This document provides definitions and examples of telemedicine and e-health. It defines telemedicine as the use of telecommunications technologies to provide clinical care from a distance, and e-health as using digital technologies for health services and information. Case studies are presented on using telemedicine in minor injury units, ambulance services, multidisciplinary teams, and dermatology. E-health is discussed in terms of integrating information technologies into healthcare. Issues covered include ethics, economics, and factors for success. Further information sources are listed.

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

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

3. Definitions
Telemedicine
E-health

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

5. 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. 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. 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. 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. 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. TEIS one
• Starting point:
– "The use of Information and Communication
Technology (ICT) to deliver healthcare at a
distance"

11. 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. 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. 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. Characteristics of tm systems
• Interaction style
• Data types
• Equipment
• Action
• Patient numbers
• Duration

15. 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. Data types
• Text
– Patient notes
– Diagnosis
• Image
– X-rays
– Pathology slides
– CT/MRI/… scans
– Audio/video signals

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

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

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

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

21. Categories of telemedicine
HCP Patient HCP  HCP
CHARACTERISTICS: TYPE A TYPE B TYPE C TYPE D TYPE E TYPE F
Interaction Style Real-Time Real-Time Store/Fwd Store/Fwd Real-Time Store/Fwd
Data Types Multiple Multiple Data Multiple Multiple Data
Equipment Special Special Special General Special General
Action Direct Indirect Direct Indirect Direct Indirect
Number of
Patients
1 >1 1 >1 >1 1
Duration Short Term Long Term Short Term Long Term Short Term Short Term
LABEL tele-
medicine
tele-care tele-
monitoring
tele-health tele-review tele-referral

22. 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. Cornwall MIUs

24. Gosport MIU

25. 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. Dundee trial

27. 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. East Midlands cancer network

29. 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. 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. 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. 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/

35. e-health

36. 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. 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
1980 1990 2000 Jean-Claude Healy
May 2000
(Banks) (Health…)
Manufacturing Business Services Public Services

38. Are hospitals a thing of the past?

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

41. 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. Other issues
Ethics
Economics
Success factors

43. 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. 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. 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. 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. Further information

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

50. 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. 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. 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/