1. Telemedicine & e-Health
Nicolette de Keizer
Dept Medical Informatics University of Amsterdam

2. Evolution of telemedicine
1924: radio doctor
1975 first RCT “Comparison of television and telephone for remote medical consultation” in NEJM
NASA checks vital signs of astronauts
’90: introduction of the Internet

3. Outline Definitions: e-health, telemedicine Quality assurance
Laws and ethics
Technical possibilities
Impact on health care
Factors for failure and success
Example in Teledermatology

4. Definition Telemedicine
“ The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities” WHO(2002)
Telemedicine is the use of telecommunication technologies to provide healthcare services across geographic, temporal, social, and cultural barriers J. Reid, 1996

5. Definitions: e-Health
51 unique definitions (Hans Oh, JMIR, 2005)
administration of health data electronically (ESA)
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. (Eysenbach, JMIR, 2001)
The use of internet technology by the public, health workers, and others to access health and lifestyle information, services and support (Wyatt, JECH, 2002)

6. Calling names Virtual Outreach Hospitals Without Walls
Reaching The Unreached
Bridging the Urban-Rural divide

7. eHealth vs telemedicine

8. Quality assurance Code of behaviour
Certificate of (trusted) third party
Code of behaviour
Instructions for use
Filters
Certificate of (trusted) third party

9. Code of behaviour: e-Health code of Ethics
Sincerity: objectives, financial interest
Honesty: no misleading information
Quality: correct and recent information with acknowledgement
Informed consent: use of data
Privacy: carefull use of data
Professional: professional care
Responsible care provision

10. Laws and Ethics Autorisation – right to read and change information
Identification – is person X person X?
Laws/Privacy
Internet not restricted to country borders
Responsibility - Who?

11. “I didn’t know it would go so fast”
Example NL
Statement
20/3/05
Disciplines to internet physician
Drug prescription via the internet should be prohibited
Agree
44%
Neutral 1%
Disagree
Minister surprised about internet development
55%
“I didn’t know it would go so fast”
March 2005

12. Example NL (2)
College of Hospitals advices Patient and Internet, 20/3/2000
Buying health products via Internet occurs on a limited scale:
5% of interviewees once bought health products via the Internet (most commonly vitamines)
Of the interviewees 71% do not intend to buy in the future.
March 2000

14. Teleconsultation
Videoconferencing (real-time)
Store-and-forward

15. Entities involved in Telemedicine
Telemedicine Platform
Desktop PC, Laptop,Palmtop/PDA
Telemedicine Software
Acquisition,Storage and display
Transmission of patient related information
Clinical Devices
Digital ECG, Electronic Stethoscope, Digital Camera,Tele-pathology Microscope, X-Ray Digitizer
Communication Media
(mobile) phone, Internet, Bluetooth

16. Which settings benefits from telemedicine?
Only large distance
Also small distance

17. Telemedicine – large distances
Developing countries
Army
Places hard to reach
Disasters
Space
An evaluation of the first year's experience with
a low-cost telemedicine link in Bangladesh. Vassallo DJ, Hoque F, Roberts MF, Patterson V, Swinfen P, Swinfen R. Journal of Telemedicine and Telecare, 2001

18. Mobile TMU

19. Telemedicine – small distances
Jail
Shy, socially challenged people
Pressure of work, shortage of personell
Nursing homes

20. Impact on health care
Quality of care
Access to care
Cost of care

21. Impact on health care Quality of care Diagnostics
Treatment (AIDS patients in South Afrika,Cell-life)
Patient satisfaction (early treatment, no live physician)
Cell-life

22. Outcome measures Quality of Care
Diagnostic accuracy
Delay in treatment
Preventable consultations
Adherence to medication
Quality of life
Mortality and morbidity

23. Impact on Health Care Access to health care
Patients with communication disabilities (dumb, deaf)
Isolated patients, hard to reach
Independent of time / place
Contact with fellow-sufferers
Education

24. Outcome measures Access to Care
Patients satisfaction
Timeliness disease detection
Adherence to (treatment) advice

25. Impact on health care Costs of Health care
Prevention of diseases – lower costs for society
Prevention of consultations
Lower costs due to less specialist consultations
Higher costs due to more consultations
No valid evidence for cost reduction by telemedicine (Whitten, BMJ, 2002)

26. Typology of cost studies
Types:
Cost analysis - What does the service cost ?
Cost minimization - Does the service save money ?
Cost effectiveness analyse - What is the balance between costs and effects?
Perspective: patient, care provider, society?

27. Other outcome measures
Physicians satisfaction
Technical aspects: quality of photo’s, performance of application
Usability of the service

28. Factors of success and failure
Satisfaction patients and health care professionals
Better involved patients
Addition not replacement to physicians practice
Failure
Fear of technique
Inaccurate
Limitations in time, money and knowledge

29. Types Tele-Radiology Tele-Cardiology Tele-Pathology Tele-Ophthalmology
Tele-Dermatology
Tele-Psychiatry
Tele-Surgery
Tele……..Anything

30. An example of a study in Teledermatology

31. Context High pressure on health care due to:
Shortage on full-time specialists
Aging population
Physical joint consultations
33% less referrals (Vierhout et al, Lancet, 1995)
Modern information and communication technology  more possibilities  telemedicine

32. Teledermatology Telemedicine application in dermatology Dermatology:
High number of GP consultations (ca. 8%)
Visual orientation
Teledermatology worldwide and in NL:
Local implementations and financial compensations
No robust scientific evidence for effectiveness and efficiency
(o.a. Eminovic et al, BJD 2007)

33. Conventional care versus teledermatologie
patient
info
Dermatologist GP
Teledermatology GP
Info +
images
advice
Dermatologist
35%
patiënt
patient
Less referals?
Less costs?

34. PERFECTD
Primary care Electronic Referrals: Focus on Efficient Consultation using Telemedicine in dermatology
Virtual consultations between GPs and dermatologists

35. Website
KSYOS TDCS®

36. PERFECT D: outcome measures
Unnecessary referrals
Patient satisfaction
Costs savings

37. PERFECTD methods Multicentre cluster RCT Randomisation GPs
Control group = conventional care / referral
Intervention group = teledermatology
All patients go to live dermatologist
Cost minimizing study

38. Patient referred to dermatologist
Less consultations?
Live dermatologist
Patient referred to dermatologist
Control group
Intervention
group
Description signs + digital photos to derm
Teleadvice + intervention GP
Dermatologist decision:
Consultation necessary or
unnecessary

39. Less costs? Societal perspective Modelling cost componentsGP
Dermatologist
Programme costs (camera, software, training, etc.)
Patient
Employer
Cost value input: PERFECTD RCT, Handbook, experiment, expert opinion
Monte Carlo simulatie (sensitivity & scenario analyse)

40. Cost Benefit Costs Benefits - less consultations to outpatient clinic
+ Time GP
+ investments (camera, website, internet)
+ training GP
+ easy to refer
Benefits
- less consultations to outpatient clinic
- less try-outs by GP
- Faster treatment in outpatient clinic

41. Cost model

42. Results 605 patients included 312 intervention, 293 control group
Preventable consultations:
39% intervention group, 18.3% control group
Most important reason for difference is RECOVERY of patients
Costs:
Conventional care: Euro (95%CI, – 461.2)
Teledermatology: Euro (95%CI, – 484.0)

43. Scenario analysis Unneccesary referals >17%
GP TD time <7.5 minutes

44. Scenario analysis
Distance to GP < 55km
Distance to dermatologist

45. Conclusions
Less referals to outpatient clinic but no difference in costs
Cost effective when teledermatology is used for specific patient groups or settings:
Higher percentage unneccesary referals
Larger distance to dermatologist
Less time for GP ->integration TD with GP system

46. …Questions?…