Prof Diana Schmidt's Talk at AIIMS on 8th January 2008

Diana Schmidt AIIMS 2008

Factors for success & failure of Telemedicine in Germany & USA

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Factors for success and failure of Telemedicine in Germany and USA

Diana Schmidt



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1. Introduction and background2. Infrastructure for telemedicine3. Telemedicine proper4. Success factors5. Summary 6. Acknowledgements and references

Telemedicine in Germany and USADiana Schmidt



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1. Introduction and background (1)

Motivation for Telemedicine: cut costs and/or improve patient outcomes

Nature of this talk: spotlight, not floodlight

Health care systems: German: see [WHO]US: see ???

Questions about Telemedicine:• in routine clinical use?• barriers & facilitators?• proven benefits?



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Statistics Germany USAArea (million km2) 0.3 69.6Population (million) 80 303 average population/km2 222 32Hospitals 2,200 > 6,000 Hospital beds 670,000 1 millionPhysicians 278,000 731,000Dentists 65,000 464,000Pharmacists 48,000 250,000

Sources: Areas & hospitals (Germany): Wikipedia (3.10.2007); population (Germany): [Haas], population (US): US Census Bureau (3.10.2007); hospitals (US): ???, beds, physicians, dentists, pharmacists: [WHO]

1. Introduction and background (2)



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2. Infrastructure for telemedicine (1)

Infrastructure differences Germany/USA:

a. Multi-purpose Telehealth/telemedicine networks in USA but not in Germany

b. Development of national smart cardin Germany but not in USA

c. EPR in hospitals comparison of status quo in Germany & USA



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• Available for multiple types of telemedicine activities• Provide (hard- &) software and service to support

telemedicine activities• Open (to any health care provider/facility) or closed• Owner: state, university, health plan …• Often several in same region• May run physical network or be internet-basedUS Government: Telehealth network grant program since

2003 ([Puskin])

2. Infrastructure for telemedicine (2)USA: Telemedicine/telehealth networks



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• Founded by U of Utah, now merged with IHC (big health plan provider in Utah) network

• Open network, 28 member sites• Provides and maintains its own lines• Provides sites with internet & email access if required• Types of activities supported:

– Clinics (see next slide)– Education, e.g.:

• Disaster preparedness• PhD in Nursing Oncology for nurses at remote college ([UU])

– Lectures, e.g.:• Diabetes brown bag – monthly via video or phone conferencing• Pediatric Grand Rounds – weekly

– Administrative meetings via teleconferencing

2. Infrastructure for telemedicine (3)Example: Utah Telehealth Network (UTN)



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• Prison clinics (weekly) – security aspect• Acute stroke intervention (24/7 access to neurologists

using teleconferencing & transmitting CT images)• Emergency burn assessment (transport necessary?)• Teleconsulting & Ophthalmology for remote Navaho

reservation (almost 50% Diabetes)• Teleradiology with image transmission to UTN & other

consultants• Telepharmacy for rural hospitals manned only by

pharmacy technician

2. Infrastructure for telemedicine (4)Examples of Clinics supported by UTN



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• Cost (for network members)• Funding (for UTN) – for > 10 years via annual grant applications

(consumed staff resources)• Now the U recognises that UTN is indispensable for some of its

work, & finances substantially on a regular basis• Universal Service support mechanism of Federal Communications

Commission ([FCC])• Acceptance of technology by health professionals (patients like it!)• Legal: Remote supervision of pharmacy technicians was not

allowed (law now changed)• Licensure of physicians is a state, not a national prerogative

barrier to cross-state telemedicine• People: One dependable, warm-hearted person on the help line

instead of a menu.• Names (e.g. “Telebob” for Polycom Practitioner Cart)

2. Infrastructure for telemedicine (5)UTN: barriers & facilitators



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Starting point (1997):

“Telemedicine can boost the quality and affordability of health care and health administration. However, although many worthwhile applications exist, Telemedicine has not achieved nationwide implementation. There is a big gap between its potential and its realization. Thus, ambitious research projects and trials of applications have been completed successfully but continue to be used only in a few hospitals, towns or regions.” ([Berger])

2. Infrastructure for telemedicine (6) Germany: Development of smart card



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Roland Berger report was followed by further government initiatives in consultation with representatives of health care professions, health industry & academia.

Status quo:• Specification documents ([BMG1], some also in English) for patient

health card, health professional card & telematics platform are in place

• Laws ([BMG1]) about introduction of cards & platform are in place• 7 test regions will be / are being used for tests prior to nationwide

introduction• Flensburg test region: 10,000 patients, 25 physicians, 2 hospitals &

all large insurance providers started testing cards & infrastructure in December 2006 (functionality initially minimal, increasing in stages)

• Timing???

2. Infrastructure for telemedicine (7) Germany: Development of smart card



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Initially (for nationwide introduction):• Administrative data: Name, address, birth date, sex, insurance

status• ID (photo & microprocessor for further ID checks)• European insurance card on reverse side (replaces paper forms

needed for treatment in other European countries)• Electronic prescriptions (replace the current paper prescriptions)Later (voluntary = patient decides whether to use or not):• Emergency data• Documentation of medication• Physicians’ letters• Ultimately, the Electronic Health Record.

2. Infrastructure for telemedicine (8) Germany: Functionality of smart card



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Laws ([GKV-Modernisierungsgesetz] 2004):• §67: Diagnoses etc. are to be communicated electronically instead of on paper asap

in a manner suitable for case oriented cooperation between caregivers• §68 (financing a personal health card): Health insurers may give patients financial

support for 3rd party storage & transmission of health data• §290 insurance number: identification of patient (fixed) & insurer (changeable)

Privacy & data security requirements:• Encrypted transmission of health data• Security of access to end devices (= software in physicians’ practices, insurance

systems, telematics servers)• Authentication

Measures to ensure fulfillment of requirements:• Access to patient data is only possible in conjunction with a Health Professional Card

or Security Module Card• The patient decides what data goes in & who has access• Legal ban on demanding health data from a patient

2. Infrastructure for telemedicine (9) German smart card: laws & security aspects



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2. Infrastructure for telemedicine (10) German smart card: what it looks like



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2. Infrastructure for telemedicine (11) EPR in hospitals: status quo Germany/USA

From report [Hübner 2007]:

9%

34%

0%

17%

36%

4%

24%

36%

4%

24%

12%

1%

0% 5% 10% 15% 20% 25% 30% 35% 40%

Fully functional EPR inplace

Have startedimplementing EPR

Contract in place butnot yet started

We are developing anEPR plan

We haven't yet startedplanning

Don't know

Germany USA



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3. Telemedicine proper (1)

Differences Germany/USA due partly to differences in• population densities (few really remote locations in

Germany, many in USA)• health care systems• legal situations• remuneration rules

Focus in this talk on• Home telehealth• Interaction between health professionals



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• Communication between health professionals and patients in their own homes

• Synchronous (e.g. telephone, videoconferencing) and asynchronous (e.g. email, regular uploading of patient data by patient or carer)

• Terms used: Home telehealth, tele home care (written as 1, 2 or 3 words)

• Maybe the most rapidly expanding area of eHealth in the USA• Has been pursued much longer and generated many more scientific

publications in USA than in Germany (USA since at least early 80s, Germany almost no activity before 2000)

• Focus here on projects of the group of Stan Finkelstein at the U of Minnesota in Minneapolis

3. Telemedicine proper (2) Home telehealth



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Project (initially not tele-) in place at least by 1984 ([Finkelstein 86]).• Purpose: Better monitoring (more frequent measurements) and thus better

care by using home measurement (lung capacity, body weight, breathing rate, pulse).

• Most doctors were sceptical as to reliability of data provided by patients without supervision.

• The director of the Minnesota Cystic Fibrosis Center (see [Cappello 2004]) supported the project.

• It was shown ([Brown-Ewing]) that the home monitoring helped in early detection.

Lessons learned:• However great the data and the system, they are no use without adherence.

The difficulty of achieving adherence is still the biggest non-technical barrier in Stan’s home telehealth projects.

• A successful system means a lot of data to be analysed – only feasible in clinical routine with the aid of automated or semi-automated checks.

3. Telemedicine proper (3) Home telehealth: SM Finkelstein, U of MN, Cystic Fibrosis project



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Project to monitor lung transplant patients in order to detect pulmonary decline early.

• [Finkelstein 99]): home monitoring spirometry data is reliable and valid, and detects pulmonary decline earlier than clinic spirometry.

• An algorithm to make the data analysis feasible in routine clinical practice was developed and shown to be comparable to the standard human clinical review of the same data.

• At the end of the research program, it took 2 years to convince a health plan to implement a clinical home spirometry program and thus to make the transition from research to a clinical program. Problem: funding. Eventually, CMS (Medicare/Medicaid) decided to reimburse the costs of home spirometry for all lung transplant and asthma patients.

“Virtual visit” projects ([Finkelstein 04, 06a], [Finkelstein 06])• Include randomised controlled trials to look at outcome measures of

home telehealth for diverse patient groups, including cost.

3. Telemedicine proper (4) Home telehealth: SM Finkelstein, U of MN, further projects



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• Used particularly in diagnosis involving images, in particular in:

– Radiology

– Pathology

– Dermatology

– Neurology

but also e.g. for meetings (teleconferencing).

We focus here on teleradiology.

3. Telemedicine proper (5) Interaction between health professionals



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• A field (in Germany one of the few) in which telemedicine is used widely and in routine

• The DICOM EMAIL module can transmit DICOM image data as S/MIME attachments securely. It is already well established in clinical routine, fulfils security requirements such as authentication and encryption, and is supported by KIS/RIS/PACS systems.

• For many applications it is relatively easy to prove cost benefit due to saving high costs for transport of patients.

• USA: Radiologists early on got the government to pay for radiological interpretation over distance, so reimbursement is no problem.

• USA: Interpretation industry, e.g. Nighthawk

• Germany: Teleradiology, the situations in which it may be used and the process of teleradiology consultations are defined in the part of the law that deals with X-rays etc. But with initial state funding the facilitators (see above) suffice to achieve establishment in clinical routine.

3. Telemedicine proper (5) Teleradiology: a success story



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3. Telemedicine proper (6) Teleradiology: German system in Greenland

RSNA Daily Bulletin - Thursday, Nov 30 2006. Also see [Engelmann].



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4. Further success factors: legal

• Germany: National law enforces existing business processes in current form (paper forms of various sorts) and cannot easily be changed ([Warda]) new law needed to put certain electronic documents on equal footing with paper documents

• Germany: Medical Association’s professional code of conduct (legal status) medical treatment may not be carried out purely by post, communication media or computer communication networks ([MBO-Ä])



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4: Further success factors: financial

• As yet often too little evidence that Telemedicine saves money - maybe because often the benefit is not reaped where the costs of implementation and operation arise

• Progress is being made – but more easily for some application types than for others

• US: Medicare/Medicaid and private insurance providers are moving in some cases

• Germany: Scale of charges and fees for reimbursement of physicians has legal status, does not include any aspects of telemedicine as chargeable items.

• German law lays down what health insurance bodies may and may not pay for. Telemedicine is regarded as a research area and as such may not be financed by health insurance.



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• lack of standards for data formats, communication interfaces and encryption procedures ([Warda])

• Acceptance by patients: fear of privacy infringements

• Acceptance by physicians: fear of loss of revenue due to elimination of duplication of diagnostic procedures etc.

• Acceptance by all: will relationships between patients and health care workers suffer?

4: Further success factors: other



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The journey from successful completion of a telemedicine project to integration in routine clinical practice is usually long and arduous. It depends on many barriers and facilitators, most of them non-technical and often nation- or state-specific.

5: Summary



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I am very grateful tothe Health Informatics Division at the U of Minnesota, and

most particularly Lael Gatewood, for welcoming me for a month there in May/June 2007;

colleagues at the U of Minnesota for conversations and information: Lael Gatewood (many and diverse, particularly on health care in USA), Stan Finkelstein on his home telehealth projects, Stuart Speedie on telemedicine in USA;

colleagues in the Department of Medical Informatics at the U of Utah, and particularly Joyce Mitchell, for hospitality and conversations in June 2007;

Dr. Marta Petersen and Deb LaMarche of Utah Telehealth Network for conversations and information.

6: Thanks, references



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[Berger] Roland Berger and Partner GmbH, Thies M, Grohs B. Telematik im Gesundheitswesen - Perspektiven der Telemedizin in Deutschland, 1998. http://www.imse.med.tu-muenchen.de/mi/lectures/ehealth/references/1998-01-roland-berger-studie-telemedizin.pdf*

[BMG1](E) German Ministry of Health. Legal and technical documents (some in English) concerning the electronic health card. http://www.bmg.bund.de/nn_667298/DE/Gesetze-und-Verordnungen/zur-Gesundheit/zur-gesundheitskarte/zur-gesundheitskarte-node,param=.html__nnn=true*

[Brown-Ewing]E Brown-Ewing LJ, Finkelstein SM, Budd JR, Kujawa SJ, Wielinski CL, Warwick WJ, Nguyen S. Implementation of a home-based program for early detection of clinical deterioration in cystic fibrosis. Med. Instrum. 22 (1988) 240-246

[Cappello 2004]E The better doctor. The New Yorker, December 6th, 2004 (from www.newyorker.com/archive, accessed June 15 2007)[Engelmann]E Engelmann U, Münch H, Schröter A, Schweitzer T, Christoph K, Eilers R, Olesen H, Møller Jensen J, Meinzer HP. A teleradiology concept for entire Greenland. Int.

J CARS (2006) 1:121-123[FCC]E Federal Communications Commission. Universal Service. http://www.fcc.gov/wcb/tapd/universal_service* [Finkelstein 86]E Finkelstein SM, Budd JR, Warwick WJ, Kujawa SJ, Wielinski CL, Ewing LB. Feasibility and compliance studies of a home measurement monitoring program for

cystic fibrosis. J. Chronic Dis. 39 (1986) 195-205[Finkelstein 99]E Finkelstein SM, Snyder M, Edin Stibbe C, Lindgren B, Sabati N, Killoren T Hertz MI. Staging of bronchiolitis obliterans syndrome using home spirometry. Chest

116 (1999) 120-126[Finkelstein 04]E Finkelstein SM, Speedie SM, Demiris G, Veen M, Lundgren JM, Potthoff S. TeleHomeCare: quality, perception, satisfaction. Telemedicine J and e-Health 10

(2004) 122-128[Finkelstein 06]E Finkelstein SM, Speedie SM, Xinyou Z, Ratner E, Potthoff S. VALUE: Virtual Assisted Living Umbrella for the Elderly – user patterns. Proceedings of the 28th

IEEE EBMS Conference (2006) 3294-3296[Finkelstein 06a]E Finkelstein SM, Speedie SM, Potthoff S. Home telehealth improves clinical outcomes at lower cost for home health care. Telemedicine J and e Health 12:128-

136, 2006[GKV-Modernisierungsgesetz] German Ministry of Health. Law to modernise statutory health insurance, 2003.

http://www.bmg.bund.de/cln_040/nn_603200/SharedDocs/Gesetzestexte/GKV/18-Gesetz-zur-Modernisierung-der-,templateId=raw,property=publicationFile.pdf/18-Gesetz-zur-Modernisierung-der-.pdf*

[Haas] Haas P. Gesundheitstelematik: Grundlagen, Anwendungen, Potenziale. Springer 2006[MBO-Ä] Bundesärztekammer (German Federal Medical Association). Professional code of conduct, 2006.

http://www.bundesaerztekammer.de/downloads/mbostand20061124.pdf*[Puskin]E Puskin DS. Overview of Health Resources & Services Administration Telehealth, 2007. http://www.hhs.gov/healthit/ahic/materials/02_07/cc/hrsatelehealth.ppt* [UU]E University of Utah Health Sciences Center. Distance learning option for the (Nursing) PhD program. www.nurs.utah.edu/programs/phd_distance/index.htm* [Warda] Warda F, Noelle G. Telemedizin und eHealth in Deutschland: Materialien und Empfehlungen für eine nationale Telematikplattform. DIMDI, Auflage 1, 2002.

http://www.dimdi.de/static/de/dimdi/public/wiss/telematikbuch19_02_03_web.pdf*[WHO]E Busse R, Riesberg A. Health care systems in transition: Germany. Copenhagen, WHO Regional Office for Europe on behalf of the European Observatory on Health

Systems and Policies, 2004. www.euro.who.int/Document/E85472.pdf*

E In English (E) Partly in English * Accessed January 4 2008

6: Thanks, references

http://www.imse.med.tu-muenchen.de/mi/lectures/ehealth/references/1998-01-roland-berger-studie-telemedizin.pdf

http://www.bmg.bund.de/nn_667298/DE/Gesetze-und-Verordnungen/zur-Gesundheit/zur-gesundheitskarte/zur-gesundheitskarte-node,param=.html__nnn=true



http://www.newyorker.com/archive

http://www.fcc.gov/wcb/tapd/universal_service

http://www.fcc.gov/wcb/tapd/universal_service

http://www.bmg.bund.de/cln_040/nn_603200/SharedDocs/Gesetzestexte/GKV/18-Gesetz-zur-Modernisierung-der-,templateId=raw,property=publicationFile.pdf/18-Gesetz-zur-Modernisierung-der-.pdf



http://www.bundesaerztekammer.de/downloads/mbostand20061124.pdf

http://www.hhs.gov/healthit/ahic/materials/02_07/cc/hrsatelehealth.ppt

http://www.nurs.utah.edu/programs/phd_distance/index.htm

http://www.dimdi.de/static/de/dimdi/public/wiss/telematikbuch19_02_03_web.pdf

http://www.euro.who.int/Document/E85472.pdf

Prof Diana Schmidt's Talk at AIIMS on 8th January 2008

Health & Medicine

Transcript of Prof Diana Schmidt's Talk at AIIMS on 8th January 2008