Global Telemedicine and EHealth

Global Telemedicine and eHealth (A Synopsis)

M. Jordanova1,2, F. Lievens3,4

1Space and Solar-Terrestrial Research Institute, Bulgarian Academy of Sciences, Bulgaria 2Educational Program Coordinator, Med-e-Tel, [email protected]

3Board Member, Secretary and Treasurer of International Society for Telemedicine & eHealth (ISfTeH), Switzerland 4Director, Med-e-Tel, Belgium, [email protected]

Abstract- The presentation uses as a baseline the importance of Telemedicine and eHealth for the optimization of all possible levels of existing healthcare systems and for the development of efficient, timely, optimal, patient-centric healthcare worldwide.

The paper is focused on global aspects of Telemedicine and eHealth adoption such as successful practices and cost effectiveness and is also focused on obstacles for worldwide implementation of telemedicine.

The importance of improved and continuous international cooperation and coordination is also emphasized. Attention is dedicated to the necessity always to be aware about what is globally going on trough international networking initiatives such as the International Society for Telemedicine and eHealth (ISfTeH, www.isft.net) and Med-e-Tel (The International eHealth, Telemedicine and Health ICT Forum for Education, Networking and Business, www.medetel.eu).

The global overview of Telemedicine and eHealth development supports professionals in influencing local policy when the role of telemedicine/eHealth in the health care sector is concerned; building public awareness about eHealth and its potentials; building multi-stakeholder consensus on principles, policies, and strategies related to effective eHealth implementation.

Keywords: eHealth, telemedicine, networking

I. INTRODUCTION

Within the last decades information and telecommunication technology (ICT) has become an integral part of healthcare. Decision makers, patients, providers, etc. often present ICT applications in the health sector as one of the panaceas for reforming healthcare and improving healthcare costs, quality and efficiency.

II. DEFINITIONS AND TERMINOLOGY

Telemedicine is defined as an application of ICT to provide and support healthcare and exchange healthcare information when a distance separates the participants [1]. The word is a combination of two Greek words τήλε = tele - meaning “at a distance” and “medicina” or “ars medicina” meaning “healing” and its introduction is ascribed to Thomas Bird. In 1970’s Bird had used this phrase in order to illustrate health care delivery, where physicians examine patients at a distance through the use of telecommunications technologies. Till the middle of 1990’s the term telemedicine was widely spread and accepted without questions. With more involvement of the electronic communication systems, the major

International Organizations - World Health Organization (WHO), European Union (EU), International Telecommunication Union (ITU) and European Space Agency (ESA) - have officially adopted the denomination "eHealth". "eHealth refers to the use of modern information and communication technologies to meet the needs of citizens, patients, healthcare professionals, healthcare providers, as well as policy makers“ [2]. It is necessary to underline that “e” in the eHealth does not stand only and exclusively for electronic”. It characterizes in details what eHealth is all about [3]:

• Efficiency - one of the strategic promises of eHealth is to increase efficiency in health care, thereby decreasing costs;

• Enhancing quality of care; • Empowerment of consumers and patients or patient-

centered medicine replacing the traditional model of patients moving upward, unchanged for 6000 years;

• Encouragement of a true partnership between the patient and healthcare professionals;

• Education (continuing medical education) through online sources;

• Exchange of information; • Extending the health care beyond national boundaries; • Ethics; • Equity; • Easy-to-use … In addition to eHealth, one more term was introduced and

used lately as an even broader description for eHealth, i.e. Modern Communication Health Environment (MCHE) [4]. It combines all aspects of healthcare and ICT as well as the four aspects of eHealth – eCare, eLearning, eSurveillance and eManagement.

What is the correct terminology? Unfortunately, to this very moment, the terminology as related to application of ITC in healthcare has neither been agreed in Europe nor worldwide. Paradoxically even between and within EU countries different terms are used to describe one and the same service. Positions differ and the preferences are usually influenced by individual experience, personal and professional viewpoints. Thus for some authors telemedicine and eHealth are synonyms. Others accept that eHealth is a broader term and includes telemedicine. A third group separate the terms, accepting that telemedicine incorporates

Proceedings of the 3rd International Conference on E-Health and Bioengineering - EHB 2011,24th-26th November, 2011, Iaşi, Romania___________________________________________________________________________________________________________________

telecardiology, teleradiology, telepathology, tele-ophthalmology, teledermatology, telesurgery, tele-nursing, etc, while eHealth comprises of e-Santé, Information and Communication Technologies in health (ICT-Health), all types of health communication services, PACS, patient information systems, e-education, e-prescription, etc.

Further in this paper the terms telemedicine and eHealth will be used as synonyms.

III. TELEMEDICINE/EHEALTH FOR OPTIMIZATION OF HEALTHCARE

More than a century has passed since the first documented attempts to develop telemedicine applications, i.e. W. Einthoven’s successful transmissions of ECG signals via telephone in 1905. Lots of efforts were dedicated to the development of eHealth, thousands of projects were conducted all over the world. Since mid-1990s, telemedicine/eHealth programs have become common throughout the world in nearly every area of healthcare - radiology, pathology, education, homecare, emergency care, mental health, rehabilitation, cardiac monitoring, surgery, etc. Time proved that telemedicine may help solving the healthcare dilemma, i.e.:

• Steadily increasing elderly population in developed countries, going hand in hand with relative decrease in resources (fewer taxpayers) and increasing percentage of chronic patients with multiple disease;

• Increasing healthcare expenses due to development of new technologies, necessity to secure health services to the increasing world population; increasing amount of chronic patients and elderly living alone; growing number of individuals with limited health and/or physical disabilities but with the ambition for independent living; quicker spread of diseases due to worldwide connections;

• Governmental healthcare expenditures growing faster than economic growth;

• Decreasing amount of health care professionals as compared to the demand of healthcare services;

• Ensuring access to health care for all individuals as one of the basic human rights;

• Ensuring the continuity of healthcare [5]. Numerous data and analyses proved that

telemedicine/eHealth has the potential to change our lives. A survey performed by International Business Machines Corporation (IBM) in 2006 asked 150,000 people from 104 countries to list the technologies that will be the breakout hits in near future. The company narrowed the results down to the five innovations that were the "most impactful” and they were: the 3-D Internet; mind-reading cell phones; nanotechnology for energy and the environment; eHealth (telemedicine); and real-time speech translation [6]. eHealth was included among the top five technologies that are believed to be able to change our future.

Scientific studies also support the increasing acceptance of eHealth applications in various areas of health care such as

chronic heart failure [7-8], wound care [9], psychiatry [10-13], psychology [14], surgery [15], chronic disease and care for elderly and house bound patients [16-17], electronic health records [18], mobile eHealth solutions [19], etc.

Cost effectiveness of telemedicine, which is its major promise, is also confirmed. Especially interesting and convincing are long duration studies performed in countries with large territories such as Russia and Brazil. According to the estimates of West Siberian physicians, the patient paid approximately 40 times smaller fee for the virtual consultations rendered by a Moscow expert, than it would have taken to make a trip to Moscow to consult this same expert. The quality of the service is the same [20-21].

Another brilliant example is the tele-cardiology service at the State of Minas Gerais in Brazil (territory equivalent to France, population 19 M inhabitants living in 853 cities). It has been operating since June 2006 in 82 remote and isolated villages in the state. Preliminary results of the evaluation of economical feasibility of telehealth systems have shown that the savings resulting from a 1.5% reduction on the number of treatments outside the village are sufficient to cover the operational cost of the system [22-24].

Wisely chosen eHealth applications are beneficial everywhere. Let’s cite one more study from a comparatively “smaller” region in Italy. In 2001 24-hrs 7-day-a-week toll-free telephone hotline service for children and adolescents with Type 1 diabetes was organized in Parma region. An extensive survey, study carried out from 1st January 2001 to 31 December 2006, showed that the total number of children receiving help was 421 (mean age 10.8±3.8, mean duration of diabetes 4.5±3.5 years). Within the 5 years period 20 075 calls were recorded, or an average of 11 calls per day! 52% of the calls were emergency calls. Thanks to the available service, the admittance to hospital for a Diabetic ketoacidosis fell from an average of 10 cases per 100 children per year to 3 cases per 100 children per year. Thus the costs for admission decreased of 60% [25]. A more detailed analysis of cost-effectiveness is provided by [26] for those that are interested.

It is already proven that telemedicine/eHealth is able of: • Optimizing healthcare delivery and making it quicker,

timely, high quality and affordable for all, everywhere, at any time;

• Decreasing the difference in healthcare services between developed and developing countries;

• Optimizing the work of healthcare staff; • Closing the gaps between healthcare demand and

available services due to shortage of healthcare funds and staff;

• Reduction of healthcare budgets; • Enhancing education to empowered citizens and many

more. (For more evidence based results the reader may refer to the “Knowledge Resource” section of Med-e-Tel. This free of charge virtual library is available at http://www.medetel.eu/index.php?rub=knowledge_resources&page=info and summarizes over 2000 abstracts, papers, books and Power Points on various


telemedicine/eHealth topics. The database is searchable by year, topic and country and is updated on an annual basis.)

Despite of undoubted telemedicine/eHealth advantages humanity is still far away from the world of cyber healthcare, from extensive application of telemedicine/eHealth for the benefit of all. Experts admit that telemedicine/eHealth has a vast and still unrealized potential. The question is what are the obstacles hindering the wide application of telemedicine.

IV. OBSTACLES

The future of telemedicine/eHealth depends on overcoming the various challenges.

1. Regulatory Telemedicine/eHealth generates serious regulatory

challenges. Those challenges are already complex where the provider and receiver are in the same country, yet even more so, when the provider is not in the same country as the recipient.

A 2009 USA court case raises questions illustrating this. In brief, a Colorado psychiatrist Christian Hageseth received a nine-month prison sentence for prescribing an antidepressant to a California teenager over the Internet without a California medical license [27]. The teenager later committed suicide. Carleton Briggs, Hageseth's attorney, said the case, believed to be the first of its kind, could hinder telemedicine "because no one would dare practice telemedicine without being licensed in all 50 states." The court decision was based on the requirement of the American Medical Association that states that physicians, who practice online prescribing, have to have an existing relationship with the patient and the appropriate licenses.

2. Legislation Information on country-level telemedicine policies and

strategies is not easily accessible. In general specific laws focused on telemedicine/eHealth applications are lacking in most countries with some exceptions:

Malaysian Telemedicine Act is a specific telemedicine legislation, included in the Laws of Malaysia. The aim of the Act 564 or the Telemedicine Act of 1997 is to provide “the regulation and control of the practice of telemedicine and aims to protect citizens from doctors or others who might not be clinically competent”. Unfortunately the Act imposes impractical restrictions such as requiring health care providers to register with Malaysia’s Director General, a measure that can limit practices and practitioners from other countries [28].

India is another leader in telemedicine legislation. Its eHealth law 35, which is still under discussion, includes mutual recognition between countries for the medical license granted by a physician’s home country and allows reciprocity between countries to allow licensed doctors to practice telemedicine in both countries. The law underlines that “registration, which would ensure that physicians are liable

under medical negligence and malpractice laws in the country where the telemedicine patient resides or communicates from” [28].

France is yet another example. Section 78 of the 2009 HPST law (Hospitals, Patients, Health and Regions) defines and authorizes telemedicine services. A year later one more decree, a Decree No. 1229 was accepted for further regulation of telemedicine applications.

Unfortunately these are just the first steps towards the development of laws exclusively regulating telemedicine applications. In many other countries there are attempts to include some aspects of eHealth legislation in the regulation of telecommunication, general healthcare or social services. Nevertheless that these national legislations reflect local traditions, local health and social welfare goals and systems, local aspects of available or pre-planned telecommunication accesses, etc. they are steps forward towards development of worldwide telemedicine laws.

When a cross border application of telemedicine is discussed, the European Union is a good example. Despite of wide discussions and decades of investment in telemedicine/eHealth EU has not yet adopted specific telemedicine legislation valid for the entire community. On the other hand, the increasing mobility of EU citizens makes it a must to ensure quality medical care beyond national borders. That’s why EU-27 and the members of the European Economic Area adopted, on 19 April 2007, a common declaration on their commitment to pursue structured co-operation on cross-border electronic health services across Europe. Telemedicine/eHealth services are partially included in two important documents – the European Innovation Partnership (EIP) announced in October 2010 and especially in Digital Agenda for Europe, adopted in May 2010 by the European Communication.

The Digital Agenda for Europe plans to foster development and application of EU-wide standards, interoperability testing and certification of eHealth systems by 2015 through stakeholder dialogue. In addition, Digital Agenda’s Key Action 13 underlines the commitment of EU to undertake pilot actions to equip Europeans with secure online access to their medical health data by 2015 and to achieve by 2020 widespread deployment of telemedicine services. The Key Action 14 goes even further and proposes a recommendation to define a minimum common set of patient data for interoperability of patient records by 2012.

The first steps in EU legislation are facts but when cross border legislation is concerned, it is always necessary to remember that the issues of the conflict of laws have also to be taken into consideration. The private international law addresses four important questions:

• Where can the parties sue each others? That is; which courts may have jurisdiction over the dispute?

• Which country’s law will govern the dispute? • Can a chosen court decline to exercise its

jurisdiction over the dispute?


• Where can the resulting judgment be recognized and enforced [29]?

3. Standards and guidelines The lack of widely accepted and applicable standards for

the use of various telemedicine/eHealth services is another significant obstacle for it worldwide adoption. For years the creation of standards involves numerous organizations. Some of them are:

• Not-for-profit organizations such as the American Society for Testing and Materials (ASTM); the Health Level Seven International (HL7) that is a global authority on standards for interoperability of health information technology with members in over 55 countries; the Healthcare Information and Management Systems Society (HIMSS); the European Committee for Standardization (CEN) etc.;

• International – examples are the International Telecommunication Union, International Organization for Standardization or

• National – such as the Standards Australia e-health; Office of E-Health Standards and Services, US Department of Health and Human Services or the American Telemedicine Association (ATA) to name some.

It is worth listing some of the standards and guidelines developed by ATA as an example to be followed:

• Core Standards for Telemedicine Operations (February 2008) including the fundamental requirements to be followed in providing remote medical services, interactive patient encounters, and any other electronic communications between patients and practitioners for the purposes of health care delivery [30];

• Evidence-Based Practice for Telemental Health (July 2009) is an educational tool to aid practitioners in providing appropriate mental health services via telehealth technologies [31];

• Practice Guidelines for Teledermatology (December 2007) that aimed to support the development and practice of coherent, effective, safe and sustainable teledermatology practices [32];

• Telehealth Practice Recommendations for Diabetic Retinopathy (May 2004) is a roadmap of technical standards, clinical guidelines and administrative procedures [33].

Another interesting example comes from Russia: In 2010 the Russian government decided to facilitating implementation of electronic health records (EHRs) by dedicating 24 billion Rubles for the next two years to stimulate the start up of EHRs application. The plan has fixed the period 2011-2012 as introduction of electronic records; years 2012-2015 will be used for detailed filling in of EHRs, including past medical history and by 2015-2020 all providers have to work in automated mode. But the first step of the Russia government was to approve a national standard for development of EHRs in 2006 (GOST R 52636-2006) [34].

If the standardization problem has to be summarized, its core is that:

• Various data standards exist – standards in clinical practice, standards for bioscience tests, standards for picture transmissions etc.

• For some services too many different standards have already been developed and yet there is a lack of unified standard – just to use as an example distributing and viewing any kind of medical image - ASTM, ANSI X12 (EDI); CEN, DICOM, are part of the applied standards;

• Lack of common strategy in developing standards and as a results the community is a witnessing multi-level, multi-scale developments, competing initiatives, fragmentation, lack of information, lack of computability, etc.

4. In addition The above listed obstacle for telemedicine/eHealth

implementation does not cover all problems. Main challenges for wide implementation of eHealth still

remain: • Language differences; • Traditions and routines in medical practices; • Ethical issues; • Licensing – let’s not forget that medical license is

geographically restricted; • Privacy - health information is regarded as particularly

sensitive information and has to be strictly protected; • Taxes and insurance issues; • The right of the patient of informed consent to the

procedure - each country has different understanding and approach to what constitutes informed consent.

In the light of the above mentioned obstacles the importance of improved and continuous international cooperation and coordination is essential.

V. NETWORKING AND COORDINATION

Within the world of telemedicine/eHealth, it is crucial for all the players to be aware what is globally going on. Therefore cooperation and networking are most important factors going hand by hand. Let’s focus on two specific networking enabling initiatives:

The International Society for Telemedicine and eHealth (ISfTeH, www.isft.net) is a not-for profit membership organization of national, regional, international associations and others, institutions, organizations, corporations, individuals and students, established under Swiss law. ISfTeH is the international representative body of national and international Telemedicine and eHealth organizations and is dedicated to broadly promoting telemedicine/eHealth around the world. ISfTeH supports the start up of National Associations or Societies and facilitates their international contacts. Its aim is to disseminate knowledge, information and experience and to provide access to recognized experts in the eHealth field worldwide. As part of ISfTeH educational activity, a Working Committee “Education” is functioning.


The mission of this Committee chaired by Prof. M. Mars from South Africa is:

• Listing existing programs on eHealth; • Establishing basic eHealth templates for fundamental

training programs; • Coordinating eHealth educational efforts around the

Globe; • Assisting the set up of new courses in eHealth; • Defining the needs of universities and specialists for

basic and continuous education. eHealth science, practice and market need a meeting place.

Such a place is Med-e-Tel (The International eHealth, Telemedicine and Health ICT Forum for Education, Networking and Business, www.medetel.elu). Med-e-Tel is a highly specialized event that brings suppliers of specific equipments and service providers together with buyers, healthcare professionals, decision makers and policy makers from many countries around the globe and provides them with hands-on experience and knowledge about currently available products, technologies and applications. Med-e-Tel is a forum where state-of-the-art products, ideas, projects, etc are presented and discussed. Year after year it becomes a nesting place for new co-operation and partnerships between scientific groups and institutions, small, medium and large size enterprises, etc from all over the world. Annual editions called together participant from over 50 countries. WHO, EC, ESA, ITU, UNOOSA, are only part of the major players that took part in the event.

The next and 10th edition of Med-e-Tel will take place at Luxexpo in Luxembourg, April 18-20, 2012 and will follow the standard format including exhibition, scientific program, media corner.

Med-e-Tel provides lots of educational opportunities through its extensive program of presentations, panel discussions, workshops and satellite symposia. It is accredited by the European Accreditation Council for Continuing Medical Education (EACCME) to provide European external CME credits for medical specialists. EACCME credits are recognized by the American Medical Association as well as by some countries in Asia and Middle East. This is the highest possible recognition of the extreme value of Med-e-Tel’s Education program.

ISfTeH and Med-e-Tel are working together. They are as the two sides of a coin. They both lead the way from needs to practical applications, highlights quantitative numbers and results, serve networking – meeting real people, real business, real achievements, real products, discussing real problems, and education for business, science, practitioners and citizens. ISfTeH and especially Med-e-Tel are the perfect organizations for following what globally is going on and what are the new trends in the area of eHealth.

Of course there are many other events covering this field. In fact, there are hundreds of them each year! For the purpose of this paper, we are concentrating specifically on Med-e-Tel. One can find references to other events, supported by ISfTeH,

on the International Society for Telemedicine and eHealth website (www.isft.net).

VI. CONCLUSION

Telemedicine/eHealth is already a must, with no way back, a fantastic and broad challenge for the future but it requires cooperation and coordination at all possible levels, it requires networking and planning, readiness to learn from the others and no need to re-invent the wheel.

The coordination in telemedicine remains a challenge, i.e. to make all the possible players representing business, administration, science, insurances, etc., to coordinate their skills and efforts to achieve an optimal development within the health environment using modern communication systems. No doubt, this is a Sisyphean task. But when this is achieved, the benefits will be for all of us as tax payers since citizens will rely on high quality affordable healthcare at anytime, anywhere.

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