Telemedicine and e-health

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Telemedicine and e-health

• Dr Jim BriggsUniversity of Portsmouth
• jim.briggs_at_port.ac.uk

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Contents

• Definitions
• Types of telemedicine
• Case studies
• E-health
• Other issues
• Further information

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Definitions

• Telemedicine
• E-health

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Raw definitions

• Telemedicine
• medicine at a distance
• cf television

• E-health
• health services delivered electronically
• E-commerce

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No standard definition

• "To define telemedicine is to have something in
  common with Humpty Dumpty that is, by making a
  word to mean whatever you want it to mean."
  BJHCIM
• Google search throws up 13 defns
• http//www.google.com/search?qdefineTelemedicin
  e

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US government

• "The use of medical information exchanged from
  one site to another using electronic
  communications for the health and education of
  patients or providers and to improve patient
  care."
• http//cms.hhs.gov/glossary/default.asp (Dept of
  Health and Human Services)

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ATA one(s)

• "the use of medical information exchanged from
  one site to another via electronic communications
  for the health and education of the patient or
  health care provider and for the purpose of
  improving and extending the availability of
  patient care"
• http//www2.umdnj.edu/omcweb/1998/telemedicine.htm
  
• "access to medical care for consumers and health
  professionals via telecommunications technology"
• http//www.atmeda.org/about/aboutata.htm
• e-health is the "use of the Internet for
  healthcare"

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JMIR

• "e-health is an emerging field in the
  intersection of medical informatics, public
  health and business, referring to health services
  and information delivered or enhanced through the
  Internet and related technologies"

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e-health 2002 conference

• e-health is "the leveraging of the information
  and communication technology (ICT) to connect
  provider and patients and governments to educate
  and inform health care professionals, managers
  and consumers to stimulate innovation in care
  delivery and health system management and, to
  improve our health care system"

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TEIS one

• Starting point
• "The use of Information and Communication
  Technology (ICT) to deliver healthcare at a
  distance"

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TEIS scope

• Telemedicine and e-health are terms that are
  applied to the use of Information and
  Communication Technologies (ICT) in medicine,
  health and social care delivery
• As such, the subject divides into two main areas
  
• improvements to existing services in terms of
  their efficiency and effectiveness - for example,
  pathology, radiology, education and training, and
  Electronic Patient
• new service delivery development - for example,
  teledermatology, teleophthalmology.

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TEIS scope

• For our purposes, we define our area of interest
  as those applications that
• use information and communication technology
• to deliver health and/or social care in new
  ways
• on a person to person basis
• where those people are physically apart

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Types of telemedicine

• CJ Fitch, JS Briggs, RA Beresford, "System issues
  for telemedicine systems", Health Informatics
  Journal, vol. 7, no. 3/4, September/December
  2001, pp222-230

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Characteristics of tm systems

• Interaction style
• Data types
• Equipment
• Action
• Patient numbers
• Duration

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Interaction style

• Real-time (synchronous)
• Participants all active at the same time
• Use any synchronous technology (e.g. phone)
• Most commonly video conferencing
• Less often but becoming more common vital signs
  monitoring
• May need high bandwidth

• Store-and-forward (asynchronous)
• Participants do not need to be active at the same
  time
• Use any structured form of message passing
• Most commonly email
• Less often but becoming more common systems
  exchanging messages
• May not need high bandwidth

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Data types

• Text
• Patient notes
• Diagnosis

• Image
• X-rays
• Pathology slides
• CT/MRI/ scans
• Audio/video signals

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Equipment

• General purpose
• Off the shelf PCs

• Specialist
• Electronic stethoscopes
• Image capture equipment
• Image display equipment (possibly)

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Action

• Intervention
• Direct influence on patient treatment

• Advice
• Indirect influence
• Final decision made by intermediate party

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Patient numbers

• One patient at a time

• Multiple patients
• e.g. where a number of patient cases are
  considered at the same time

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Duration

• Timespan over which communication sessions take
  place
• single interaction
• single episode of care (multiple interactions
  over same problem)
• long-term (multiple episodes)

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Categories of telemedicine
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Case study MIU

• Minor Injury Units
• replacing "unviable" accident emergency
  departments
• nurse led
• deal with "straight-forward" problems
• Linked to central AE department by video link to
  provide expert backup
• Examples
• Cornwall
• Portsmouth/Gosport

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Cornwall MIUs
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Gosport MIU
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Case study - ambulance links

• ECG, etc. links from ambulance to hospital
• Expert backup for paramedics
• Reducing "call to needle" time for rural heart
  attack patients
• Dundee study reduced average time from 125 to 52
  minutes Pedley et al BMJ 2003
• Also, advance warning to AE staff of details of
  incoming cases

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Dundee trial
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Case study - MDTs

• Multi-disciplinary teams (e.g. in cancer care)
  need to discuss patient cases
• Travel costs (i.e. time) prohibitive
• Video-conference links allow staff to meet at
  more frequent intervals

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East Midlands cancer network
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Case study - teledermatology

• Overload on specialist dermatologists - long
  waiting lists for referrals
• tds provides commercial service
• specially trained nurses take digital photos
• specialist software routes to consultant
  dermatologists (anywhere in UK) for diagnosis
• consultant can work from home
• tds replaces local consultant but not totally

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tds sites

• North Manchester
• reduced waiting list from 18 months to 17 days in
  6 weeks
• Medway
• dealt with backlog of 3000 patients in 15 weeks
• Expanding into Essex, Hertfordshire and Texas
• http//www.tds-telemed.com/

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Case study - WorldCare

• Consortium of 4 big American hospitals
• Provide "second opinion" service worldwide (20
  countries)
• tele-radiology
• tele-pathology
• patient management consultation
• Local physician remains responsible
• http//www.worldcare.com/

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Case study - NHS Direct

• Biggest telemedicine project in the world
• Mainly telephone service
• Expanding to
• web
• online diagnosis for common conditions
• health encyclopaedia
• my NHS healthspace (personal info portal) news,
  reminders, knowledge
• digital TV
• http//www.nhsdirect.nhs.uk/

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e-health
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The banking metaphor

• Most transactions carried out by the customer
• Centralisation of specialist services
• Decentralisation of non-specialist services
• including at home
• Services become "commodities"
• Is there a need for specialist equipment?

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Integration of ITinto Business Sectors
Manufacturing
Business Services
Public Services
(Banks)
(Health)
Integration of IT
1980
1990
2000
Jean-Claude Healy May 2000
IT as a gadget Trojan horse networks, Full
Integration of IT into Business (Organisational,
Legal) Re-engineering of the system
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Are hospitals a thing of the past?
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e-health blueprint - Malaysia

• Four Flagship Applications
• Tele-Consultation
• Tele-Continuing Medical Education for Health
  Professionals
• Mass Customised Personalised Information and
  Education
• Lifetime Health Plan

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e-health - Pusan, S Korea

• Medical Tourism
• 2 hours by air for 2 billion people
• 1 with disposable income 20 million
• Cardiac - Cancer - Mental Health
• Costs can be competitive
• Popular tourist resort for families

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Other issues

• Ethics
• Economics
• Success factors

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Medico-legal/ethical issues

• Who is (legally) responsible for the patient's
  treatment?
• What country's laws apply?
• Where is the clinician licensed to practice?
• Can a correct diagnosis be made by telemedicine?
• Stanberry B. The Legal and Ethical Aspects of
  Telemedicine. Royal Society of Medicine Books,
  1998.

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Economics of telemedicine

• Infrastructure (network) costs
• getting cheaper
• Equipment costs
• getting smaller and cheaper
• People costs
• access to expertise
• travel by healthcare professionals
• building costs

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Economics 2

• What else to include?
• Patient costs
• is this the reason business cases fail?
• Social costs
• cost to society of being ill
• environmental cost of travel

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What makes tm a success?

• Why has telemedicine caught on in some
  disciplines and some places, but not in others?
• high-level support
• fortune right-time, right-place
• mature technology
• evangelists
• Do implementers of tele-X learn from
• the X literature?
• the telemedicine literature?

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Further information
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TEIS

• UK Telemedicine and E-health Information Service
• http//www.teis.port.ac.uk
• http//www.teis.nhs.uk
• Over 2000 records covering
• telemedicine/e-health activities (gt220)
• organisations
• people
• publications
• equipment

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TIE

• Telemedicine Information Exchange (US)
• http//tie.telemed.org/
• Covers
• Extensive bibliography (gt14,000 entries)
• Projects
• Events calendar
• Funding sources
• News

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CEW

• Confederation of e-health websites (Q)
• http//www.teis.port.ac.uk/orgs/cew/
• Other organisations include
• UK E-health Association
• Royal Society of Medicine
• IHM/ASSIST
• Norwegian Centre for Telemedicine
• EHTEL

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Journals

• Telemedicine
• Journal of Telemedicine and Telecare
• IEEE Transactions on Information Technology in
  Biomedicine
• Telemedicine Journal and e-Health
• Telehealth Practice Report
• Health informatics more generally
• Medical Informatics and the Internet in Medicine
• Health Informatics Journal
• Journal of Medical Internet Research

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The end

• jim.briggs_at_port.ac.uk
• Healthcare Computing Group,University of
  Portsmouth
• http//www.disco.port.ac.uk/hcc/
• http//www.teis.port.ac.uk/