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Telemedicine and e-health

Dr Jim BriggsUniversity of Portsmouthjim.briggs@port.ac.uk

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Contents

DefinitionsTypes of telemedicineCase studiesE-healthOther issuesFurther information

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Definitions

TelemedicineE-health

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Raw definitions

Telemedicine: medicine at a

distance

cf television

E-health: health services

delivered electronically

cf 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." [BJHC&IM]Google search throws up 13 defns http://www.google.com/search?

q=define:Telemedicine

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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 styleData typesEquipmentAction Patient numbersDuration

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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 HCP Patient HCP HCP

CHARACTERISTICS: TYPE A TYPE B TYPE C TYPE D TYPE E TYPE F

Interaction Style Real-Time Real-Time Store/Fwd Store/Fwd Real-Time Store/Fwd

Data Types Multiple Multiple Data Multiple Multiple Data

Equipment Special Special Special General Special General

Action Direct Indirect Direct Indirect Direct Indirect

Number of Patients

1 >1 1 >1 >1 1

Duration Short Term Long Term Short Term Long Term Short Term Short Term

LABEL tele-medicine

tele-care tele-monitoring

tele-health tele-review tele-referral

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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 A&E department by video link to provide expert backupExamples: 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 hospitalExpert backup for paramedicsReducing "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 A&E 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 casesTravel costs (i.e. time) prohibitiveVideo-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 referralstds 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 Texashttp://www.tds-telemed.com/

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Case study - WorldCare

Consortium of 4 big American hospitalsProvide "second opinion" service worldwide (20 countries) tele-radiology tele-pathology patient management consultation

Local physician remains responsiblehttp://www.worldcare.com/

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Case study - NHS Direct

Biggest telemedicine project in the worldMainly 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 customerCentralisation of specialist servicesDecentralisation of non-specialist services

including at home

Services become "commodities"Is there a need for specialist equipment?

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Integration of ITIntegration of ITinto Business Sectorsinto Business Sectors

Inte

gra

tion

of

ITIn

teg

rati

on

of

IT

IT as a gadgetTrojan horse: networks, …Full Integration of IT into Business (Organisational, Legal) Re-engineering of the system

19801980 19901990 20002000 Jean-Claude HealyJean-Claude HealyMay 2000May 2000

(Banks) (Health…)ManufacturingManufacturing Business ServicesBusiness Services Public ServicesPublic Services

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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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USAUSA

EUROPEEUROPE

AUSTRALIAAUSTRALIA

(For 24hr medical coverage)

Telemedicine links

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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

EthicsEconomicsSuccess 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 Servicehttp://www.teis.port.ac.ukhttp://www.teis.nhs.ukOver 2000 records covering: telemedicine/e-health activities (>220) organisations people publications equipment

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TIE

Telemedicine Information Exchange (US)http://tie.telemed.org/Covers: Extensive bibliography (>14,000 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@port.ac.ukHealthcare Computing Group,University of Portsmouthhttp://www.disco.port.ac.uk/hcc/http://www.teis.port.ac.uk/