive benefits are gained from videoconferencing, paperless transactions, and online access to patient record. With a goal of producing a positive answer to such questions an architecture for multipurpose mobile telemedicine applications has been developed. The core technology is based upon a wearable personal computer with a smart-card interface coupled with speech, pen, video input and wireless intranet connectivity. The TransPAC system with the MediLink software system is designed to provide an integrated solution for a broad range of health care functions where mobile and hands-free or limited-access systems are preferred or necessary and where the capabilities of other mobile devices are insufficient or inappropriate. Structured and noise- resistant speech-to-text interfacing plus the use of a web browser-like display, accessible through either a flatpanel, standard, or headset monitor, gives the beltpack TransPAC computer the functions of a complete desktop including PCMCIA card interfaces for internet connectivity and a secure smartcard with 16-bit microprocessor and upwards of 64K memory. The card acts to provide user access control for security, user custom configuration of applications and display and vocabulary, and memory to diminish the need for PC-server communications while in an active session. TransPAC is being implemented for EMT and ER staff usage.

Surgical procedures can be performed and monitored in operating rooms physically isolated, but electronically linked to a parent medical center, and certainly from distant consultation. Quality of surgical care has been measured in retrospect rather than in real time, and outcomes have generally not had the benefit of immediate consultation and group analysis. However, telemedicine can connect consultants, surgeons, patients, and databases. The Yale Telemedicine Center has developed network schemes, which connect the OR of trainees with the laboratory of the teacher, and has opened a continuum between pedagogy and product. The program has connected regional hospitals, connected components of hospital systems, and has been used in international testbeds. The particular operative procedures studied have been laparoscopic procedures. The consultant is based at Yale and is connected with the distant OR to share the laparoscopic surgical field. Connection includes real time video, audio and the ability to draw instruction on the OR screen. Bandwidths as low as 12kbs(POTS) have been employed with modification with effective intervention. The potential for quality improvement is substantial, and inclusion in quality programs is strongly recommended.

Telemedicine has been in daily practice at our neurosurgical department for five years. In our experience the standard personal computer-based telemedicine systems Medicom^® and especially RADO Lookm^® are reliable, easy to use, and of high quality performance.

Telemedicine makes possible better patient management at regional hospitals and the avoidance of patient transports. Therefore treatment costs in neurosurgical patients can be highly reduced.

A large telemedicine project is now under development in Moscow. The general task of the project is to link oncology research centres and hospitals meeting the project profile, and to provide on-line (using real-time video conferences) and off-line (via distributed database of medical information) information exchange. There was no existing technology available for use at the project’s base which was ready to meet all requirements, so we are using specially created technology for video networks (DiViSy V.97). We suppose this technology to be more applicable for use in telemedicine networks than are business video conference technologies and classical Internet/Intranet technologies. We affirm in our conclusion that now is the time for developing special telemedicine standards, recommendations of compatibility, etc., and that we are ready to take part in this process.

This is a controlled pilot study of twenty patients to see if heart failure management can be optimised in the community using telemedicine. The study seeks to examine the feasibility, acceptability and reliability of using telemedicine in this context. Heart failure is a common condition. It is an important cause of mortality and morbidity and has large cost implications for the NHS. Most patients are managed in the U K in General Practice based on clinical assessment by the practitioner. Twenty patients with a mean age of 75.1 years and mean New York Heart Association grade of 1.75 were randomised in to two equal groups (telemonitoring and control) and observed for a period of three months. All twenty patients had a Cardiologist assessment and quality of life measurement at the beginning and end of the study. Patients in the telemedicine group had their blood pressure, pulse and weight data collected daily and undertook a weekly video conference with the nurse. Control patients had their blood pressure, weight and pulse measured at six weekly intervals. The study has been extended for a further six months beyond its initial three-month observation period to see if the initial short term benefit in the telemedicine group is maintained.