1. Manchester 20031 Telemedicine and e-health Dr Jim Briggs University of Portsmouth jim.briggs@port.ac.uk

2. Manchester 20032 Contents Definitions Types of telemedicine Case studies E-health Other issues Further information

3. Manchester 20033 Definitions Telemedicine E-health

4. Manchester 20034 Raw definitions Telemedicine: medicine at a distance cf television E-health: health services delivered electronically cf E-commerce

5. Manchester 20035 No standard definition "To define telemedicine is to have something in common with Humpty Dumpty — that is, by making a word to mean whatever you want it to mean." [BJHC&IM] Google search throws up 13 defns http://www.google.com/search?q=define: Telemedicine

6. Manchester 20036 US government "The use of medical information exchanged from one site to another using electronic communications for the health and education of patients or providers and to improve patient care." http://cms.hhs.gov/glossary/default.asp (Dept of Health and Human Services)

7. Manchester 20037 ATA one(s) "the use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or health care provider and for the purpose of improving and extending the availability of patient care" http://www2.umdnj.edu/omcweb/1998/telemedicine.htm "access to medical care for consumers and health professionals via telecommunications technology" http://www.atmeda.org/about/aboutata.htm e-health is the "use of the Internet for healthcare"

8. Manchester 20038 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. Manchester 20039 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. Manchester 200310 TEIS one Starting point: "The use of Information and Communication Technology (ICT) to deliver healthcare at a distance"

11. Manchester 200311 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. Manchester 200312 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. Manchester 200313 Types of telemedicine CJ Fitch, JS Briggs, RA Beresford, "System issues for telemedicine systems", Health Informatics Journal, vol. 7, no. 3/4, September/December 2001, pp222-230

14. Manchester 200314 Characteristics of tm systems Interaction style Data types Equipment Action Patient numbers Duration

15. Manchester 200315 Interaction style Real-time (synchronous) Participants all active at the same time Use any synchronous technology (e.g. phone) Most commonly: video conferencing Less often but becoming more common: vital signs monitoring May need high bandwidth Store-and-forward (asynchronous) Participants do not need to be active at the same time Use any structured form of message passing Most commonly: email Less often but becoming more common: systems exchanging messages May not need high bandwidth

16. Manchester 200316 Data types Text Patient notes Diagnosis Image X-rays Pathology slides CT/MRI/… scans Audio/video signals

17. Manchester 200317 Equipment General purpose Off the shelf PCs Specialist Electronic stethoscopes Image capture equipment Image display equipment (possibly)

18. Manchester 200318 Action Intervention Direct influence on patient treatment Advice Indirect influence Final decision made by intermediate party

19. Manchester 200319 Patient numbers One patient at a time Multiple patients e.g. where a number of patient cases are considered at the same time

20. Manchester 200320 Duration Timespan over which communication sessions take place single interaction single episode of care (multiple interactions over same problem) long-term (multiple episodes)

21. Manchester 200321 Categories of telemedicine

22. Manchester 200322 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. Manchester 200323 Cornwall MIUs

24. Manchester 200324 Gosport MIU

25. Manchester 200325 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. Manchester 200326 Dundee trial

27. Manchester 200327 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. Manchester 200328 East Midlands cancer network

29. Manchester 200329 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. Manchester 200330 tds sites North Manchester reduced waiting list from 18 months to 17 days in 6 weeks Medway dealt with backlog of 3000 patients in 15 weeks Expanding into Essex, Hertfordshire and Texas http://www.tds-telemed.com/

31. Manchester 200331 Case study - WorldCare Consortium of 4 big American hospitals Provide "second opinion" service worldwide (20 countries) tele-radiology tele-pathology patient management consultation Local physician remains responsible http://www.worldcare.com/

32. Manchester 200332 Case study - NHS Direct Biggest telemedicine project in the world Mainly telephone service Expanding to: web  online diagnosis for common conditions  health encyclopaedia  my NHS healthspace (personal info portal): news, reminders, knowledge digital TV http://www.nhsdirect.nhs.uk/

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35. Manchester 200335 e-health

36. Manchester 200336 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. Manchester 200337 Integration of IT into Business Sectors Integration of IT IT as a gadget Trojan horse: networks, … Full Integration of IT into Business (Organisational, Legal) Re-engineering of the system 198019902000 Jean-Claude Healy May 2000 (Banks) (Health…) Manufacturing Business Services Public Services

38. Manchester 200338 Are hospitals a thing of the past?

39. Manchester 200339 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. Manchester 200340 USA EUROPE AUSTRALIA (For 24hr medical coverage) Telemedicine links

41. Manchester 200341 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. Manchester 200342 Other issues Ethics Economics Success factors

43. Manchester 200343 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. Manchester 200344 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. Manchester 200345 Economics 2 What else to include? Patient costs is this the reason business cases fail? Social costs cost to society of being ill environmental cost of travel

46. Manchester 200346 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. Manchester 200347 Further information

48. Manchester 200348 TEIS UK Telemedicine and E-health Information Service http://www.teis.port.ac.uk http://www.teis.nhs.uk Over 2000 records covering: telemedicine/e-health activities (>220) organisations people publications equipment

49. Manchester 200349 TIE Telemedicine Information Exchange (US) http://tie.telemed.org/ Covers: Extensive bibliography (>14,000 entries) Projects Events calendar Funding sources News

50. Manchester 200350 CEW Confederation of e-health websites (Q) http://www.teis.port.ac.uk/orgs/cew/ Other organisations include: UK E-health Association Royal Society of Medicine IHM/ASSIST Norwegian Centre for Telemedicine EHTEL

51. Manchester 200351 Journals Telemedicine: 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. Manchester 200352 The end jim.briggs@port.ac.uk Healthcare Computing Group, University of Portsmouth http://www.disco.port.ac.uk/hcc/ http://www.teis.port.ac.uk/