e-health Present and future Ramona Mayer EBG MedAustron GmbH, Wiener Neustadt, Austria

eHealth . . . "eHealth is the single-most important revolution in healthcare since the advent of modern medicine, vaccines, or even public health measures like sanitation and clean water” Silber D. The case for eHealth. (Presented at the European Commission's first high-level conference on eHealth May 22/23 2003.) European Institute of Public Administration 2003.

From medical informatics to eHealth Classical Medical Informatics – stand alone era (1970+) Health Telematics – early telecom days (1985+) eHealth – Web era (1995+) Pervasive and ubiquitous eHealth - ambient intelligence era (2005+)

From medical informatics to eHealth Classical Medical Informatics – stand alone era (1970+) Systems for the storage, retrieval, sharing and optimal use of biomedical data, information and knowledge Health Telematics – early telecom days (1985+) Regional health care networks Remote diagnosis and telemedicine applications Decision Support Systems

From medical informatics to eHealth eHealth – Web era (1995+) Internet based applications and services Medical content for prevision Intranets for health service management Pervasive and ubiquitous eHealth - ambient intelligence era (2005+) Health knowledge infrastructure Wearable and implantable systems Biomedical informatics for personalized health Health GRIDs

eHealth mHealth Electronic Medical Records Telemedicine eCardiology Telemedicine eRadiology Consumer Health Informatics Virtual healthcare teams Health knowledge management

„eHealth“… eHealth encompasses a range of services that are at the edge of medicine/healthcare and information technology e-health encompasses much of medical informatics, but has to prioritise the delivery of clinical information, care and services rather than the functions of technologies No development of basic technology, but development of beneficial applications for patients physicians care facilities health care insurance companies etc

EC definition of eHealth “….the use of modern information and communication technologies to meet needs of citizens, patients, healthcare professionals, healthcare providers, as well as policy makers" http://europa.eu/

WHO definition of eHealth "eHealth is the cost-effective and secure use of information and communications technologies in support of health and health-related fields, including health-care services health surveillance health literature health education, knowledge and research" (World Health Organization , Ninth plenary meeting, 25 May 2005 - Committee A, seventh report)

5 Steps of eHealth Electronic diabetes diary

Steps of eHealth… Step 1 - Information Step 2 - Communication (action) Providing information for patients or doctors e.g. via the web (information in one direction), Medical databases like PUB MED Step 2 - Communication (action) The exchange of information between two people involved (patient - doctor, doctor - doctor...) without direct and current reaction of the communication partner (e.g. on-line diabetes diary) Step 3 - Interaction (action + reaction) Exchange of information or dates between people involved with immediate reaction of the communication partner (e.g. telemonitoring, telesurgery…)

Steps of eHealth… Step 4 - Transaction Electronic handling of a complete (treatment)process (“All or nothing”) Step 5 - Integration (e.g. Electronic health record - EHR) Electronic health biography – central documentation for all health relevant data from birth to death

Step 1 – Information Providing information for patients or doctors e.g. via the web (information in one direction) DIAB-MEMORY

Step 1 – Information Provider of the information Information medium Publishing companies, authors Provider of medico technical equipment Pharmaceutical companies Health insurance companies Physicians and health care professionals … Information medium Print media CD, DVD, … Computer network / Internet Recipients Physicians Patients Family members

Step 1 – Information Physicians Patients http://www.medterms.com/ Medical literature http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db= PubMed Medical database (z.B. Drug informaton systems) http://www.druginfosys.com /… Patients Health advisor http://www.netdoktor.at/ Dictionary of medical terms http://www.medterms.com/ …

Step 1 – Information Health on the Web Estimated ~ 20,000 health websites Used by 98 million adults 75% of people who have web access Average of 3.3 times per month More than consult doctors each day

Step 1 – Information Health on the Web Pro Con Correct information can lead to more knowledgeable and less anxious patients more participatory health decisions Con Misinformation can lead to confused patients Bad decisions, false hope, harm

Step 2 – Communication Communication = Action The exchange of information between two people involved (patient - doctor, doctor - doctor...) without direct reaction of the communication partner (e.g. online diabetes diary) Electronic diabetes diary

Step 2 – Communication Online diabetes diary Diabetes-diary allows to document the blood glucose values enables the physician to access the data adjust the insulin dosage accordingly The patient can communicate with the physician online save time and unnecessary office visits. from: http://www.diabetes-diary.com/

Step 2 – Communication Online diabetes diary

Step 2 – Communication Online diabetes diary From: http://www.diabetestagebuch.de/

Step 3 - Interaction Interaction = action + reaction Exchange of information or data with immediate reaction of the communication partner (e.g. telemonitoring,…) Electronic diabetes diary

Step 3 - Interaction Telemedicine Most useful when Specialist services are in very high demand or patients are extremely isolated ( Antarctica or remote communities in Australia, Africa and Alaska) Telemedicine encompasses any medical activity involving an element of distance (R. Wootton)

Step 3 - Interaction Telemedicine Online versus store-and-forward Functional Telecardiologye Teleradiology Telesurgery Teledermatology Telecare (homecare) Action Telemonitoring Second opinion Telediagnosis etc… Multimedia (Text, Audio, Image, Video, Augmented Reality)

Step 3 - Interaction Telemedicine 1. Live telemedicine via videoconference 2. Store-and-forward telemedicine – transmit for assessment offline Typical telemedicine interaction: store and forward followed by live interaction Data types Text ( e.g. patient's notes) Images (e.g. x-ray, CT, etc) ( Telemedicine often relies on images)

Step 3 - Interaction Telemonitoring Schaubildtitel Schaubildtitel 2. CardioMessenger sends a SMS daily and additionally in the case of an event 1. Patient with an implant with home monitoring function 4. Physician with secure internet access 3. Automatic data processing at the service centre www.biotronik.com

Step 3 - Interaction Teleradiology Quelle: http://www.chili-radiology.com/

of a complete (treatment)process Step 4 - Transaction Transaction Electronic handling of a complete (treatment)process (“All or nothing”) Electronic diabetes diary

Step 4 – Interaction Electronic health card For example : Austria Rollout until end of 2005 Electronic handling of a complete (treatment)process Includes: On the reverse side = EHIC - European Health Insurance Card Digital signature At present the ecard cannot be used at: Private medical practice Other contractual partners (e.g. optician, midwife, …)

Step 4 – Interaction Electronic health card } Patient record Physician letter Health care provider index Work in progress e-medication √ Administrative data EHIC - European Health Insurance Card

Step 5 - Integration Electronic health biography = central documentation for all health relevant data from birth to death Electronic diabetes diary

Step 5 - Integration Central data repository Local data repositories + central index Case record (e.g. under discussion in Germany) Live long electronic health record Any combination is under discussion in countries across Europe!!

E-health in different environments for example: General Hospital Ion beam facility eHealth on the EU-level

eHealth in a general hospital Administration Billing Hospital information system (HIS) Procurement Logistic Medical data Radiological images and findings Lab- Information System Discharge letter Teleconference etc… Step 1 - 3

Clinicians are very busy and under constant pressure to perform ! They will NOT change their behaviour, unless the new workflow is clearly more efficient on a personal and individual level ! Sulivan2002; Holzinger & Errath 2004

Usability ….. For an interface to be a success it must provide the right functionality at the right place at the right time and in the right form from the user's point of view! Holzinger 2000

E-health in different environments for example: General Hospital Ion beam facility eHealth on the EU-level

and Hungarian hospitals Concrete project: Platform for the planned co-operation between the Ion beam Research and Treatment centre MedAustron in Wiener Neustadt, Austria and Hungarian hospitals

MedAustron eHealth services Provided services Accept patient information Accept medical findings Accept radiological images and findings Provide RT planning information Dose information Plan details Provide medical reports

Scenario I Patient base data Medical relevant data CT/MRI/PET-CT/US Patient referral without pre-irradiation Possible data input from referring hospital Patient base data Medical relevant data Histological data Surgical report Other findings CT/MRI/PET-CT/US RT planning documents Applied dose Medical report Available data output from MedAustron

Teleconference

Scenario II Patient base data Medical relevant data CT/MRI/PET-CT/US Patient referral with pre-irradiation Possible data input from referring hospital Patient base data Medical relevant data Histological data Surgical report Other findings CT/MRI/PET-CT/US RT plan + applied dose RT planning documents Applied dose Sum dose Medical report Available data output from MedAustron

Scenario III Patient referral with pre-irradiation Step 5 1 2 Possible data input from referring hospital Electronic Health Record Patient base data Medical relevant data Histological data Surgical report Other findings CT/MRI/PET-CT/US RT plan + applied dose RT planning documents Applied dose Sum dose Medical report 4 3 Available data output from MedAustron

E-health in different environments for example: General Hospital Ion beam facility eHealth on the EU-level

eHealth for Regions A network for transnational co-operation Aim Support of an innovative process by building a platform for the exchange and generation of ideas for co-operation Provision of experiences and knowledge about the specific challenges of transnational collaboration in the field of eHealth among the network partners Finally the co-operation should be run by the partner themselves!

eHealth for Regions Co-operation fields and pilots (examples) Personal information medical sticks Developed for patients with chronic diseases, who are often travelling in European neighbouring countries on business or vacancies Objectives To improve the cross-border medical service, esp. for travelling pts. with chronic diseases To support physicians with information treating foreign patients To omit unnecessary examinations of patients USB sticks are prepared with structured medical information based on the European emergency health card Partners: Denmark, Finland, Germany, Lithuania, Norway, Poland, Sweden Step 1

eHealth for Regions Co-operation fields and pilots (examples) Ferries with Tele ECG at the Baltic Sea Objectives A better health care support for travelling citizen to reduce time from symptoms to treatment TT Line transports 2000 to 4000 passengers every day between Trelleborg (Sweden) and Travemünde or Rostock (Germany) First aids room equipped with a transtelephonic ECG recorder ECG transmitted to multilingual server of telemedicine centre in Bad Segenberg (Germany) routed from there to co-operating cardiac centres in a readable format Step 2

Summary : eHealth = „ … in a broader sense, characterizes not only a technical development, but also a new way of working, an attitude, and a commitment for networked, global thinking, to improve health care locally, regionally, and worldwide by using information and communication technology.” Eysenbach G. What is e-health? J Med Internet Res 2001;3(2):e20, adapted by Pagliari et al. 2005

Challenges… National legal regulations and obligations AND: Legal and ethical implications of using health information technologies which may result in harmful effects in certain cases are not yet clear... Safety (data integrity and completeness) Data security and protection System developers need to employ quality and safety assurance methods to avoid clinical risks and legal liability Interoperability Implementation and integration of eHealth systems into care processes are constrained by insufficient levels of systems interoperability (though moves to ensure standardisation in many current e-Health implementation programmes will reduce this) Acceptance (availability and usability)

5 Steps of eHealth Accelerated progress Used in daily practice Moderate progress Electronic diabetes diary Accelerated progress Used in daily practice

Summary eHealth is not able to solve the problems of the health and social systems BUT the problems of the health and social systems cannot be solved WITHOUT eHealth

...working together towards an ehealthy future