Telemedicine & e-Health

Nicolette de Keizer

Dept Medical Informatics University of Amsterdam

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

Outline

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

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

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)

Calling names

• Virtual Outreach

• Hospitals Without Walls

• Reaching The Unreached

• Bridging the Urban-Rural divide

eHealth vs telemedicine

eHealth

Telemedicine

Quality assurance

• Code of behaviour• Certificate of (trusted) third party

Code of behaviour: e-Health code of Ethics

1. Sincerity: objectives, financial interest

2. Honesty: no misleading information

3. Quality: correct and recent information with acknowledgement

4. Informed consent: use of data

5. Privacy: carefull use of data

6. Professional: professional care

7. Responsible care provision

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?

Example NL

www.artsennet.nl, 20/3/05“I didn’t know it would go so fast”

Disciplines to internet physician

Minister surprised about internet development

Drug prescription via the internet should be prohibited

Agree

Neutral

Disagree

55%

44%

1%

Statement

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.

Teleconsultation

• Videoconferencing (real-time)• Store-and-forward

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

Which settings benefits from telemedicine?

Only large distance

Also small distance

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

Mobile TMU

Telemedicine – small distances

• Jail• Shy, socially

challenged people• Pressure of work,

shortage of personell• Nursing homes

Impact on health care

• Quality of care• Access to care• Cost of care

Cell-life

Impact on health care

Quality of care– Diagnostics– Treatment (AIDS patients in

South Afrika,Cell-life)– Patient satisfaction (early

treatment, no live physician)

Outcome measures Quality of Care

• Diagnostic accuracy• Delay in treatment• Preventable consultations• Adherence to medication• Quality of life• Mortality and morbidity

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

Outcome measures Access to Care

• Patients satisfaction• Timeliness disease detection• Adherence to (treatment) advice

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)

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?

Other outcome measures

• Physicians satisfaction• Technical aspects: quality of photo’s,

performance of application• Usability of the service

Factors of success and failure

• Success:– 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

• Tele-Radiology

• Tele-Cardiology

• Tele-Pathology

• Tele-Ophthalmology

• Tele-Dermatology

• Tele-Psychiatry

• Tele-Surgery

• Tele……..Anything

Types

An example of a study inTeledermatology

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

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)

Conventional care versus teledermatologie

GP Dermatologist

Dermatologist

patiënt

patient

info

Info + images

advice

patient35%

Conventional care

Teledermatology

GP

Less referals?Less costs?

PERFECTD

• Primary care Electronic Referrals: Focus on Efficient Consultation using Telemedicine in dermatology

• Virtual consultations between GPs and dermatologists

Website

KSYOS TDCS®

PERFECT D: outcome measures

– Unnecessary referrals– Patient satisfaction– Costs savings

PERFECTD methods

• Multicentre cluster RCT • Randomisation GPs

– Control group = conventional care / referral– Intervention group = teledermatology

• All patients go to live dermatologist• Cost minimizing study

Less consultations?

Live dermatologist

Patient referred to dermatologist Control group

Interventiongroup

Description signs + digital photos to derm

Teleadvice + intervention GP

Dermatologist decision:Consultation necessary or

unnecessary

• Societal perspective• Modelling cost components

– GP– Dermatologist– Programme costs (camera, software, training, etc.)– Patient– Employer

• Cost value input: PERFECTD RCT, Handbook, experiment, expert opinion

• Monte Carlo simulatie (sensitivity & scenario analyse)

Less costs?

Cost Benefit

• Costs + 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

Cost model

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: 345.3 Euro (95%CI, 242.5 – 461.2) – Teledermatology: 354.0 Euro (95%CI, 228.0 – 484.0)

Scenario analysis

Unneccesary referals >17% GP TD time <7.5 minutes

Scenario analysis

Distance to GP < 55km Distance to dermatologist

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

…Questions?…