EHTEL Briefing Paper Sustainable Telemedicine

8/6/2019 EHTEL Briefing Paper Sustainable Telemedicine

1/37

hea l t hw a r e

European Commission

DG Enterprise & Industry

Sustainable

Telemedicine:

paradigms

or uture-proo

healthcare

A Briefng Paper

Prepared for the Sustainable Telemedicine Task Force, EHTEL

Version 1.0 Date: 20 February 2008


2/37

Sustainable Telemedicine: paradigms or uture-proo healthcare

With this Brieng Paper, EHTEL substantiates its role as an integrative enabler: Beyond being a platormand networking node, EHTEL creates an added value or all stakeholders in healthcare. I would like tothank all those who contributed to this publication.

While the report summarises positions and experience gained rom EHTEL activities over nearly 10 years,its novelty and empirical oundation stem rom the support o its two major stakeholder groups, i.e. theMinistries o Health and the EHTEL/ELO network including the National eHealth competence centres.Members o both groups kindly supported this work.

From a strategic perspective, the 2004 European eHealth action plan successully initiated a top-downprocess by anchoring eHealth at the policy level, thus inducing large scale inrastructural and market de-velopments. Its now time to deploy the complementary bottom-up process: We need to concretise theEuropean eHealth strategies by reconnecting citizens, patients and health proessionals and developingwin-win constellations in practical daily lie.

By going back to the roots o healthcare and reconciling those undamental values with innovative techno-logical approaches, we are putting public health into practice and thus ostering a new breed o population-oriented service industry. The present report shows that this process is already starting, but still in lack oa acilitating strategic ramework. In order to achieve sustainable results, telemedicine and telehealth needexplicit implementation, support, concrete incentives and reality-based cross-stakeholder scenarios.

Developing electronically supported interaction between all stakeholders points at ostering personal andproessional relationships as well as business relationships to the advantage o all. Further measureswould be to establish a true interdisciplinary telemedicine service ramework to overcome the multidisci-plinary scattering o individual services and to agree on a common language o structured denitions ortelehealth and telemedicine solutions.

EHTEL is determined to address all eHealth stakeholders and will contribute to establish such rame-works, which will assist the birth o better health and care or all. This report in hand, we are undertakingthe rst step into the right direction.

Martin D. Denz, EHTEL President

Foreword



3/37


I would like to express my gratitude to the co-authors and co-editors o this document. Firstly this BriengPaper was made possible by a generous investment o time and knowledge by two major stakeholder

groups o EHTEL, i.e. the Ministries o Health (MoH) Group and the EHTEL/ELO Network o eHealthCompetence Centres. The communication with the National Member States was acilitated by the surveyon Strategies and Roadmaps or Sustainable Telemedicine. The survey is the basis o a comprehensiveinormation assembly on the po-sition o telemedicine in National eHealth Strategies, the regulatory andpolicy ramework or telemedicine services plus a collection o best practice examples, which is availableto EHTEL members and other groups on request.

We thank warmly the two co-acilitators o the survey, Drs Chris Flim o NICTIZ, the National IT Instituteor Healthcare in the Netherlands (EHTEL prime contractor) and Drs Jelle Attema o NITEL (part o EPN, aplatorm or the inormation society in The Netherlands).

Stephan H. Schug,

Editor-in-Chie, Member o the EHTEL Management Team

Acknowledgements



4/37

Telemedicine has pioneered the use o communication technologies within healthcare. Hence telemedi-cine services are principally available or decades some even say or as much as 130 years (reerring toan early telephone based medical consultation1). This not-withstanding European health policy recentlyocused more generally on eHealth services.

Hence inrastructure elements like enhanced health insurance cards and e-services like reimbursementand the Electronic Transmission o Prescriptions have become the ocal point or inormation and commu-nication technology (ICT) in healthcare. But clinical ICT applications besides and beyond the EHR shouldnot be orgotten, and with the evolving availability o eHealth inrastructures we are likely to observe goodopportunities or a renaissance o telemedicine with a new generation o highly interconnected servicesintegrated into clinical use cases as e.g. the case management o chronic heart ailure. These serviceswill be geared at being or wide and routine use, but also will be part o the business process and thussustainable.

Telemedicine services respond to todays health and social demands, i.e. treatment o chronic patients,support or the quality o lie o elderly people living at home and they also support the patient empower-ment o well-inormed citizens to make healthcare choices.

The 2004 eHealth action o the European Union (eHealth - making healthcare better or European citizens:An action plan or a European eHealth Area), which is the current guideline or the implementation o the

EUs vision on eHealth and orms an important part o European i2010 strategy, mentions telemedicineservices as an upcoming milestone: By end 2008, the majority o European health organisations andhealth regions (communities, counties, districts) should be able to provide online services such as tele-consultation (second medical opinion), e-prescription, e-reerral, telemonitoring and telecare. Given thisobjective the EU will intensiy the attention towards Telemedicine services in 2008.

With this Brieng Paper, EHTEL would like to oer all stakeholders, i.e. politicians, citizens/patients, healthproessionals, healthcare providers, health insurers and many others a snapshot o the State o the Art onthe European, National and Regional levels with the ocus on sustainable services. Based on a summaryo what has been achieved particularly in the orm o routinely used (but oten still small scale) telemedi-cine services across Europe a set o recommendations towards a Vision or Europe 2020: Integrated

Telemedicine Services is established.

EHTEL aims to contribute to the rebalancing o deployment eorts between

inrastructure and clinical services, and between ICT experts and health proessionals.

Furthermore EHTEL will analyse, what should be done to make additional telemedi-

cine services sustainable to support the health and social needs o European citizens/

patients.

Executive Summary



1 Practice by Telephone. The Lancet, Nov. 29, 1879, p. 819


5/37

Starting rom a minimum o denition work (telemedicine is basically care at a distance), the BriengPaper highlights the success actors o sustainable services as opposed to discontinued or only minimally

maintained services rom pilot projects. Here the current challenge is to aggregate the achieved pieceso evidence, to consolidate the results, to integrate approaches on the basis o international, open stan-dards, and to drive them towards operational development. Furthermore, a distinct shit is needed romtelemedicine applications as stand-alone, added-value components driven by the paradigm o technolo-gy-push, toward eHealth services emerging as one-o-many eatures in digital medical work environmentsdriven by the paradigm o demand-pull.

By adopting the terminology o Internet services, the Brieng Paper dierentiates between distributed,networked use o specic specialised medical expertise, i.e. teleservices between health proessionals/doctors (D2D) like teleconsultation, teleradiology and telepathology rom telemedicine services directly

oered to patients (D2P) such as telemonitoring and telehomecare, emergency care, care o mobilepatients and Internet based patient consultations.

The vision on telemedicine services in European countries can be divided in three types:

Those which are an integral part o the most actual eHealth strategy where telemedicine applica-tions are developed as part o this eHealth strategy;

Those mentioned in the most actual eHealth strategy, but where telemedicine applications arenot or not yet developed in direct relation to this strategy;

Those not mentioned in the eHealth strategy but where some ew developments o telemedicineapplications in practice are emerging.

State-o-the-art o telemedicine and telehealth in Europe is completed by Best Practice examples andNational case reports thereby providing a sound basis or a long term vision or integrated telemedicineservices.

On the basis o the observations the Brieng Paper delivers some key messages:

Facilitating change or proessionals and patients;

Involving proessionals and patients in eHealth through telemedicine;

Establishing a culture o interdisciplinary and cross-sectoral collaboration;

Making National strategies or sustainable telemedicine explicit; Establish a European support ramework or sustainable telemedicine.

These recommendations are o course open or comments by the Members and Partners o EHTEL andour dierent stakeholder groups. They will serve as oundations or EHTEL creating a cross-stakeholdertelemedicine expert group and developing new initiatives or the two coming years with a view to supportall stakeholders in the deployment o eHealth and telemedicine services in support o the transormationo health care delivery.




6/37

Executive Summary

1 Introduction 1

2 EHTEL Task Force Sustainable Telemedicine 2

3 Telemedicine: Defnitions, Classifcations and Strategies 3

3.1 Denitions and classication approaches by EU, WHO and Journals 3

3.2 National Extensions o Telemedicine denitions 4

3.3 European Strategies 4

4 Lessons learned: Sustainable telemedicine services

vs. discontinued or only minimally maintained pilot projects 6

4.1 Early pilot projects 6

4.2 Lessons learned rom early telemedicine pilots 6

5 Principal Telemedicine Services 8

5.1 Telemedicine services as a response to health and social demands 8

5.2 Tele-services primarily between health proessionals (D2D) 9

5.3 Telemedicine services directly oered to patients (D2P) 11

5.4 Telemedicine services or niche markets 13

5.5 Cross-border telemedicine 13

6 Telemedicine as component o eHealth roadmaps

and deployments in Europe 14

6.1 Positioning o Telemedicine in National eHealth Strategies 14

6.2 Regulatory and policy ramework or sustainable Telemedicine services 16

7 Best Practice examples and National case reports 21

7.1 Telemedicine services directly oered to patients (D2P) 21

7.2 Telemedicine in support o collaboration o health proessionals (D2D) 23

8 Vision or Europe 2020: Integrated Telemedicine Services 26

8.1 Facilitating change or proessionals and patients 26

8.2 Involving proessionals and patients in eHealth through telemedicine 26

8.3 Establish a culture o interdisciplinary and cross-sectoral collaboration 27

8.4 Making National strategies or Sustainable Telemedicine explicit 27

8.5 Establish a European supporting ramework or Sustainable Telemedicine 28

9 Annex: Environment o the EHTEL Task Force Sustainable Telemedicine 29

9.1 Networking and cross-stakeholder dialogue 29

9.2 EHTEL 4C o Healthcare Approach 29

9.3 HEALTHWARE project 29

9.4 Healthware User & Citizen Open Group 30

9.5 Healthware telemedicine workshops - co-organised by CNES, C2Team and EHTEL 30

9.6 Telemedicine related Position papers by the EHTEL Patient Task Force 30

Contents*



* The material rom this document can be quoted or non-commercial purposes with the source being indicated.


7/371


Telemedicine or more generally: telehealth services are increasingly established as a means to acilitatethe distribution o human resources and proessional competences. More particularly, these services canspeed up diagnosis and therapeutic care delivery or emergencies, support virtual hospitals in patientshomes and allow primary healthcare providers in geographically dispersed locations to receive continu-ous assistance rom specialised coordination centres. Thus telemedicine is, or will be, a major topic onthe agendas o health and social care policies in Europe and worldwide. With new technology such asinteractive DVB-RCS satellite technology, additional options or connecting proessionals-to-proessionalsand proessionals-to-patients, as well as or the design and deployment o completely new, integratedservices and applications become easible.

While some telemedicine services had been successully piloted already decades ago, uptake and rou-tine usage o such services is still subject to noticeable variations. Narrowly targeted services like telem-onitoring o patients with high risks o atal cardiac events or some orms o surveillance in the sense otelehomecare are in routine use in many countries already. With almost universal availability o broadbandconnectivity and de acto internet standards or audio and video streaming, teleeducation and telepresencebecome an obligatory element o medical teaching and continuous medical education. Imaging orientedservices like teleradiology and to a lesser extent telepathology have been successully embedded inclinical environments and are nowadays oten part o routine health care. Some o these services maylack external visibility since they have been established as in-house services (e.g. a radiologist assessingdiagnostic images rom a radiological workstation at home or a pathologist assessing specimens o a high

capacity link within an academic hospital). The latter might also be a refection o the still restrictive legalenvironment which is much stricter when extramural services are oered.

At the same time the potential o telemedicine to enable the digital networking o patient-oriented medicalcare is currently ar rom being suciently unlocked and needs to be better and more widely utilised. Thenation-wide use o telemedicine services seems to be particularly delayed i compared to the long testingphase established through the many EU and nationally-unded pilot projects.

Possible reasons or this include the lack o appropriate and ready to use interoperable and more partic-ularly highly secure communication inrastructures, poorly documented and unproven Return on Invest-ments (RoI) models, the unclear and restrictive legal environment and probably most particularly the lack

o reimbursement schemes or telemedicine by statutory as well as private health insurance schemes.

Telemedicine can signicantly contribute to and will be a crucial element in, the necessary transormationo national and regional health care systems. It can only be achieved with sucient awareness and com-mitment by local, regional, national competent authorities, the active support o clinical proessionals andcitizens/patients looking or more eective and convenient services.

1 Introduction



8/372


The European Health Telematics Association is an international non-prot association with the missionto support all stakeholders in implementing and using ICTs to deliver health and social care. Establishedin 1999 under Belgian law, the activities o the association began with initial support rom the EuropeanCommission, enabling EHTEL to oer a comprehensive source o eHealth inormation aimed at meet-ing the demands o those responsible or the provision o eHealth, together with the means or eectivenetwork and access. EHTEL provides to its members a cross-stakeholder platorm or inormation, com-munication, representation, networking and co-operation in support o the implementation o inormationand communication technologies (ICT) in health and social care in Europe.

The cross-stakeholder dialogue has become a guiding principle or EHTEL activities. In the ramework oa recent EHTEL conerence it was concluded that, Continuity o healthcare is a key element o agendasin Europe. This leads to the challenge to enable improved inormation management and patient-centredcollaboration among all health proessionals and across a wide range o care environments. The ullbenets o eHealth will only be realised by connecting people. This involves a undamental shit in per-spective and the understanding that eHealth is not simply a set o products or applications but a rangeo options to improve and transorm healthcare services. Hence EHTEL believes that using ICTs in healthand social care in Europe oers an unparalleled opportunity to revolutionise: (1) The quality o health andsocial care services provided to patients and citizens, (2) The speed and ease o access to those services;and (3) Their eciency and cost eectiveness. The association brings together under one roo all o theconstituencies with an interest in ICTs in health and social care: National and regional health authorities

and systems, Hospitals and other health institutions, Public and private insurance providers, Health pro-essionals, Health managers and executives, Patients, Citizens and consumers, Industry, Researcher andacademics.

Telemedicine has been on the agenda o EHTEL already by representation in its initial workgroup structurethroughout the years 2000 to 2002. Since the organisational structure has meanwhile been adopted tobecome a fexible organisation o task orces, the topic is now ollowed-up in the two task orces Sustain-able Telemedicine and the task orce on Chronic Disease Management.

This brieng paper has been prepared or the Task Force Sustainable Telemedicine and has been sup-ported through some external unding in the ramework o the Healthware project (http://healthware.alca-

sat.net/) in relation the Healthware Users and Citizens Open Group (UCOG). This document builds also onthe study Strategies and Roadmaps or Sustainable Telemedicine Analysis & Recommendations basedon Country Reports on Telemedicine in Europe. This study was subcontracted by EHTEL with the aim toestablish an inventory on National Telemedicine roadmaps. The survey has been perormed by NICTIZ,the National IT Institute or Healthcare in The Netherlands and national coordination point and knowledgecentre or IT and innovation in the healthcare sector, with the support o NITEL. NITEL is part o EPN, aplatorm in The Netherlands or the inormation society promoting the possible benets o ICT or society.NITELs aim is to improve Dutch healthcare by stimulating the implementation and use o telemedicineservices, to help remove barriers, and to enhance opportunities or telehealth.

2 EHTELTask Force Sustainable Telemedicine



9/373


For the purpose o this brieng paper, EHTEL understands the term telemedicine as ollows: Telemedi-cine services provide means to improve accessibility to high quality health care in case o shortage oappropriate health proessionals or the necessary medical expertise or skills at the site o the patient.

Telemedicine thus covers a broad spectrum o services such as teleconsultation, second opinion, tele-homecare and teletraining and builds on technologies such as video-conerencing supported by the ex-change o medical images and medical records as well as remote monitoring. Communication inrastruc-tures include ordinary telephone land-lines, internet connections o various speeds and in many instancesalso satellite links to enable health care in remote and isolated areas.

3.1 Defnitions and classifcation approaches by EU, WHO and Journals

The overarching theme o telemedicine is best described as being care at a distance, e.g. Telemedicineis an umbrella term that encompasses any medical activity involving an element o distance1. As the eldhas urther developed various elements have been added and some denitions o the term telemedicineby third parties are provided:

In 1993 the European Commission dened: Telemedicine is the rapid access to shared and re-mote medical expertise by means o telecommunications and inormation technologies, no mat-ter where the patient or the relevant inormation is located.

In 1995 the Journal o Telemedicine and Telecare named telemedicine again as Medicine prac-tised at a distance and emphasised that it does not only encompass both diagnosis and treat-ment, but also medical education.

The World Health Organisation (WHO) stated in 1998: Telemedicine is the delivery o healthcareservices, where distance is a critical actor, by all healthcare proessionals using inormation and com-munications technologies or the exchange o valid inormation or diagnosis, treatment and preven-tion o disease and injuries, research and evaluation, and or the continuing education o healthcareproviders, all in the interests o advancing the health o individuals and their communities.

Also in the WHO denition o Health Telematics special reerence was given to Telemedicine inorder to bridge the spatial distance between patient and physician or between several attending

physicians (examples: telediagnostics, teleradiology , teleconsulting).At the same time WHO dierentiated between telehealth with the meaning o telepreventionand telemedicine with the sense o curative telemedicine. Yet this dierentiation has not beenadopted over the world with the consequence that telehealth and telemedicine are oten usedsynonymously.

By adopting the classication o Internet services, this Brieng Paper dierentiates urthermoreservices between health proessionals/doctors (D2D aka B2B) like teleradiology and telepa-thology rom services directly oered to patients (D2P aka B2C) like telehomecare, care omobile patients and Internet based consultations. This will be additionally highlighted or principaltelemedicine services in section 5.

3 Telemedicine: Defnitions, Classifcation and Strategies


1 Wootton R et al (2001) Recent advances: Telemedicine. BMJ, 323:557-560


10/374


3.2 National Extensions o Telemedicine defnitions

Denmark: Telemedicine is a technology in which the transer o video, pictures, sound and test

results enables experts who are not physically present to be involved in the diagnostics and careo a patient.

Ireland: The National Telemedicine Strategy ocuses on telemedicine and telecare- Telemedicine applies to communications involving doctors and hospitals;- Telecare applies to communications involving nurses & carers and is increasingly ocused in the

community and on the home;- Which combined are: The use o inormation and communications technology to deliver health-

care remotely.

Norway: Telemedicine is dened as means to improve health care services in general. Overcom-ing shortage o appropriate medical expertise is one aspect amongst others.

The Netherlands: Telemedicine is about processes in healthcare that have two characteristics:a. Physical distance is bridged using inormation and communication technologyb. Two actors are involved, where at least one is a health care proessional

The terms telehealth and telecare (in comparison with telemedicine) have been particularly highlighted byUK (England):

Telehealth is the delivery o health related services and inormation via telecommunications tech-nologies. Telehealth is an expansion o the unctionality o telemedicine and unlike telemedicine(which ocuses on the curative aspect) it encompasses preventive, promotive and curative as-pects.

The term telemedicine is at times interchanged with telehealth. Like the terms medicine andhealth care, telemedicine oten reers only to the provision o clinical services while the termtelehealth can reer to both clinical and non-clinical services such as medical education, adminis-tration and research.

Telecare is a combination o equipment, monitoring and response that can help individuals toremain independent at home. It can include basic community alarm services able to respond inan emergency and provide regular contact by telephone as well as detectors which detect actorssuch as alls, re or gas and trigger a warning to a response centre.

3.3 European Strategies

The 2004 eHealth action o the European Union (e-Health - making healthcare better or European citi-zens: An action plan or a European e-Health Area2) is still the guideline or the implementation o the EUsvision on eHealth. It orms an important part o European i2010 strategy, i.e. Achieving stronger growthand creating jobs that require higher qualications within a dynamic, knowledge-based economy.


2 http://ec.europa.eu/inormation_society/activities/health/policy_action_plan/index_en.htm


11/375


3.3.1 National Extensions o Telemedicine defnitions

While the overall objective o the action plan is better access, quality and eectiveness o care, The action

plan sets out a roadmap or greater use o technologies, new services and systems, built around an objec-tive o a European e-Health Area. It identies practical steps to get there through work on electronichealth records, patient identiers and health cards, and the aster rollout o high speed Internet access toenable optimum interactions among health care proessionals and with the general public. It also calls onMember States to develop national and regional e-Health strategies. Thanks to this plan, by the end o thedecade, the EU should be well-placed to measure the impact o e-Health technologies on the quality andeciency o services, as well as overall productivity. e-Health will become commonplace or health proes-sionals, patients and citizens.

An important action oreseen in this Action Plan was or all member states to develop an eHealth road-map: By end 2005, each Member State is to develop a national or regional roadmap or e-Health. Thisshould ocus on deploying e-Health systems, setting targets or interoperability and the use o electronichealth records, and address issues such as the reimbursement o e-Health services. As documented inthe eHealth ERA project3,4, most Member States have reached this milestone and dened National eHealthroadmaps.

By reviewing those eHealth strategies and priorities per country, it has become evident that telemedicineis in most cases not mentioned so ar. This must however not necessarily imply that telemedicine servicesare not under preparation or have not already been established. Rather or the time being, eHealth strate-gies seem to be ocused mainly on overall eHealth planning and implementation tasks like establishing asecure communication inrastructure; dening and deploying interoperable network services etc. Yet it

makes it more dicult to obtain a realistic representation o the status o telemedicine, telehealth and re-lated services throughout Europe.

3.3.2 EU Telemedicine plans

Telemedicine services are mentioned as an upcoming milestone in paragraph 4.3.2 o this Action Plan:By end 2008, the majority o European health organisations and health regions (communities, counties,districts) should be able to provide online services such as teleconsultation (second medical opinion), e-prescription, e-reerral, telemonitoring and telecare. Given this objective the EU will intensiy the attentiontowards Telemedicine services in 2008. Thus Telemedicine is explicitly mentioned in the annual policystrategy 20085, chapter 2: Priority actions or 2008, paragraph 2.4 Security and Freedom oresees:

Initiative on telemedicine or chronic disease management (home health monitoring).

Starting e.g. with the organisation o the event TeleHealth 2007, the European Commission is preparing acommunication on Telemedicine and Innovative Technologies or Chronic Disease Management that isoreseen to be published in October 2008. The elements to be addressed are inter alia: legal obstacles(tax, social security, liabilities, claims), nancial issues like patient reimbursement, practical issues (ac-creditation, certication, labelling), data protection and privacy and last but not least: Interoperability. Fur-thermore a public consultation has been launched in October 2007, aimed at gathering telemedicine ex-pertise in all Member States. The Communication on Chronic Diseases and Telemedicine will particularlytackle the legal and privacy issues linked to cross-border telehealth and telemedicine services.


3 http://ec.europa.eu/inormation_society/activities/health/docs/policy/200703ehealthera-countries.pd4 http://ec.europa.eu/inormation_society/activities/health/docs/policy/ehealth-era-ull-report.pd5 Communication rom the Commission to the Council, the European Parliament, the European Economic and Social Committee o the Regions, Annual policy strategy

or 2008, Brussels 21-2-2007 COM(2007) 65 nal, c. http://ec.europa.eu/atwork/synthesis/doc/aps_2008_en.pd


12/376


As opposed to most eHealth services, many telemedicine services already oversee a longer history odevelopment and testing. Since the now-a-days evolving inrastructures o eHealth have not been avail-able previously, rst generation telemedicine services were mostly based on proprietary technologies andhence implemented as islands.

4.1 Early pilot projects

Ater two decades o pioneering work rom around 1975 to 1995, ollowed by a decade o transition withearly adopters using telematics applications to improve their daily work in health and social care in limitedscenarios, telemedicine has then clearly started to become an important issue or implementation, opera-tional deployment o services and a promising market or industry.Great eorts have been undertaken and a great number o projects have been carried out in order to ex-ploit the telemedicine and eHealth potential. Most o these projects have not accomplished sustainability,but have created a large variety o dierent, in most cases insuciently interoperable, applications.

The current challenge is to aggregate the achieved pieces o evidence, to consolidate the results,to integrate approaches on the basis o international, open standards, and to drive them towards

operational development.

4.2 Lessons learned rom early telemedicine pilots

Various insights and experiences have been gained rom projects and services in dierent parts o Europeand hence, dierently organised healthcare systems during the past two decades. These insights areconsidered on the background o what can now be observed:

A shit rom telemedicine applications as stand-alone, added-value component driven by the para-digm o technology-push, toward eHealth services emerging as one-o-many eatures in digitalmedical work environments driven by the paradigm o demand-pull.

The experiences range rom technically well-done applications without or with scenario-dependent ac-ceptance by the users, to technically simple, out-o-the-box solutions with great acceptance and clinicalimpact. In some cases, telemedicine solutions have even initiated changes in medical best practice ore.g. diagnostic procedures.


4 Lessons learned: Sustainable telemedicine servicevs. discontinued or only minimally maintained pilot projects6

6 Excerpt romInsight and experience gained rom clinical telemedicine applications, presented by Alexander Horsch et al. at the Healthware workshop, Luxembourg,

March 2006.


13/377


A careully balanced distribution o benets among the stakeholders;

the general use o equipment required or telemedicine such as digital stethoscopes or digitalcameras or daily work and not only reserved or the potentially rare use o a telemedicine service,so that the health proessionals are amiliar with the handling;

the digitisation o work environments with the side-eect o creating a good basis digital telecom-munication;

a good education and training o users;

clear operational models or collaboration between health service providers; sound economicalmodels not expecting single eHealth services to aord basic telematics inrastructures whichrather have to be implemented on a national scale to serve all services;

all these have been identied as key success actors or sustainable, well-accepted services.

In order to gain a broad acceptance among users, telemedicine and eHealth services o the next genera-tion must be both working saely and smoothly to operate elements o inormation and communicationtechnology, supporting integrated care processes inside healthcare providers and between healthcareproviders and patients. They must not put any urther burden on healthcare proessionals, but rather helpthem to work in a more ecient and eective way.



14/378


5.1 Telemedicine services as a response to health and social demands

Europe is acing the challenge o delivering quality healthcare to all its citizens, at an aordable cost. Theincreasing demand by citizens or best quality healthcare, the costs o managing chronic diseases, andthe need or prolonged medical care or an ageing society are major actors behind this challenge. Tele-medicine services are suited to close the clash between raising needs and limited resources, i.e. they area possible solution or the challenges o todays health and social care. Thereore, in this paragraph thepotentials o telemedicine services are linked to the major challenges o healthcare systems all over Eu-rope. These challenges can be viewed rom many dierent perspectives. For the social challenges, em-

phasis is put on the cost perspective and the citizen perspective.

5.1.1 Treatment or chronic patients

Already 70% o healthcare budget is spent on treatment o chronic diseases. The demand is thereore toreduce costs, e.g. by seeking or solutions which may: Reduce the number o (poli)clinical control visits necessary; Transer rom expensive (hospital) care to cheaper alternatives; Reduce the volume o acute hospitalisations because o complications (preventing upront in-

stead o damage-control aterwards).

Chronic diseases are aecting the quality o lie o patients and sometime their relatives. There is thereorea demand rom the citizens or solutions which may: Help them in taking part in daily lie i possible without loss o privacy; Prevent or reduce patient hospitalisation, travelling long distances and waiting or control visits; Recognise and treat rst signs o complications as soon as possible.

5.1.2 Support or the quality o lie o elderly people including living at home

Without changing the way elder citizens are supported in 2020, almost 20% o all working people will haveto work in healthcare. This may lead to a scarcity o proessional resources. At the same time, quality olie is not only about health, but also about wellness aspects, e.g. getting attention. Older people are not

always used to technology and ICT tools.

Here too, there is a demand to reduce costs, e.g. by seeking or solutions which may: Use the scarce resources in a more ecient way; Oer a standard set o services as a basis or all citizens; Manage the rising o costs or this segment; Integrate ICT (e.g. telehomecare) in care, living and wellness.

Here again, there is a demand rom the citizens or solutions which may; Help to identiy the best t o services or each individual;

Support citizens in their individual choices; Give citizens more individual choices or health and wellness services; Make telecare services available in an assisted ambient manner.


5 Principal Telemedicine Services


15/379


5.1.3 Patient Empowerment: Citizens want inormation to make their own choices

Specic patient groups will take more control in their own hands regarding their health.

Other groups o patients will rely on their caring proessionals or these choices.In both cases the choice is made by the citizen, not the proessional.

5.1.4 Individualised Care provision: Case vs. disease management

Care will shit to an integrated approach o diseases where dierent proessionals play their role in theservice chain. For patients with multiple diseases a next step will be made towards case management, toprovide custom made healthcare services to individuals.

This requires a culture shit or proessionals; rom individualists to team players. To support the choiceso patients fexible healthcare according a caeteria model has to be established. At the same time morehealthcare services will be provided directly to the citizen, who is willing to pay or extra services eitherthrough insurances or in a retail model.

5.1.5 Distributed, networked use o specifc specialised medical expertise

The continuous medical and technological developments require more and more specialisation. This im-plies that not all expertise is available at every location. Especially small hospitals look or possibilities tomaintain delivering a broad range o services.

Here too, there is a demand to reduce costs, e.g. by seeking or solutions which may:

Ensure optimal use o expertise knowledge or larger groups o patients; Stimulate the optimal use o scarce resources through cooperation at a distance.

Here again, there is a demand rom the citizens or solutions which may help to: Get inormation on specic expertise in the region, national or abroad; Make this specic expertise available or individual citizens.

5.2 Tele-services primarily between health proessionals (D2D)

Telehealth comprises interactions between health providers and citizens/patients (D2P) and within the

group o health providers (D2D) in support o healthcare and prevention given the act that there is nodirect physical contact with each other7. I the patient is present at this consultation, this could be ex-tended to D2D2P. Still the ollowing descriptions concentrate on the healthcare providers being theprimary partners o the tele-services.

5.2.1 Teleconsultation/Second Opinion

Generally speaking, teleconsultation is the consulting participation o a distant physician or o other health-care proessionals. Although the videoconerencing systems oten used or teleconsultations allow thistype o telepresence, not every system solves the maniold problems o media discontinuities in medicine.

These can only be overcome by an accompanying exchange o documents enabled by shared medicalrecords or the electronic transmission o reports and ndings.


7 c. Denition o Telemedicine by the Swiss Association or Telemedicine and eHealth, endorsed also by ISTeH.8 Nerlich M, Schall T, Stieglitz SP, Filzmaier R, Balas A: A Generic Approach To Teleconsultation - An opinion based Guideline rom G-8 GHAP

Subproject 4 Group (International Concerted Action on Collaboration in Telemedicine - Teleconsultation Guideline Consensus Process)


16/3710


The primary use o imaging procedures has led to new medical services or the purposes o remote evalu-ation (teleradiology, telepathology etc.) and teleconsultation as well as teleconerencing. Mere secondary-opinion procedures or ensuring a better diagnostic and therapeutic quality have already been applied as a

matter o routine in many institutions throughout Europe. The issue that is still being discussed is the extentto which the work o an expert (specialist) on site can or should be replaced, or example, as regards toperorming an intra-operative rapid histological diagnosis using means o telepathology.

Teleconsultations are increasingly used in those specialist elds o medicine, in which corresponding diag-nostic ndings data (mainly images) can be transmitted digitally. In addition to the disciplines already men-tioned, these specialist elds comprise, among others, ophthalmology (eye undus), dermatology (macro-scopic and microscopic skin lesions), cardiology and surgery (summarising evaluation o X-ray images andother ndings). The ollowing denition was given in the drat or a guideline on teleconsultation:

Teleconsultation is the consultation o one (or more) distant health care proessional(s) by a locally presenthealth care proessional about a patients case, diagnosis and treatment using telecommunications andinormation technology to bridge the spatial distance between the two (or more) participants. Teleconsul-tation oers opportunities o improving cooperation, especially among healthcare proessionals, and si-multaneously enhances the quality o patient care. The videoconerencing systems oten used or telecon-sultations allow or the remote presence o an (additional) colleague, but do not solve the maniold problemso media discontinuities in medicine. These can only be overcome through an accompanying exchange odocuments.

The technologies used are not specied so that telephone consultation is also included in this denition.Since numerous attempts to contact a specialist are necessary or simultaneous second opinion proce-

dures between two highly qualied doctors to be able to communicate with each other directly (at thesame time), asynchronous communication using mailbox procedures, the medical multimedia data beingtransmitted via email, has gained increased acceptance and become the preerred methods e.g. or ob-taining second opinions o highly specialised physicians e.g. in Gastroenterology.

5.2.2 Teleradiology

Teleradiology is the transmission o X-ray images and material generated with other imaging methods andtheir evaluation. It reers to an assessment in selected settings such as an evaluation by a consulted spe-cialist, teleradiological evaluation by the radiological supervising physician o a hospital; and to the case oan outsourced emergency service, provided by a large hospital to smaller clinics that have no internal ra-

diological emergency service. There are additional applications or education and urther training and orscientic purposes.

Teleradiology has been the most rapidly adopted orm o telemedicine services, since the use o digitalimaging procedures has increased quickly, even outside the tele context. Hence teleradiology is alreadyused routinely in many European healthcare institutions.Primary teleradiology implies the use o some imaging procedures without a radiologist being active onsite. This scenario is rejected by some health proessional organisations because o quality concerns. Inaddition it may cause job loss o medical specialists.

The demand or broadband data connections in the healthcare sector is caused to a high degree by tele-radiology applications, since huge data volumes must be transported regularly, in particular, as regards



17/3711


diagnostic lm sequences or image sequences (CT Scan, MRI). Thereore, an essential role concerning theeasier use o teleradiology applications is the introduction o advanced image compressing algorithms inaddition to the better availability o transer capacities (e.g. bre optics or high bandwidth satellite links).

Although a high level o standardisation o image ormats has been achieved through DICOM, which ismeanwhile supported by most o the (digital) imaging devices, many issues relating to secure image datatransmission remain still to be solved.

5.2.3 Telepathology e.g. or rapid histological diagnosis

Telepathology with the aim o a second evaluation o images has been widely deployed already. But thebenet and reliability o the systematic replacement o a pathologist on site, e.g. or rapid histological di-agnosis, is still disputed. Undisputed are applications in radiological and pathologic education and urthertraining as well as or scientic purposes.

In certain surgical operations usually when there is a suspicion o a malignant recurrence a part o theintra-operatively removed tissue is examined by the clinical pathologist during an operation. I no patholo-gist is active at the relevant hospital, the tissue must be transported to an external pathologist. This leadsto prolonged operation and anaesthesia times and, besides additional stress on the patients health, toeconomic disadvantages. Telepathology can, under certain conditions, reduce the above-mentionedstress through a aster transmission o pictures and the relevant ndings. Instead o sending the tissuesample with a courier to pathological evaluation, it is processed on site perhaps under video-control othe consulted pathologist by a specically qualied employee and put into a remote-controllable exami-nation microscope (robot microscope). The pathologists control commands or the microscope and theimages o the preparation are transerred in real-time so that the remote clinical pathologist can commu-

nicate his evaluation ater only a ew minutes.

Telepathology also includes the transmission o images or second-opinion procedures, or education andurther training and or scientic purposes. Corresponding applications have proven their worth in the eldo haematology, where telehaematological evaluation is used or quality assurance and reerence pur-poses in combination with specic diseases.

5.2.4 Proessional learning and training

There is a separate area o opportunities closely related to the distributed, networked use o specic spe-cialised medical expertise but with a ocus on the skills o the proessional himsel. Telemedicine provides

a range o new possibilities to learn and train proessionals. E.g. by viewing real-lie operations or sharingexperiences with colleagues worldwide.

Also in this area opportunities are abundant to provide proessionals with telemedical skills to be able toprovide care through telemedicine services to their patients.

5.3 Telemedicine services directly oered to patients (D2P)

5.3.1 Telemonitoring and Telehomecare

Telemonitoring comprises the remote monitoring and care o patients, who might be subject to recurrent/deteriorating disease and/or to disability in their amiliar home environment. Thus complex monitoring



18/3712


tasks that are otherwise only possible during inpatient treatment in hospitals are perormed in an ambula-tory or the patients home environment. Telemonitoring has hence potentials o substituting the hospitalsmonitoring activities and oers improvement potentials or unobtrusively accompanying patients who

might be subject to recurrence, or example, ater a stroke. In this eld, or example, sensory systems thatcan be applied in the direct environment o the patient are used. One eld o application is expanded ormso diagnostics, or example, using ECG data transmitted by telemetric means or via a data connection.Furthermore, comprehensive care concepts or chronic patients, in particular within the sense o second-ary prevention, can be realized with this procedure. So the patient is able to make use o medical monitor-ing and care services in his direct personal environment. Given appropriate side conditions, the patientmay lead an autonomous lie despite his suering rom severe health problems. Yet in addition to the careo geriatric patients, attention must also be given other patient groups and their requirements.

5.3.2 Emergency care and care o mobile (travelling) patients

Telemedicine in support o the medical care o emergency patients includes, among other elements, datacommunication between the hospital, the emergency service and a consulted physician or providingadvice to the physician active on site. Care o mobile (travelling) patients is also a possible eld. The careo emergency patients is o the classical domains o telemedicine and is also a relevant application or theEuropean healthcare sector. Enabled by early data communications between the emergency service onsite and the admitting hospital, the hospital sta can make the necessary preparations or even otherdecisions, such as the use o a rescue helicopter in good time. Teleconsultation, i.e. providing expertadvice to the physicians and/or paramedics on site, is also possible.

As another example, passengers on board airplanes and ships may also receive medical advice or can be

attended to by the crew under the supervision o doctors including, or example, telediagnosis and tel-etherapy, i the appropriate telecommunication acilities are in place and i the crat are connected, e.g. viasatellite, to the relevant operations centres. Concrete applications were tested, or example, within theramework o the NIVEMES EU project with emphasis on Greece. In addition, there are commercially oper-ated telemedicine applications or passengers and crews o cruise ships (c. section 5.4).

5.3.3 Patient Consultations and Internet based online services

Telehealth also comprises to counsel patients directly via communication lines, typically the Internet. Whilethis service can be part o telecare or telehomecare services it can also directly be oered in the rame-work o health inormation portals or internet pharmacies.

Thus some eHealth portals oer pay-or-services like individual therapeutic counsel and prescriptions overthe Internet in addition to general health inormation. While this is normally accessible to every Internetuser, some national regulations and the Proessional Code o Conduct o some Medical Associations donot support this kind o proessional interaction. Typically only non-binding, general expert advice is incompliance with the Code-o-Conduct o Medical Proessions9.

Finally health proessionals also join discussion orums o consumers and patients on the Internet eitheras proessional moderators, contracted resource or sometimes also in the sense o a volunteering role andinormal communication. While in accordance with the ideal o a ree exchange o inormation, content and


9 E.g. Medical Associations in Germany reuse medical treatment over the Internet without cryptographic security measures. In addition, starto treatment is principally not permitted over the Internet.


19/3713


quality o discussions among medical laymen and, in part, among laymen and physicians are subject tohigh variations which may result in turn, into health risks or the audience, some orums have developedto well qualied Internet-supported sel-help groups.10 Hence, certain online discussions and ora or

health related issues may enable the qualied exchange o inormation in the support o prevention, dis-ease management, sel-help and consumer and patient empowerment.

5.4 Telemedicine services or niche markets

While the services described so ar are complementary to regular, brick-and-mortar healthcare, somespecial environments or circumstances make telemedicine being the only option to provide healthcare atall or at sucient quality. The service oered is mostly teleconsultation; particularly ships and military mis-sions oten use multi-unctional equipments enabling also remote imaging (teleradiology) and remote di-

agnoses or special dis-eases (like teledermatology). Aviation healthcare: Telemedicine services or passengers and personnel in airplanes.

Maritime healthcare: Telemedicine services on board o ships or oshore.

Space healthcare: Telemedicine services in space, e.g. Telemonitoring.

Deence healthcare: Telemedicine services to support health proessionals working in military mis-sions in remote or third world countries (Balkan states, Aghanistan, Iraq,), e.g. Telesurgery,

Teleradiology.

Disaster Relie: Telemedicine in areas o natural disasters (earth quakes, foods etc.).

Satellite based telemedicine is particularly suited to support those scenarios. While those applicationsmay dominate the public perception o telemedicine and at the same use a serious amount o nancialresources, they are normally only models or new medical or technological approaches (like robots) but willnot lead to large scale implementations as such. Hence these services are treated as specialities andgadgets without connection to the nation-wide roll-out o new eHealth enabled services.

5.5 Cross-border telemedicine

Excellent medical competency centres might oer their expertise at an international level (e.g. interna-tional centre or rare metabolic disorders or a telepathology consultation centre, e.g. the service oered byCharit, Berlin, Germany). In such cases, arising liability issues are to be claried among other things orexample, by analogy with the model o a telemedicine agreement proposed by the WHO.

During telemedical treatment, the transerred inormation can overcome any national border, easily at anydistance. The resulting needs are interoperable applications and a clearly dened legal and also nancialramework. Cross-border telemedical treatment requires interoperable applications and a binding legaland nancial ramework.


10 For example some message orums on the subject: Diabetes mellitus.


20/3714


The current status o Telemedicine deployment is mirrored by the positioning o telemedicine and tele-health in the eHealth strategies and roadmaps o European States and o course by integration o tele-medicine services with the eHealth inrastructure and other eHealth services. This overview synthesisesinormation obtained rom National representatives (Ministries o Health and/or telemedicine experts) o:

Austria, Belgium, Bulgaria, Cyprus, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ice-

land, Ireland, Italy, Latvia, Luxemburg, The Netherlands, Norway, Poland, Romania, Slovakia, Spain, Swe-

den, Turkey, and United Kingdom on the positioning o telemedicine in National eHealth strategies (section6.1) and the regulatory and policy ramework or sustainable telemedicine services (section 6.2).

6.1 Positioning o Telemedicine in National eHealth Strategies

In general the vision on Telemedicine in European countries can be divided in three types:

Vision on telemedicine is an integral part o the actual eHealth strategy and telemedicine applica-tions are developed as part o this eHealth strategy;

Vision on telemedicine is mentioned in the actual eHealth strategy, but telemedicine applicationsare not developed in direct relation to this eHealth strategy (yet);

Telemedicine is not mentioned in the eHealth strategy and ew developments o telemedicine ap-plications in practice are visible.

Overall most countries have an eHealth strategy but ew examples o explicit strategies on telemedicineexist (e.g. Ireland, Romania). Some countries have made choices or certain projects or types o tele-medicine applications, but arguments or empirical oundations or overall choices on telemedicine, projectsor application-types have not been documented.

6.1.1 Roadmap excerpt: Austria

The main aims o telemedicine projects and developing eorts are the required increase o medical qual-ity or all citizens in Austria, increase o accessibility to medical services and the decrease o costs or thedierent partners.

6.1.2 Roadmap excerpt: Bulgaria

The advantages o the implementation o telemedicine solutions in healthcare are:

Higher accessibility each patient will have the chance to be treated by the best specialists in therespective area;

Higher eectiveness o the health assistance better and stable results are achieved concern-ing the improvement o the patients health status;

Better economical eect - the amount o hospital-stay and the days or ambulatory treatment get

lower, then the amount o active labour days or each patient is rising that lits the gain or theemployers and infuences positively the economical growth o the country as a whole. That alsowill bring lower treatment costs or the health insurers.


6 Telemedicine as component oeHealth roadmapsand deployments in Europe


21/3715


6.1.3 Roadmap excerpt: Denmark

Telemedicine provides a number o ways to enhance the quality o care and service and thereby the

level o patient satisaction. Furthermore, telemedical solutions can help, ensuring a more rational use oresources available to the Danish health care system.

Telemedical solutions may entail a number o advantages or the patient, including aster and better diag-nosis, ewer extra medical investigations, no unnecessary transportation etc. In certain cases, the use otelemedical solutions will also enable relatives to remain close to the patient, to the benet o the patientspsychological well-being. For the health care proessionals, new possibilities will emerge: consultationswith experts, better decision support, less travelling etc. With telemedicine, existing physical limitationscan be disregarded. The patient doesnt necessarily have to come to the expert; nor do images need tobe moved physically. This can all result in better communication internally in hospitals and between hos-pitals, practice sector and community health care. Equipment, proessional expertise and emergency alertcan be put to more ecient use.

6.1.4 Roadmap excerpt: Ireland

The Department o Health & Children, together with the Health Board Executive (HeBE) commissionedthe preparation o this strategic vision and approach or the development o telemedicine in Ireland.

The purpose o the National Telemedicine strategy is to:

Firmly establish the use o telemedicine as a normal support tool to healthcare delivery putingtelemedicine rmly on-the-map;

Bring telemedicine to the consciousness o decision makers at all levels, particularly those chargedwith service modernisation and change;

Establish basic principles;

Establish basic inrastructure, and

Make signicant initial progress.

6.1.5 Roadmap excerpt: Italy

Telemedicine is seen as an important aspect o improving quality o health care and increasing eciencyin the new National HealthCare Plan.

6.1.6 Roadmap excerpt: Norway

The overall vision o the eHealth strategy is better healthcare services with the use o ICT. Telemedicine isdened as means to improve health care services in general. Overcoming shortage o appropriate medicalexpertise is one aspect amongst others.

6.1.7 Roadmap excerpt: The Netherlands

Telemedicine is considered one o the innovative means to improve healthcare.



22/3716

6.1.8 Roadmap excerpt: United Kingdom England

The vision is set out in the White Paper report Our health, our care, our say: A new direction or com-

munity services: The objective is to deliver a radical and sustainable shit in the way that services aredelivered; away rom the one size ts all approach o reactive treatment, oten in a hospital setting, to aperson-centred service making use o new technological opportunities.It is expected the increased use o telecare/telehealth will:

Reduce the need or residential/nursing care;

Unlock resources and redirect them elsewhere in the system;

Increase choice and independence or services users;

Reduce the burden on carers and provide them with more personal reedom;

Contribute to care and support or people with long term health conditions;

Reduce acute hospital admissions;

Reduce accidents and alls in the home;

Support hospital discharge and intermediate care;

Contribute to the development o a range o preventative services;

Help those who wish to die at home to do so with dignity.

6.1.9 Roadmap excerpt: United Kingdom Scotland

A policy report was published; the Kerr Report and the Government document in response, which is thecurrent policy document called Delivering or Health.

Some recommendations that were made:

Provide care as close to the patient as possible, at home or close to home;

Provide other care as much as possible in local communities;

Hospitals should do what they are good at = ocus on core competences and stop small serv-ices or ragmented disciplines;

Provide tools or empowering and sel management o patients.

To reach these objectives there is a big role or ICT (or eHealth), with a ocus on Electronic Health Recordsand telehealth.

6.2 Regulatory and policy ramework or sustainable telemedicine services

The successul establishment o sustainable telemedicine services builds on various regulatory actors, i.e.the adaptation o the legal ramework or teleservices, organisational aspects, nancial elements like reim-bursement schemes and also technical measures like standardisation and the inclusion into relevant inra-structure planning.




23/3717

Those actors are complemented by elements, which might be summarised as change managementlike user awareness, assessment o user demands and needs, cultural changes in healthcare provisionand healthcare governance. Finally also the development o business models, and last but not least, the

overall market readiness o industrial suppliers are important actors.

6.2.1 Regulatory and policy ramework: Belgium

A national strategy has been developed to exploit the eHealth/telemedicine opportunities with the Be-Health inrastructure. The goal o the strategy is to involve all relevant actors, to create coherence be-tween the dierent (inormation) systems, to guarantee privacy, the quality o data and saety, and to en-hance optimal use o the available means.

On the legal level, a sectorial committee is responsible or privacy, quality o data.

Organisational support was provided by the inauguration o a vision-group responsible or the denitionand development o a vision o eHealth/telemedicine. In this group all relevant actors are involved. Amaintenance-group is responsible or the technical and nancial aspects o the BeHealth platorm.Since the BeHealth platorm integrates a number o initiatives in the Belgian health care and social secu-rity system, the nancial impact o the development o the platorm is small: existing budgets are beingused.

6.2.2 Regulatory and policy ramework: Denmark

The implementation o sustainable telemedicine services is supported by the national government and its

institutions responsible or telemedicine by: Legal recommendations rom the National Board o Health;

A national Health Net, based on Internet technology, as technical support or the exchange oclinical images, videoconerencing etc. (MedCom the Danish Health Net);

Financial incentives (e.g. Diagnoses Related Groups codes or telemedicine support);

Dening a national implementation strategy with national dissemination projects.

6.2.3 Regulatory and policy ramework: Estonia

From various cross-border telemedicine projects, particularly those carried out in the Baltic countries, suc-cess actors or telemedicine have been identied, like project implementation by experts with good pro-essional background and having received special training; most important is to enable projects to be-come part o the health care delivery process.

Telemedicine services are part o a national strategy and have received dedicated support;

6.2.4 Regulatory and policy ramework: France

From the legal point o view, the Ordre National des Mdecins (National Council o Doctors, in charge o

ethical rules) has started to dene the responsibility o practitioners in distant expertise. For the nancialsustainability o telemedicine, work is underway to dene special invoicing but this is still very slow anddicult.




24/37


25/3719

While health care is a public matter in Norway, the implementation o telemedicine still depends on localcommitment and their involvement. The strategy to manage this includes common public adaptation (i.e.

as providing inrastructure and standards) and local authorities liability, commitment and ownership.

User involvement is an important principle in Norwegian governmental policies, but has not held a spe-cic role within development o telemedicine strategies. The primary movers within this work have beenery souls, committed health care personnel, particular groups o expertise, and public health authori-ties.

A technical inrastructure or electronic interaction in the health care sector is already in existence. Thesupply by the market is straightorward since the public health care services use applications rom com-mercial companies. A primary challenge in the near uture is to include the various stakeholders in health-

care into the use o electronic interactions.

6.2.8 Regulatory and policy ramework: Sweden

A versatile inrastructure is provided by Sjunet with a dedicated IP inrastructure that interconnects allCounty Councils. This means all primary care and hospitals are possible to interconnect.

The obstacles perceived or the more extensive use o Telemedicine are:

During these rst years there were stability and support problems in the inrastructure. This hascaused discussion i this is useul at all. We will solve this by new inrastructure and a more activesupport organisation.

Since telemedicine takes at least two parts, the matter o coordinating people into special roomsat a certain time is problematic. The spontaneous meeting like making a phone call does nothappen. And good tools or planning have not been available.

It is still a special event to sit in ront o a camera. Education and training are necessary. And thesharing o medical images has not been perect because o old inrastructure. Also many doctorslike to meet patients and colleagues live.

In some (very ew) cases discussions about nancing has been an issue. I municipalities needmedical expertise or care o elderly, the responsibility and payment issue or the doctor must besolved.

6.2.9 Regulatory and policy ramework: The Netherlands

The approach to nancing telemedicine has been to provide buying power to insurance companies andconsumers and hence to support good initiatives or programs indirectly through nancial subsidies. Thisis typically a one-time subsidy and hence sustainability should reach ollowing this. Furthermore new tarisor innovative services are needed. Also some insurance providers have selected telemedicine services tooer added value to their customers.

From an organisational aspect new procedures or disease and sel management have been created withthe goal to promote cooperation ocused on the patient, not on the providers. Furthermore healthcare

consumers are provided with objective online inormation to be better supported in their choices.

The technical platorm or telemedicine services will be provided through the National AORTA inrastruc-ture and a nation-wide EHR which is dened and implemented using international standards.




26/3720

The legal basis is established through the legal basis or eHealth services, i.e. by the legislation on PatientIdentication (BSN) and on EHR. The latter regulates proessional obligations, patient rights, authorisation,data protection, etc.

User demands have been documented as:

Trust in quality and security o solutions;

Customer Centric services;

Stimulating awareness o customers;

Always available, easy to use services integrated in daily lie;

One-stop-shop or customer service;

Personal budgets or these services (caeteria model).

The Health-IT industry has developed already protable business models or some services oering fexi-ble subscription packages targeted or sucient numbers o subscribers.

6.2.10 Regulatory and policy ramework: UK-England

From an organisational viewpoint, delivery o the programme (within the National Programme or IT) ismanaged through the Local Ownership Programme. The Department o Health has established a Na-tional Framework Agreement (NFA) or telecare which encompasses both telecare and telehealth solu-tions. Multi-disciplinary teams have been created at the health and local authority level that will developand deploy integrated care plans.

To encourage the adoption o these services by means o nance, the government has made available 80Munder the Preventative Technology Grant in nancial years 2006/07 and 2007/08.

Interoperable telemedicine solutions are supported by the development and application o internationalstandards. At the same time those standards enable to integrate telehealth solutions to the core eHealthinrastructure which is based on open international standards. A barrier to deployment is the missing scala-bility o the present technology that will need to be overcome in order to achieve sustainable deployment.

6.2.11 Regulatory and policy ramework: United Kingdom Scotland

Telehealth is handled as an integral part o eHealth and hence the means needed or eHealth are applica-ble to telehealth. At the same time telemedicine suers rom the low budget or ICT (0.5 1.0 % o healthexpenditure) provided by the government to regional health boards. The budgets will have to rise in thenear uture.

So ar no eHealth dedicated Scottish legislation exists, i.e. rulings are based on Case law.Telehealth needs reshaping o organisations and cultures or various aspects/groups like:

Patients need to be convinced telehealth services are sae and as good as a traditional visit to adoctor.

Proessionals need to be convinced that telehealth is sae, quicker and more ecient than tradi-tional procedures; proessionals are a barrier: they want to keep on working as they always havedone, and consider it a threat or their job.

Organisations need to be sure that the cultural change is manageable, has health economic ben-ets and they are able to t their HR and payment or these new proessionals.




27/3721

7.1 Telemedicine services directly oered to patients (D2P)

7.1.1 D2P Best Practice: Austria

Telemonitoring o diabetes patients over the portal healthgate.at telecommunication between dierenthealthcare providers in the project health@net https://www.healthnet.or.at/products/Healthweb/

7.1.2 D2P Best Practice: Bulgaria

The Telecentres Project includes 10 towns and/or villages in the Septemvri parish and enables bloodpressure measurement rom a distance as well as online consultations with GPs and cardiologists.

7.1.3 D2P Best Practice: Cyprus

DITIS is a project which is being developed since 1999. It has been successully deployed by PASYKAFor the home care o cancer patients. It enables the eective management and coordination o healthcareteams, or the continuous assessment, diagnosis and treatment o patients at home or wherever else theymay be.

7.1.4 D2P Best Practice: Finland

Secure inormation exchange with patients by SMS messaging is used by hospital districts.

Citizen initiated recording, where a patient can transer personally conducted laboratory tests into thepatient record system o the health care provider is in use in several hospital districts and some health carecentres. Teleconerencing where the physician is at one location, while the patient and the nurse are atanother is used in several health care centres.

7.1.5 D2P Best Practice: France

ANTADIR, the nation-wide initiative or integrated care, coordinating care or lung-diseases is a successulbut isolated example o telemedicine.

The telemedicine network o Guiana created in 2001 connects the isolated health centres o Guianato the hospital o Cayenne, thus alleviating the geographical isolation o the medical structures o theGuianese interior. The network is enabled by the presence o the French space agency CNES in Kourou.Predominant medical applications are teleconsultations in many medical specialities and teleepidemiology(early epidemiologic alerts).

7.1.6 D2P Best Practice: Greece

A project or the provision o eHealth home-based rehabilitation, ollow-up and home hospitalisation serv-ices in patients with advanced stages o chronic diseases has been run by the eHealth Unit o SotiriaHospital, Athens. The specic project concerned chronic patients suering mainly o advanced stageCOPD, with a past history o multiple hospital admissions.



7 Best Practice examples and National case reports


28/3722

FRONTIS; Hospital at Home: The Hospital at Home Department o Hygeia Hospital in Athens aims toactually convert the patients home into a hospital room in order to saely and eciently treat at home a

wide spectrum o medical conditions, which otherwise require management in a hospital. The aim is totreat at home almost any patient who does not require surgical intervention or close monitoring in an in-tensive care unit.

7.1.7 D2P Best Practice: Luxemburg

An interesting project is the Luxembourg Heart Failure telemonitoring project. (When heart ailure pa-tients ace the transition rom the hospital setting to home, they need close ollow-up to prevent deteriora-tion and exacerbation o their disease.)

7.1.8 D2P Best Practice: The Netherlands

Sel management and telemonitoring or diabetes is oered by the Diamuraal oundation. Portavita supportssel-management o anticoagulation therapy through telemonitoring and teleconsultation. Other telemonitor-ing services are oered to citizens with Chronic Heart Failure (CHF), Obstructive lung diseases (COPD) andDiabetes in many regions like e.g. Amsterdam, Zwolle, Groningen, Maastricht and Rotterdam.

An innovative home care concept enables elderly to live on their own at home. A virtual care centre andnursing home is provided through personal broadband communication combined with selected nursingelements. The audio-visual surveillance system developed or the VieDome health care project can beadapted to a wide variety o users in dierent environments. It ensures also privacy, security, trust and

condentiality o the clients.

7.1.9 D2P Best Practice: United Kingdom

(England) Kent County Council has invested 1 million in a telehealth pilot scheme involving 275 peoplewith chronic illnesses such as diabetes, heart and chest problems. The evaluation is currently ongoing butthe results look promising.

(England) Telecare oers the promise o enabling thousands o older people to live independently, in con-trol and with dignity or longer. 80 million, across 2006-07 and 2007-08, was announced or a Pre-ventative Technology Grant to support 160,000 older people to stay in their own homes.

(Scotland) The Tele-booth HealthPresence solution links clinicians with patients at a distance by videoconerencing. Consultation will include medical tests such as blood pressure, oxygen saturation, weight,pulse rate and spirometry.

(Scotland) 14 minor incident units o hospitals are connected through video-conerencing to Aberdeen oronline support. Ater 5 years as a project is has become a regular service.

(Scotland) More elderly people want quality o lie and live at home as long as possible. But personnel tosupport (especially) chronic ill, elder citizens at home is lacking.

Fourteen continuous projects exist in Scotland, among them examples in the eld o paediatric telemedi-cine, teleneurology and teleendoscopy. The projects were selected based on criteria dened by a reer-ence group.




29/3723

7.2 Telemedicine in support o collaboration o health proessionals (D2D)

7.2.1 D2D Best Practice: Denmark

Teleradiology: The aim o the lookup o X-rays and descriptions via the Internet project (2002-2005) hasbeen to give healthcare proessionals direct access to central patient inormation, which is stored in an-other county or in the hospitals own RIS (Radiography Inormation System) or PACS (Picture ArchiveCommunication System),

Teledermatology is based on the sending o digital images o skin conditions, as a supplement to thetraditional cooperation and patterns o patient reerral between medical practice and specialists in derma-

tology. The overall aims o the teledermatology project (2002-2005) have been to: Replace/supplement general reerrals to skin specialists with telemedicine consultations.

Assure patients o equal and quick access to specialist assessments o skin images through theirown doctor.

Support continuing training o GPs through communication with skin specialists.

Establish nation-wide provision or telemedicine skin image consultation.

7.2.2 D2D Best Practice: Estonia

The Baltic International Telemedicine Network (BITNET) includes applications or neurophysiology, medicaldiagnostics, and radiology, as well as videoconerence acilities or urgent and scheduled consultations,medical rounds, and education programs.

Application o telemedicine started with teleconsultations in neurology and amily medicine.

Partnership or the heart: German-Estonian health project or the treatment o congenital heart deects inEstonia. (Publ. Aug 2005)

The training o Estonian physicians in Germany,

Training courses conducted by German and Estonian specialists in Estonia and

Use o telemedicine or consultation on a continuous basis.

7.2.3 D2D Best Practice: Finland

Teleradiology is in daily use in several hospital districts, where DICOM pictures and shared archives arecommon. Telelaboratory services between organisations are common. 90% o the hospital districts hadsome method or the electronic distribution o laboratory results in 2005. Health care centres purchasedvideo conerencing in order to consult a specialist o a hospital. Telepsychiatry and teleophtalmology areamong the services used.

7.2.4 D2D Best Practice: France

Many regions have carried on developments. Since 2000, two types o projects are commonly underconstruction. First are regional interoperability platorms to interconnect diverse healthcare organisations




30/3724

and networks and link telemedicine to other medical data interchanges. Regional Hospital Agencies (Gov-ernment local representatives) develop these tools and coordinate them with specialized videoconerencebridges on high speed IP networks.

7.2.5 D2D Best Practice: Greece

In Sikinas a teleeducation scenario has been implemented: The medical sta working in rural primary caremedical centers in Sikinas, are physically and digitally isolated and so have great diculty in ensuring theircontinuing education.

7.2.6 D2D Best Practice: Ireland

The main disciplines using telemedicine are: radiology, pathology, neurosurgery, oncology and paediatrics,and the main applications were teleradiology (25 hospitals), videoconerencing (16) and telepathology (5).

Some examples

Tele-Radiology: This is the largest telehealth service in Ireland;

Tele-Cardiology: St. James Hospital, a major tertiary hospital in Dublin, links with Sligo GeneralHospital;

Tele-Oncology: The Medical Oncology team at Sligo General Hospital (SGH) in the northwest oIreland commenced in 2002 to expedite patient cases with specialists in St. Lukes and St. Vin-cents University Hospitals (SVUH);

Tele-Primary Care-Surgical Consultations: Killybegs Community Hospital. From its Telehealth

Unit, regular video-consultations are carried out between (a) patients and the primary care teamand (b) a general surgeon in Letterkenny hospital.

7.2.7 D2D Best Practice: Norway

Some examples o Telemedicine services are:

Sounds, images and videos recorded by primary care doctor and transmitted to specialist;- Examples are stethoscopy, dermatology, ear-nose-throat conditions, examination o optic un-

dus or diabetes patients;

Telepathology, pathological support o hospitals lacking this capacity;

Teleradiology, as imaging goes digital, support can be given at distance;

Videoconerencing or psychiatry and or cancer care.

7.2.8 D2D Best Practice: Romania

The National Communications Research Institute (INSCC) rom Bucharest has coordinated several Na-tional Telemedicine Projects, among them: Implementation o a Multimedia Platorm or Complex Medical

Teleservices (TELMES) with two pilot regional telecentres at Pitesti and Iasi or teleradiology, telepathology,teleconsulting, telediagnosis, telemonitoring. The project develops a multimedia network or integratedteleservices with the aim e.g. to optimise the medical decisions to increase the quality and decrease thecosts: to expand o the services range o health proessionals in healthcare.




31/3725

7.2.9 D2D Best Practice: Sweden

Teleradiology has been set up in cooperation with the Telemedicine clinic in Barcelona to balance the lack

o radiology specialists.

Pathology project: In south east o Sweden a new inrastructure based on video inrastructure isinstalled and regular meetings are setup between these hospitals, with expert nurses locally hand-ling the equipment.

Eye bottom pictures in rebro: The very specialist in analysing eye bottom pictures is situated inrebro between Stockholm and Gothenburg. Proessionals all over the country contact her toshare their pictures using web sharing and audio conerencing.

Primary care in Vsterbotten: Vsterbotten is situated in the North o Sweden. Distance romnorth to south is some 300 km and distance rom coast to the Norwegian border is some 400 km

the three hospitals are situated in the east near the coast. Instead o travelling in taxis, ambu-lances or private cars, each primary care is equipped with video conerencing equipment. Allpersonnel at the primary care units can handle the equipment and it is the responsibility o thepersonnel at the hospitals to take care o Video patients at the same conditions as IRL pa-tients.

7.2.10 D2D Best Practice: Spain

Based on http://www.itelemedicina.com which includes reerence telemedicine projects or services oper-ating in Regions in Spain rom 2003 up to today, e.g.

Andalucia: A virtual environment to support vital emergency also allows teleconsultation between healthproessionals and training.

Baleares: The Hospital has created a service that allows, rom primary care centers, to make a request ora consult and send the pictures o their diagnosis.

Canaries: The telemedicine project consults through teleconsultation in psychiatry, radiology and derma-tology.

Castilla y Leon: Telecardiology is being practiced in some centres or Primary Care Community. Accordingto sources in the regional government, results and the demand or this service has infuenced an increaseo the coverage to 100 centres. (January 2004).

Catalonia: According to the Catalan Institute o Health (ICS), a total o 282,908 visitors have used theonline service to be oered through the webportal o which 137,805 users have requested medical con-sultation.

Galicia: In regard to telemedicine, sources in the Ministry announced strong momentum, expanding theirexisting applications (radiology, ophthalmology and dermatology) to other clinical specialties such as psy-chiatry, the Ministry is working on creating a Telemedicine Centre Address.

7.2.11 D2D Best Practice: The Netherlands

KSYOS TeleDermatologie: Through this Teleconsultation-service a General Practitioner can consult adermatologist via the internet. This reduces 50 to 70% o patient reerrals to the dermatologist!




32/3726

In most nations around Europe there is a keen awareness o the need to transorm healthcare systems tocope with current and uture social and medical challenges . Telemedicine and telehealth can be tools tomeet those challenges as long as they as they are being routinely used to support the care process.

To be sustainable, telemedicine and telehealth should not be considered as separate

rom, but as an integral part o eHealth deployment and inrastructures. eHealth inra-

structures will be the common platorm or all digital services within healthcare.

This is required both in terms o eciency and interoperability and to saeguard patient rights to privacyand data protection on one hand and to accessibility and usability o services on the other.

8.1 Facilitating change or proessionals and patients

Introduction o Telemedicine services is com

Date post:	07-Apr-2018
Category:	Documents
Upload:	amila-wijerathna
View:	218 times
Download:	0 times

EHTEL Briefing Paper Sustainable Telemedicine

Documents