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From Telemedicine to E-Health

Telemedicine did not experience the breakthrough in the 1990s that many had predicted. The revolution has simply been put on hold, say experts, not cancelled.

Norbert Sparrow

Ricky Richardson, pediatrician and chairman of the UK Telemedicine Association (Cowbridge, Wales, UK), is a man on a mission. "The traditional healthcare structure hasn't changed in 6000 years," he says, noting that the pyramidal structure was conceived by the Egyptians in 3000 bc. "In any other consumer industry, the service is delivered to the customer," says Richardson. "The medical profession has ruthlessly exploited patients for 6000 years, and it is time that patients fought back." Telemedicine, and more precisely e-health, will be their arms, he adds.

Pundits have been predicting for at least 10 years that telemedicine will dramatically transform the delivery of healthcare. Although there have been a number of promising developments, the concept has failed to achieve critical mass.

Most of the applications in use today, according to the Telemedicine Research Center (Portland, OR, USA), fall under two headings: store-and-forward technology for transferring digital images from one location to another and two-way interactive television, which enables real-time consultations. The US military has funded substantial R&D in the field, notably in the development of robotics that could support remote surgical procedures. Technology, by and large, is no longer a barrier to the deployment of telemedicine. "I'm not sure anyone completely understands why telemedicine has not developed more rapidly," says Jamil LaHam, general manager of the cardiopulmonary division at Meridian Medical (Belfast, UK), which has developed ECG devices that transmit results by phone. He and several other industry experts are convinced, however, that history will not repeat itself.

One encouraging sign, according to Richardson, is the European Commission's allocation of >1.6 billion in the Sixth Framework R&D budget to health activities. (Richardson is chairman of the working group on e-health and telemedicine within the European Health Telematics Association, which is funded and supported by the commission.) "You will see the emergence of a pan-European healthcare system," he says, "and its implementation will be made possible by telemedicine or what is increasingly referred to as e-health."

Telemedicine is a key element of the "pillars of e-health," says Richardson, but it is not the whole structure. "The first pillar is teleconsultation, the clinical application that enables a healthcare professional to access specialist skills," he explains. An emphasis on education via the Internet, both among healthcare professionals to promote a standardized level of knowledge across Europe and among consumers, constitutes the second and third columns. The fourth pillar is the establishment of a database: "the longitudinal use of healthcare event information to build a personalized lifetime health record . . . that will allow the monitoring of adverse events as they occur," explains Richardson. Much of this scenario relies on the dissemination and deployment of remote services—the establishment of global epicentres of excellence, national and regional e-prescription services, and home-care monitoring. "And that is the fifth column," says Richardson, "an ocean of opportunity that is available now that you have an IT-enabled healthcare environment." Ultimately that is what will shake off the yoke of 6000 years of exploitation, he says. "That's when you can begin to tear down the brick-and-mortar hospitals, because you no longer need as many disease palaces for healthcare transactions," he argues. He likens the process to how ATMs changed the relationship between banks and customers.

Decentralized Healthcare

As ATMs migrated from the inside to the outside wall of the bank and then to various public places, bank branches became redundant. Many were shut down, because banks were able to deliver services to customers at more convenient locations, says Richardson. The same pattern will apply to capital-intensive hospitals, he claims, and this will be especially beneficial to developing countries.

"In developing countries with mobile phones, there is no reason not to move medical data over GSM networks and to set up ambulatory services, rather than waiting for landlines to be put in place," he says. Richardson finds it especially galling that industrialized nations have traditionally promoted an antiquated healthcare model in developing countries, rather than to leapfrog the model using e-health tools. "Hospitals consume 99% of these countries' healthcare budgets, and they have no resources left over to treat patients."

By all accounts, the technology required to achieve these goals is readily available. Even the thorny issue of enabling devices to speak to each other is being resolved (see the accompanying sidebar describing a pilot project spearheaded by Germany's Fraunhofer Institute). But some obstacles remain, notably the perception that high-tech solutions engender swollen budgets, and a well-entrenched resistance to change among healthcare professionals.

"The technology is the easy bit really," says Keith Freeman, chairman of tds (Telemedicine) Ltd. (Manchester, UK), a company specializing in telemedical solutions for the treatment of dermatological and other conditions. "The difficulty resides in modifying the way that traditional healthcare systems are used to doing things. I see this as an evolutionary process, rather than the quick flip of a switch overnight," Freeman adds.

"Telemedicine will grow," says LaHam, "and that growth will be driven by the cost savings opportunities that it represents." Monitoring recovering patients at home rather than keeping them in the hospital can save substantial amounts of money without compromising patient safety, according to LaHam. "For someone admitted under emergency conditions, the average hospitalization time for congestive heart failure is two to three weeks," says LaHam. "It has been shown that if you monitor patients carefully and appropriately adjust the medication, you could avoid several admissions a year, each of which costs in the neighborhood of US $10,000. Equipping a patient with telemedicine devices for home monitoring is really quite economical," says LaHam.

Richardson fervently agrees, and he believes that the potential cost savings that e-health solutions represent will kick-start a new healthcare paradigm. "In the past, comparisons were made between a group of patients treated by means of telemedicine versus another group managed the traditional way, and naturally the first group ended up being more expensive because of the technology investment," says Richardson. "But once you remove the hotel component from the hospital, you erase 60% of the cost. If you start dismantling the bricks and mortar and radically reforming healthcare delivery, then you start to see a very different macroeconomic picture. That's when even the grey-suited mandarins at the treasury begin to take notice," he adds.

Which leaves one final obstacle: the "inherently conservative" medical professionals, to quote Richardson. He places his hope in young people beginning their careers. "When you talk to the young doctors, the prospect of working in a non-IT environment is such an absurd prospect," he says. "My big worry is that we are not redefining undergraduate medical and nursing curricula. We have a new generation of professionals who need to be trained to operate in an IT-enabled environment, and that is not the case right now," says Richardson.

Power to the People

Fortunately, patients are more open to change than their healthcare providers. In fact, given the opportunity, they will embrace e-health, according to Freeman. That has been his experience providing dermatology services through his company, tds.

One-third of the population of North America and Western Europe has significant skin disease at any given time, says Freeman. "It can be extremely difficult matching demand to available services in a geographical area. When we introduced our service to Manchester in the UK, the typical waiting period to see a specialist was 18 months. It took us seven weeks to get that down to an average of 17 days," says Freeman.

The days of forcing the patient to travel, often some distance, to take up a few minutes of the specialist's precious time are numbered, concurs Richardson. "The point of interface is moving out of the hospital and into the retail and home environment. It's happening as we speak," says Richardson.

Photo Courtesy of Fraunhofer Institut Biomedizinische Technik

The Wireless Hospital

By isolating the communications module from a medical device, Penell is able to speed up the validation process for OEMs.

"Penell is developing new products for home monitoring use in which [the wireless technology] Bluetooth is used as a communication interface with a standard GSM phone or General Packet Radio Service," says managing director Bjarne Flou. In either case, "the mobile phone acts as a bridge to the Internet, opening up a new world of opportunities for on-line data exchange using standard low-cost technologies," he explains.

Penell, which specializes in hardware and software development, was recently acquired by Danish telecommunications company RTX. It has been given a mandate, according to Flou, to focus on development and design projects for the medical sector.

Reliability in Question

Although some engineers question the suitability of Bluetooth technology for use in medical applications, Flou is unruffled. The pertinent issue, he maintains, is the suitability of wireless technology in general for some medical applications. "From a medical perspective, it may pose problems under special circumstances," says Flou, who adds that wireless technology may never be reliable enough for critical applications. "But there are many other applications where a wireless technology such as Bluetooth is perfectly adequate," he adds. He cites data exchange, which is not time critical, as one area that has tremendous potential.

The use of wireless technology in an intensive-care unit was showcased by Colorado MEDtech at the recent MD&M East show.

Flou is understandably tight-lipped about current projects at Penell, but he notes that the firm has found a way to bypass validation of communication software used in a device. "Validation of medical devices can be a source of considerable delays," he notes, "and it is especially troublesome when you introduce upgrades." Penell has isolated the communications module from the medical device in compliance with the Medical Devices Directive.

Penell's capabilities include analogue and digital hardware development, embedded systems, integration of Bluetooth technology into embedded products, and battery-powered devices and products. It has been involved in the development of approximately 150 products including a battery-powered microprocessor-controlled device designed to monitor patients during transport.

Connectivity on Display

One of the more compelling exhibits at the Medical Design & Manufacturing East Exposition and Conference in New York City in June showed the use of wireless connectivity technologies in an intensive-care-unit setting. A communications technology platform that monitors and controls vital signs units, IV pumps, and other devices was the centerpiece at the booth of Colorado MEDtech, a supplier of advanced medical technology outsourcing services and imaging products.

"We were demonstrating the capability not only of transmitting and receiving medical device data through a wireless connection," says programme director Jerry Klintz, "but also the transmission of commands back to those devices." Klintz notes that there are still some security and safety issues that must be resolved before this technology can be made generally available, but, he adds, "we are on the verge of succeeding." With the Chronicle as a predicate device, says Klintz, the technology is ready to take off.

At the stand, Colorado MEDtech also displayed its Link It technology, which enables connecting new and legacy devices to the World Wide Web to allow remote software upgrades and access to clinical data. "It converts protocols from legacy instruments via an RS-232 connection into a packetized 802.EEE Ethernet. Then, we can add a wireless connection, if required, or put it straight on the Web," says Klintz. The company has developed custom versions of the product for use with existing instruments. It is also currently developing the hardware and software for an electronic plug-in diagnostic module for an electronic handheld information device.

Fraunhofer Institute Monitors Pilot Telemedicine Project

Although multiple devices with telecommunications capabilities are available for homecare applications, they are often not compatible with each other. The Fraunhofer Institut Biomedizinische Technik, Health Telematics Group (St. Ingbert, Germany), has developed a communication platform for home-based telemedicine applications that allows devices to talk to each other.

The PGS Homecare Platform is built with an open architecture and accommodates equipment from different manufacturers to provide a range of monitoring capabilities. The medical data can be securely transmitted from the patient site to a remote location staffed by healthcare professionals. A field trial was initiated with approximately 20 patients recovering from strokes in Germany's Saarland region in 2000.

The modular telematic platform is equipped with drivers for inputting blood pressure, ECG, pulse oximetry, blood glucose, and medication reminder devices. Output can be transmitted via a simple phone line or, in more advanced systems, an ISDN line for simultaneous transfer of monitoring and video signals. Standard TCP/IP protocols are used. Interoperability was achieved through the use of XML Internet technology to structure patient data, notes project manager Stephan Kiefer, a computer engineer who was responsible for the technical development of the platform.

"Although compatibility represented a challenge, the technology is generally available," says Kiefer. "One of our biggest challenges involved the user interface." Fraunhofer researchers focussed their efforts on ensuring that patients, whose mobility may be diminished, would be able to operate the patient station, he says. At the other end of the exchange, questions were raised about the ability of healthcare personnel to provide appropriate services. "Do they have the time to devote to videoconferencing, to monitor the vital signs data, and so forth?" asks Kiefer. The answers to those questions will be forthcoming when the programme is completed at the end of this year.

The other huge obstacle to the deployment of a system of this type, according to Kiefer, is reimbursement. "Patients in Germany are not willing to pay out of pocket for this technology," he says, and the government has taken a cautious attitude. Consequently, Kiefer is not optimistic that the platform will be adopted by the German healthcare system in the foreseeable future. He does hold out hope that a company will see the benefit of this turnkey platform and commercialize it elsewhere, once the pilot programmes are completed.

"We still have to show that the patient benefits from this technology and that it can save money in the long run," says Kiefer. "Our current sampling of patients is not enough to do this. We will need to plan a much larger project with more than 200 patients once this study has been completed."

Copyright ©2001 European Medical Device Manufacturer