1. Telemedicine and e-health
Dr Jim Briggs University of Portsmouth

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

3. Telemedicine E-health
Definitions
Telemedicine
E-health

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

5. 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
Telemedicine

6. 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."
(Dept of Health and Human Services)

7. 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"
"access to medical care for consumers and health professionals via telecommunications technology"
e-health is the "use of the Internet for healthcare"

8. 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"

9. 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"

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

11. 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.

12. 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

13. 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, pp

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

15. 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:
Less often but becoming more common: systems exchanging messages
May not need high bandwidth

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

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

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

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

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

21. Categories of telemedicine

22. 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

23. Cornwall MIUs

24. Gosport MIU

25. 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

26. Dundee trial

27. 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

28. East Midlands cancer network

29. 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

30. 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

31. 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

32. 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

35. e-health

36. 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?

37. 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

38. Are hospitals a thing of the past?

39. 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

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

41. 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

42. Ethics Economics Success factors
Other issues
Ethics
Economics
Success factors

43. 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.

44. 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

45. 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

46. 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?

47. Further information

48. TEIS UK Telemedicine and E-health Information Service
Over 2000 records covering:
telemedicine/e-health activities (>220)
organisations
people
publications
equipment

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

50. CEW Confederation of e-health websites (Q)
Other organisations include:
UK E-health Association
Royal Society of Medicine
IHM/ASSIST
Norwegian Centre for Telemedicine
EHTEL

51. 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

52. The end jim.briggs@port.ac.uk
Healthcare Computing Group, University of Portsmouth