Telemedicine and e-health Dr Jim Briggs University of Portsmouth jim.briggs@port.ac.uk

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

Telemedicine E-health Definitions Telemedicine E-health

Raw definitions Telemedicine: cf television E-health: E-commerce medicine at a distance cf television E-health: health services delivered electronically E-commerce

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

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)

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"

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"

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"

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

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.

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

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

Characteristics of tm systems Interaction style Data types Equipment Action Patient numbers Duration

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

Data types Text Image Patient notes Diagnosis X-rays Pathology slides CT/MRI/… scans Audio/video signals

Equipment General purpose Specialist Off the shelf PCs Electronic stethoscopes Image capture equipment Image display equipment (possibly)

Action Intervention Advice Direct influence on patient treatment Indirect influence Final decision made by intermediate party

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

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

Categories of telemedicine

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 backup Examples: Cornwall Portsmouth/Gosport

Cornwall MIUs

Gosport MIU

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 A&E staff of details of incoming cases

Dundee trial

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

East Midlands cancer network

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

tds sites North Manchester Medway 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/

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/

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/

e-health

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?

Integration of IT into 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

Are hospitals a thing of the past?

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

USA EUROPE AUSTRALIA (For 24hr medical coverage) Telemedicine links

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

Ethics Economics Success factors Other issues Ethics Economics Success factors

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.

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

Economics 2 What else to include? Patient costs Social costs is this the reason business cases fail? Social costs cost to society of being ill environmental cost of travel

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?

Further information

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 (>220) organisations people publications equipment

TIE Telemedicine Information Exchange (US) http://tie.telemed.org/ Covers: Extensive bibliography (>14,000 entries) Projects Events calendar Funding sources News

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

Journals Telemedicine: Health informatics more generally 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

The end jim.briggs@port.ac.uk Healthcare Computing Group, University of Portsmouth http://www.disco.port.ac.uk/hcc/ http://www.teis.port.ac.uk/