Case study: Case study: TelemedicineTelemedicine

IN 364 IN 364

19. mars 200319. mars 2003

Margunn AanestadMargunn Aanestad

What is telemedicine?What is telemedicine?

A wide variety in technologies, use areas, A wide variety in technologies, use areas, organisational complexity, criticality, etc.organisational complexity, criticality, etc.

Telemedicine ranges from: Telemedicine ranges from: second opinion on digital images attached to second opinion on digital images attached to

an e-mail message an e-mail message to real-time advice during emergency surgeryto real-time advice during emergency surgery

Examination, treatment, monitoring, care and administration of patients, andeducation of staff and patientsusing technologies that allow access to expertise regardless of where the patient,expert or the information is located.

ExamplesExamples

General practitioner in Alta communicates with ENT General practitioner in Alta communicates with ENT specialist in Tromsø, using ISDN videoconference + specialist in Tromsø, using ISDN videoconference + endoscopy (since 1992) endoscopy (since 1992) Teleradiology: Troms Militære Sykehus transmits all Teleradiology: Troms Militære Sykehus transmits all images to Tromsø (in 1997: 7857 patients)images to Tromsø (in 1997: 7857 patients)””Born on Broadband”: pregnancy controls, ultrasound Born on Broadband”: pregnancy controls, ultrasound images transmitted from Gravdal (Lofoten) to Bodø.images transmitted from Gravdal (Lofoten) to Bodø.Patient-oriented and homecare services, e.g. parents to Patient-oriented and homecare services, e.g. parents to children with echsema may communicate with specialist.children with echsema may communicate with specialist.Babies with ”murmurs” on the heart sound, digitalised Babies with ”murmurs” on the heart sound, digitalised sound transmitted and evaluated by specialist.sound transmitted and evaluated by specialist.Specialists’ network (pathologists, oftalmologists etc.)Specialists’ network (pathologists, oftalmologists etc.)

Interesting issuesInteresting issues

Screening of patients, reduce no. of referrals, Screening of patients, reduce no. of referrals, reduce waiting time and resource use.reduce waiting time and resource use.Transfer of competence (often from center to Transfer of competence (often from center to periphery).periphery).Distribution of risks and responsibilities (general Distribution of risks and responsibilities (general practitioner or the expert who advices?)practitioner or the expert who advices?)Confidentiality of sensitive informationConfidentiality of sensitive informationIntegrity of information (e.g. quality of Integrity of information (e.g. quality of transmitted images)transmitted images)Which country’s law applies in a cross-border Which country’s law applies in a cross-border consultation?consultation?

Challenges and barriersChallenges and barriers

Practical issues, e.g. technical competence, Practical issues, e.g. technical competence, availability of support personnel, building space availability of support personnel, building space etc.etc.Legal issues (security, confidentiality, risk)Legal issues (security, confidentiality, risk)Organisational, how shall these services be Organisational, how shall these services be organised? Dedication of resources, payment for organised? Dedication of resources, payment for services etc.services etc.Professional standards, e.g. what is a safe level Professional standards, e.g. what is a safe level of image quality?of image quality?Economic, who will pay for equipment, network Economic, who will pay for equipment, network usage and manpower?usage and manpower?

StatusStatus

Some well-working applicationsSome well-working applications

Many ”dead” pilot projectsMany ”dead” pilot projects

Concern about how to go from pilots and Concern about how to go from pilots and research projects into routine use and research projects into routine use and mass deployment of the technology.mass deployment of the technology.

Relevance for Systems Relevance for Systems Development?Development?

A complex and challenging case where the A complex and challenging case where the technology is new (immature) and open technology is new (immature) and open (generic). The goal is not well defined, and so (generic). The goal is not well defined, and so the prospective use areas and users are not the prospective use areas and users are not defined. The health care sector & organisations defined. The health care sector & organisations are large, complex, and demanding. Resource are large, complex, and demanding. Resource constraints and criticality of work tasks makes it constraints and criticality of work tasks makes it unsuited for experimentation. Still radical unsuited for experimentation. Still radical restructuring and improvement is expected. How restructuring and improvement is expected. How can one approach such a task?can one approach such a task?

Evolutionary and experimentalEvolutionary and experimental

In such cases: iterative development is the only In such cases: iterative development is the only way forwardway forwardMust be learning-based: Must be learning-based: Learn from experience, see new problems and new Learn from experience, see new problems and new

opportunities, further developing technology and opportunities, further developing technology and organisationorganisation

Design and re-design in use, by users.Design and re-design in use, by users.Design encompass much more than the Design encompass much more than the technology itself (changed work practices, technology itself (changed work practices, expanded professional knowledge, new expanded professional knowledge, new organisational forms, new legislation etc.)organisational forms, new legislation etc.)

””The uphill battle of evolution”The uphill battle of evolution”

DilemmasDilemmas

Disadvantaged starting pointDisadvantaged starting point Lacking ”proof” of effectsLacking ”proof” of effects Scarcity of resources (time, money, devotion)Scarcity of resources (time, money, devotion) Little management supportLittle management support (for some use areas:)no perceived need(for some use areas:)no perceived need Low tolerance for disturbances and faultsLow tolerance for disturbances and faults

Today:Today:

Two telemedicine case that illustrates this Two telemedicine case that illustrates this dilemma and how it can be handled:dilemma and how it can be handled:

MobiMed (ambulances in Østfold) (Master MobiMed (ambulances in Østfold) (Master thesis, Nina Mikkelson, feb.2002)thesis, Nina Mikkelson, feb.2002)

Surgical telemedicine in Oslo (RH – US) Surgical telemedicine in Oslo (RH – US) (From my own PhD work 1998-2002)(From my own PhD work 1998-2002)

The DIMedS projectThe DIMedS project

””Development of Interactive Medical Services”Development of Interactive Medical Services”

Telia, Ericsson, Rikshospitalet, Ullevål and UiO Telia, Ericsson, Rikshospitalet, Ullevål and UiO (Informatics): cooperation 1997-1999.(Informatics): cooperation 1997-1999.

Exploratory development of broadband network Exploratory development of broadband network technologies for surgical telemedicine (minimal-technologies for surgical telemedicine (minimal-invasive surgery)invasive surgery)

34 Mbit/s ATM network between the two 34 Mbit/s ATM network between the two hospitals, MPEG2 (realtime) video/audio trx.hospitals, MPEG2 (realtime) video/audio trx.

Starting surgical telemedicineStarting surgical telemedicine

Planned usage: demonstrate new Planned usage: demonstrate new procedures to other surgeonsprocedures to other surgeonsInitial interest, but constraints on viewers’ Initial interest, but constraints on viewers’ participation due to local workload. Result: participation due to local workload. Result: not very much use of RH-US linknot very much use of RH-US linkWanted to increase no. of transmissionsWanted to increase no. of transmissionsWanted to get experience with use (learn)Wanted to get experience with use (learn)Wanted to build support within hospitals Wanted to build support within hospitals for later purchase/extensionsfor later purchase/extensions

Detours and stuntsDetours and stunts

Not just surgical telemedicine:Not just surgical telemedicine: Radiologists , medical students and teachers, Radiologists , medical students and teachers,

ear/nose/throat specialists, nursesear/nose/throat specialists, nurses Not just clinical procedures, but also lectures, Not just clinical procedures, but also lectures,

discussions, meetings, seminars and demonstrations)discussions, meetings, seminars and demonstrations)

Such transmissions might be perceived to miss Such transmissions might be perceived to miss the target, be deviation from the project plans. the target, be deviation from the project plans. We argue that they were necessary and useful We argue that they were necessary and useful ”detours” in order to reach the goal (which in turn ”detours” in order to reach the goal (which in turn were changed and influenced by the detours and were changed and influenced by the detours and the new participants)the new participants)

Mobimed – Østfold countyMobimed – Østfold county

The need for telemedicineThe need for telemedicine

For myocardial infarction (hjerteinfarkt) For myocardial infarction (hjerteinfarkt) treatment should be given within one hourtreatment should be given within one hourTime delays:Time delays: From patient becomes ill until ambulance From patient becomes ill until ambulance

arrivesarrives Transport to hospitalTransport to hospital Time spent within hospital before treatment is Time spent within hospital before treatment is

started: transport from ECU to Heart ICU. started: transport from ECU to Heart ICU. (”Door-to-needle time”)(”Door-to-needle time”)

The Mobimed ”project”: The Mobimed ”project”: Some milestones (1)Some milestones (1)

1996: PW (a doctor) hears of MobiMed 1996: PW (a doctor) hears of MobiMed (transmission of ECG from ambulance) and in (transmission of ECG from ambulance) and in 1997 he goes to Falun to see the system in use1997 he goes to Falun to see the system in useFebruary 1998: a pilot study starts in Halden, February 1998: a pilot study starts in Halden, with two ambulances + cardiology ward at F. with two ambulances + cardiology ward at F. (Aim: to bypass ECU, take patient directly to (Aim: to bypass ECU, take patient directly to Heart ICU)Heart ICU)January 1999: anaesthesia nurse administers January 1999: anaesthesia nurse administers thrombolytic medication during transportthrombolytic medication during transportJuly 2000: >400 ECGs transmitted, ”call-to-July 2000: >400 ECGs transmitted, ”call-to-needle time” reduced by 50-60 minutesneedle time” reduced by 50-60 minutes

The Mobimed ”project”: The Mobimed ”project”: Some milestones (2)Some milestones (2)

1999: Askim looses its ECU (emergency 1999: Askim looses its ECU (emergency care unit)care unit)April 2000: Mobimed in Askim ambulancesApril 2000: Mobimed in Askim ambulancesOctober 2000: > 200 ECGs transmitted, October 2000: > 200 ECGs transmitted, nurse administers medication.nurse administers medication.Ambulance personnel reaches level 3 in Ambulance personnel reaches level 3 in their training (allowed to give medication)their training (allowed to give medication)2001: Sarpsborg, Moss and Fredrikstad2001: Sarpsborg, Moss and Fredrikstad

The success of the Mobimed projectThe success of the Mobimed project

Started with enthusiastsStarted with enthusiasts

Visible and tangible benefitsVisible and tangible benefits

Started small (one site), incremental Started small (one site), incremental growth, not all in one gogrowth, not all in one go

Low cost, simple solutions (no heavy Low cost, simple solutions (no heavy investments necessary before benefits investments necessary before benefits could be demonstrated)could be demonstrated)

””Bootstrapping”as strategy (1)Bootstrapping”as strategy (1)

Start with the simplest and cheapest Start with the simplest and cheapest solution that satisfy the needs of most solution that satisfy the needs of most users in their least critical and simplest users in their least critical and simplest practices and which doesn’t require a practices and which doesn’t require a large networklarge networkUse this technology as far as possible, Use this technology as far as possible, enroll more usersenroll more usersUse the same solution on more innovative Use the same solution on more innovative and beneficial waysand beneficial ways

””Bootstrapping”as strategy (2)Bootstrapping”as strategy (2)

Use the solution for more critical tasksUse the solution for more critical tasks

Use the solution for more complex tasksUse the solution for more complex tasks

Re-design/improve the solution so that Re-design/improve the solution so that new tasks can be carried outnew tasks can be carried out

(Repeat from start)(Repeat from start)