Telemedicine

By Birger Nymo

Introduction

The concept of Telemedicine is not clearly defined. In the literature there are several definitions, which largely have been modified in step with access to teletechnology. In 1975 Bird stated this definition: "Telemedicine is the practice of medicine without the usual physician-patient physical confrontation via an interactive audio-video communication system". In the early eighties Conrath et al (1983) gave a far more general definition: "Telemedicine is the use of telecommunication technology to assist in the delivery of health care". Gradually, as the division between telecommunication and the management of information became more veiled, even this definition is too narrow, even if it takes into account other relations in the health care than only the meeting between physician and patient. What is called medical computer science is an important part of the technological angle of telemedicine. Basically, medical computer science reflects the application of data technology where storage, systematising, management and filing of information internally in medical institutions are superior factors. Such applications are a condition for telebased collection and reception of information whether it is for administrative or purely medical purposes.

In many contexts the concept of telemedicine is reserved for applications where the subject is to render health services based on application of telecommunication. Classical in that sense are forms of remote consultations and remote diagnoses within various medical specialities. In some cases transmission of knowledge in the form of distance education and remote instructions is included in the concept of telemedicine.

For our purpose we have found the following definition useful: "The investigation, monitoring and management of patients and the education of patients and staff using systems which allow ready access to expert advice and patient information no matter where the patient or relevant information is located" (AIM 1990).

The concept of telemedicine leads to many protracted academic discussions. Most important for practical work with telemedicine is to associate with the three main dimensions:

Telecommunication

It is a misunderstanding to define telemedicine as a tele-service. Telemedicine cocerns a closer link between the telecommunication infrastructure to the health care structure, where the whole spectrum of tele-services is included. The public health service is built up as a hierarchical structure that assumes co-operation between a series of institutions locally, regionally and nationally. The need for co-operation and communication between the various levels differs. The most important communication partners for the Norwegian municipality health services are laboratories of various types (Stenvold, 1992). Specimens from patients are sent for analysis and the results are returned. Patients are dispatched from small hospitals to larger hospitals for examination by experts. In case such consultations should be replaced by remote consultations, the telecommunication network must comply with other demands than what is the case for communication with laboratories.

A central element of the telecommunication network is the transmission capacity required by the various medical applications. Communication to or between laboratories implies transmission of relatively small quantities of text. This requires only small transmission capacity. In many cases telebased consultations involve transmission of live pictures. In such cases the transmission capacity is a question of how much the quality of the pictures can be reduced and still be medically acceptable.

Another aspect is to what degree network and services allow on-line communication. In most cases the laboratory communication does not require "consultation" between GP and laboratory with regard to interpretation of the outcome of the analysis. The laboratory sends the results when they are ready and the GP studies them when it suits his work routine. Many types of remote consultations are a direct meeting between patient and physician and require two-way sound and picture communication.

As an integrated part of the working tools of the health services, telemedicine puts strong demands on telecommunication security. One aspect is that the contents of the communication must not come into the wrong hands. Another aspect is that in some cases of remote diagnosis it would be catastrophic if the connection is not obtained or if the connection breaks down.

Reliability and security of the telecommunication network is a deciding factor for which telemedical applications can be realised, for both practical and economic reasons.

Medical informatics

Medical computer science and information processing must be regarded in two connections: computer technology in medical equipment, and the more traditional internal EDP based systems within the institutions to take care of routines in the administration of health services.

Within modern health services the performance of diagnosis, treatment and rehabilitation is marked by a widespread use of medical technical equipment of a high technological level. An important element of this equipment is electronics and computer technology. However, the situation today is that this equipment to a limited extent is integrated into large internal information systems. The greater part of the equipment is a well defined entity in itself. A typical example is picture diagnosis where a computer tomograph produces pictures which are transferred to a film before they are included in the patient's case record or filed.

One problem concerning telemedicine is the necessity of a standardised interface in order to communicate information out from the equipment and through internal and external networks.

The core of electronic management of information at many health institutions are various administrative EDP systems. In the first place this concerns systems to take care of accounting, budget, payment, and material. Gradually, systems taking care of administration of patients and other activities have been put to use. The main motive for introduction of such systems is to increase the efficiency of paper work and the production of statistics. To a very small extent systems for administration, planning and medical treatment are integrated into one system.

The lack of national co-ordination has lead to a health service marked by a small degree of harmonisation concerning both hardware and functional use of medical information systems. There are many different systems which are representative of system dependence and a structure that is functionally adapted to local conditions. The lack of compatibility makes the transmission of information between the systems difficult, if not impossible. Another condition that tends to amplify these problems is the lack of standards. This concerns medical nomenclature, terminology, and classification.

The medical information systems require a high degree of security. Today the institutional systems are closed to the outside world. There is no gateway into them. This concerns protection of privacy, but even more important is to prevent "saboteurs" to enter and put the system into disorder.

The problems concerning integration, standardisation, security, and communication interface of medical information systems are relevant to telemedicine.

Health services

The organisation of health services is an important cue for telemedicine. Whether it concerns special cases or total strategies where telemedicine is involved as part of the working tools for the health services to obtain its objectives, quality control, economy, and legal conditions must be considered.

Quality control is to a high degree related to the question of whether telebased applications, e.g. for diagnosing, will produce the same results as by traditional methods. Telebased applications imply changes in the work routines, e.g. the expert does not himself guide the probe by an ultrasound examination. Another example is that the pathologist must examine the microscope pictures on an image display and not directly through the eye piece of the microscope. Another question is whether telebased transmission results in loss of details in the transmitted information, details that are important for the diagnosing. It is, of course, a basic condition for telemedicine from a medical point of view that the health services shall not be reduced in quality.

The legal aspects within medicine have become more pronounced by the focusing on the patients' rights. In the case of some medical applications it is important to clarify the responsibility towards diagnosis and treatment. A concrete example is when a patient together with a general practitioner call on a specialist via telecommunication. By traditional specialist consultation it is general practice that the specialist's instructions are valid. Thereby the specialist has the responsibility. The same will be the case by telebased specialist consultations, but this has not been tried before a court of justice. Another question is the responsibility of the supplier of the communication service in case of e.g. a breakdown of communication.

Economic considerations about telemedicine might be regarded from two levels, one is social economics and another level is related to the performance of one single health service in a particular situation. In the latter case it might be a question of replacing an existing arrangement with another one, based on telemedicine. A typical example is the arrangement with travelling medical specialists in areas where it is difficult to establish permanent specialist services. Around such arrangements is usually built up a system of economic transfer which keeps the balance for all parts involved. If this arrangement is replaced by a telebased service, the economic arrangement will not balance. Thereby clear-cut winners and losers will emerge. This might result in demand for a cost/benefit analysis and a demand for adjustment of the existing economic arrangements.

In the perspective of social economics the problem might be related to efficiency and effectiveness of the health services. The starting point is a steadily increasing gap between the expectations of the population to the health services and what the community can make accessible for health purposes. The question becomes partly how telemedicine can contribute to optimum production of health services from a given amount of resources, and partly how telemedicine can contribute to fulfil central health-political objectives. This perspective reaches far into the way of organising health services, and not least of all how co-operation and sharing of labour should be arranged.

Why telemedicine?

The superior goal of the health services is to fight sickness and promote health. Considerable resources are used for health purposes. Typical for European countries are health expenses to an amount of 7-9 % of gross national product, and it is steadily increasing. The health trade is characterised by a rapid development of medical technology. This applies to advanced instruments for diagnosing and treatment, drugs, technical remedies for nursing and biotechnology. One of the greatest challenges for the health services is to match the expectation of the population to the health services to the services which can be delivered on a large scale.

Another characteristic feature is a large production of knowledge through research and practical clinical work. The classical medical field is steadily divided into more specialised fields. At the same time the contact with other fields is extended. The health services will change character, partly because, in addition to the curative and preventive medicine, there will be more emphasis on predictive medicine based on the development in biochemistry and molecular biology.

In organising health services these development trends point towards a larger division of work duties and a centralisation of specialised functions. New professional environments and new equipment for diagnosing and treatment require comprehensive efforts of as well economic as organisational character. In the first place this will be important on a national level by the fact that some institutions will have nationwide responsibility for certain specialities imposed on them. In the long run we can se a need for greater international sharing of labour.

Another challenge for the public health services is that the population during the next ten years will be changed with regard to composition of age groups. Older people, who are the major users of health services, will considerably increase in number. In Norway the number of persons over the age of 80 has doubled since 1970. Towards the year 2020 this number will increase further. The part of the population over the age of 90 will increase considerably. In general, there will be more heavy users of the health services at the same time as there will be fewer persons in the age group which can produce health services and contribute to the economic resources needed by the health services. In addition, an increased number of handicapped and chronically sick persons is expected (St. meld. (White Paper) No. 41, 1987-88).

As an answer to the increasing cost of running the institutions of the health services (hospitals, nursing homes), we will have a change towards greater emphasis on primary health service. In Norway we are already phasing over to more day care activity where staying time in hospital is reduced and in the nursing sector a transition to homebased care.

In light of these challenges telemedicine must be assessed as a tool for more efficient exploitation of available resources. Telecommunication will never replace the physician or other health workers involved in a patient relation. Instead, it gives a possibility of increasing the integration between various health services and in this way contributes to better care directed towards the patient.

From technological curiosity to economical benefit

The idea of using telecommunication for medical purposes is as old as the spread of the telecommunication means. Soon after the invention of the telephone experiments were made to transfer heart and lung sounds to a skilled specialist who could give an opinion of the state of the organ. The inventor of the electrocardiograph, Wilhelm Einthoven, started experiments with remote consultations via the telephone network (Einthoven, 1906). Also in Norway such possibilities were utilised. Haukeland Hospital established in the 1920's a service where ships at sea could consult physicians in hospitals via Bergen Radio in case of accident and sickness. It has ben said that the physicians not only contributed with diagnoses and proposals for treatment, but also complicated surgical operations were performed by help of instructions via radio (Rafto, 1955).

During the 1950's and 60's many individual experiments with medical services were carried out on the basis of telecommunication. Often it was enthusiasts with medical background who saw the possibilities as the teletechnology gradually developed. We may safely assert that those experiments were mainly directed towards the technology, even if medical and organising matters were on the agenda. The equipment used was poorly adapted to the services to be practised. The cost might be so high that the data obtained could not be generalised and lead to safe conclusions (Bashur and Lovett, 1977).

Gradually the starting point for development of telemedicine changed towards the solution of concrete medical problems. Such a field was supervision of physiological functions of crews in space ships (Pool, Stonesifter and Balasco, 1975). Another field was improvement of primary health services in areas with scattered population (Fuchs, 1979, Dunn and Higgins, 1984). Telecommunication was put to use for remote consultations and remote diagnoses and for distance education of medical personnel at remote locations.

With the linking up of teletechnology with data technology the horizon of telemedicine was appreciably extended in the 1980's. Within medical computer science a series of data programs and systems were developed of both administrative and medical varieties. Even if they were intended to take care of internal tasks in institutions, they laid the foundation for new and also improved older telemedical methods. As an example, digital picture processing has now obtained a central place in several telemedical applications.

However, at the same time it may be asserted that while the health services have been progressive in adaptation of advanced medical technology, far less attention has been focused on the use of telecommunication and information processing. Introduction and acceptance of this type of technology have been slower within the health services than in several other fields (AIM, 1992). This concerns the more administrative sides for personnel, institutions, and patients, but especially within medical treatment. This is in contrast to the fact that the health services have been very information intensive at all levels. As an example a hospital bed in Europe represents a yearly production of X-rays amounting to an average of 1 Gigabyte (France and Santucci, 1991).

During the 1990's the strongest driving force for development of telemedicine is the economic dimension. Viewed from one angle this is due to the challenges facing the health services, where greater efficiency in performing the health services can moderate the conflict between access to resources and the expectations and demands of the population. Information technology is regarded as an important tool for increased efficiency (World Health Organisation, 1988, Arthur D Little, 1992). On the other hand the health services in this perspective represent a considerable market for information technology (France and Santucci, 1991).

In Europe the economic driving force is clearly demonstrated by the two development programmes under EC direction concerning health services and telecommunication, by AIM (Advanced Informatics in Medicine) and the RACE (Research and development in Advanced Communication in Europe) project TELEMED. In both programmes the participants are a composition of research institutions, medical institutions and industry concerned with information technology.

In the TELEMED project the perspective is to find the problems emerging when medical experts communicate through a broadband network. Based on trials and experiments the experience is transformed into technical specifications regarding equipment for telecommunications and terminals. The objective is to produce commercial systems adapted to co-operation between medical experts within diagnosis and therapeutics (TELEMED 1991).

In the AIM programme objectives are clearly expressed to promote a more efficient co-operation within the health services through development of tools, techniques and practice about medical informatics and telecommunication with a common European foundation. A further objective is to prepare the European market and strengthen the competitive force of European industry within this field (AIM 1992).

Telemedicine in Norway

The Norwegian public health services are decentralised and based on the principle of treatment on the lowest efficient level of care. The primary health service is the responsibility of the municipalities while the counties are responsible for the hospitals. Each county has a central hospital and a varying number of local hospitals. The country is divided into five health regions. Each region has a regional hospital with the responsibility of taking care of special medical competence and treatment. On a national level there are also some hospitals to take care of particularly rare or complicated types of illnesses.

The hierarchical structure assumes co-operation between a series of units. This implies transfer of large amounts of information between the various levels. In the same way as for the rest of Europe, electronic processing of information is largely tied to administrative routines inside the institutions. The public health service lacks an integrated electronic information system. It is rightly asserted in several connections that management of information is lagging behind in time in relation to the demands created by the development of treatment of patients (Health region 3, 1988).

However, in one field the work with better resource utilisation through integrated information exchange has progressed; i.e. medical emergency reporting services. By law a common national emergency reporting service is to be established, which co-ordinates communication readiness for various medical levels and co-operating services such as police and fire service (Odelstings Prop. No. 26, 1988-89). The core of the communication system is a communication centre for acute medical needs on a county level, where the various telephone and radio services can be exploited for co-operation.

An example of a more classical incitement to telemedical thinking is the project "Telematics in the health service of Finnmark" When the idea was launched in 1986, the starting point was the lacking coverage of health personnel, long distances, and in general poorer health services in this county than in the rest of the country. The main ingredients of the project (Andersen, 1992) were video conferences for remote diagnoses, education and professional meeting activities between the county hospital and the University Hospital of Tromsø. The experience gained was satisfactory to a degree that the local health authorities have decided to include telematics in their strategic plans and to strengthen the co-operation between health services within and outside the county.

Telemedicine in North Norway

The largest effort within telemedicine in Norway is a project under the direction of Norwegian Telecom. Following the good result from an experiment with transmission of ultrasound pictures through the telecommunication network between the local health services at Jevnaker and Ullevål Hospital in Oslo (Andersen and Nordby, 1988), the project "Telemedicine in North Norway" was established. There are two reasons why the project was located in the northern part of Norway: One is the geography of that part of the country, scattered population and in many places poor heath services, especially for medical specialist services. Secondly, this area has a well developed infrastructure of telecommunication, especially networks for video conferences and video transmission (Nymo, 1989).

From the outset the project tried to incorporate the three dimensions of telemedicine, namely medical informatics, health services, and telecommunication. This has made the approach to the project rather complex. It ranges from development of technical equipment through participation in international standardisation work to assessment of questionnaires concerning the satisfaction of the patients with the telemedical services. The superior objective was to arrive at medically secure, technical, and organising solutions for the Norwegian health services. A joint approach to the problems was field trials where an approach crossing professional borders was taken care of through co-operation between the Norwegian Telecom Research (NTR), other research institutions, individuals and institutions in the health services. The most important collaborator for the field trials has been the University Hospital of Tromsø (RiTø).

The field trials can be characterised as explosive. Ideas around techniques and procedures have been developed in a real situation, and these have been further developed into equipment and routines. Thus systems for telepathology and teleradiology have been developed, systems which have been commercialised and which are currently in operation. Tests have been made within this area which confirm the fact that the systems render a satisfactory quality of medical services.

The field trials have also had a considerable educational effect. The trials have concretised the possibilities offered by information technology for the health services. Various participants from the health services have from their own point of view put information technology on the agenda as a solution of challenges in the health services. Thus, a structured effort, initiated by the Department of Health and Social Affairs, is in progress to standardise medical information transfer within the health services. A special centre for competence concerning information technology in the health services is established. This centre has, among other things, led negotiations for a framework agreement for services for the health sector based on electronic mailboxes. One triggering factor has been the work with transmission of assessment of samples from the laboratory to the recipient of the information. In the county of Nordland telemedicine is included by the authorities as an important tool to achieve a superior objective of more efficient hospital services. At last there is a clear tendency that the various medical disciplines take the initiative for new telemedical experiments. A special nationwide function within telemedicine is established at RiTø in order to take care of national competence in the field and to provide efficient use of telemedicine.

Simplified, the work span of the project can be divided into two axes:

Remote diagnosing can be described as a medical practice where a medical specialist diagnoses a patient based on teletransmitted information about the patient. Particular focus has been placed on information through pictures. Direct contact between the medical specialist and the patient depends on whether the specialist is in a clinical field (e.g. skin, psychiatry) or in a laboratory field (e.g. pathology, radiology). Remote consultation implies that a medical specialist confers with another medical specialist about particular difficult cases, interpretation of findings, etc.

The trials with remote consultation and remote diagnoses included in the project can be structured according to medical fields, the type of telemedical services involved and the various aspects of telecommunication.

In addition to the medical services practised during remote consultations, matters concerning education, instructions and co-operation between health institutions are also kept in mind.

Within electronic exchange and collection of information the following subjects are dealt with:

1. Mapping of communication structures
   
   The objective of mapping information handling and communication within various disciplines and various levels in the health services is to introduce information models as a foundation for the demands to be complied with for the aids to information and communication. Mainly, it concerns two types of information: patient information (patient case record, applications, requisitions, etc.) and operational information (economy, circulars, statistics, etc.).
   
   
2. Standardising medical document exchange
   
   Information systems in the health services must be characterised as isolated systems in view of their limited possibility of interplay. Transport of information between participants and further treatment by the recipient is thereby limited. The standardisation work is intended to harmonise the information handled by various data processing systems so that information from several systems can be integrated and compared. The second demand is a form of electronic handling that is accessible to all the communication participants. The project has participated in national as well as international standardisation work.
   
   
3. Sample analysis and laboratory communication
   
   To obtain practical experience with electronic information exchange, a system is made for the handling of sample analysis results from a clinical-chemical laboratory to the recipient of the information. Clinical-chemical laboratories are some of the most important communication collaborators for the primary health services. It is a stated requirement for more efficient laboratory communication. Experience from the work with laboratory communication is closely related to verification of specifications evolved through the standardisation work.
   
   
4. Electronic access to medical knowledge and experience
   
   Large amounts of knowledge are generated through research and practical work within medicine and related professional fields. The quality of health services depends on the professional qualifications of the health personnel. It is not a trifling challenge to keep oneself professionally updated. There are several electronic sources for medical information in the form of facts databases, literature databases and electronic conferences for particular professional fields. The project has been working with a system for medical information services (MEDIS) where emphasis is put upon making access to the information sources as simple as possible for the users. Among other things, this is achieved by making a uniform interface to the various information sources.

The challenge

As data technology has taken over from electromechanical equipment in telecommunication, the horizon for exploitation has been considerably extended. However, a condition is that data technology has a widespread use in the community, where it is used to systematise, store, file, and treat information. When this is the case, we have a technical foundation for collection, reception and treatment of information by help of telecommunication. Thereby, new fields for exploitation are found. It may be a long road from the fact that technical foundations exist to the realisation of new fields for exploitation. This is related to the need for social changes in the form of organising, work routines and roles. It is a challenge for the health services, the supplier of telecommunication and for the producers of medical technical equipment and medical information systems.

The challenges facing the health services make it necessary to try new methods for practising the services. The main problem in Europe, and even more so in the USA, is the rising cost involved with health services. Better utilisation of resources through extensive co-operation between participants is a more realistic solution than increased share of the society's expenses for health purposes. In this light more focus should be directed towards telemedicine in a fully organising and strategic perspective.

This implies that the field of telemedicine changes from a local or regional starting point with focus on loose concrete problems, giving poor coverage of specialist services in rural areas, to the making of a telemedical infrastructure that matches the general infrastructure of the health services. The structure can be based on the existing work sharing between the levels of the health services, but it must have enough flexibility to realise new patterns of co-operation. For example, there are many reasons why greater emphasis should be put on homebased rather than institutional care for the growing number of persons in need of nursing. Thus, the infrastructure must also include homebased care. As the sub-specialisation continues, it might be impossible for small nations to establish lasting professional environments on a national basis. Professional environments in the form of networks across national borders is one way to organise such services.

There are a great number of applications of telecommunication within the health services. Some are more important than others. An American investigation (Little, 1992) calculated the potential for the yearly reduction of costs for some application groups. The application group found to give the highest reduction of costs is electronic handling and transport of patient information. The investigation calculated that in the USA it is possible to save USD 30 billions (30,000,000,000) yearly by employing such applications. The potential for cost reduction by systematic use of video conferences for remote consultation and education was estimated to a yearly amount of USD 200 millions.

Systematic exploitation of applications assumes flexible possibilities for telecommunications. In today's pilot projects and other work within telemedicine, by and large the applications are realised in general teleservices in different networks. For some purposes this does not result in the best cost optimum solutions. At the same time users' choice of type of communication is limited. For many medical purposes where pictures are part of the information basis, there is a need to choose transmission rate according to a particular situation. In an acute case there are other demands for speed of connection and transmission than for routine examinations.

ISDN seems to give the necessary flexibility by using a combination of basic access and primary rate access. The primary health services' need for communication both to local hospitals and in the homebased care, basic access offering two 64 kbit/s channels (B-channels) in the great majority of cases give sufficient capacity for the applications we see today. For telemedical services between hospitals the flexibility will be secured by primary rate access (30 B-channels). In a complete "health network" it is also necessary to integrate mobile communication, especially in cases of catastrophes.

References