SIT EXPO 2004 – E-HEALTH CONFERENCE

1. SIT EXPO 2004 – E-HEALTH CONFERENCE CASABLANCA - 20 – 21 FEVRIER 2004 TELEMEDECINE EXPERIENCE TUNISIENNE DEVELOPPEMENT ET EXPLOITATION EVALUATION ORGANIZATION PROJETEE EVOLUTION VERS LA TELE SANTE Sit Expo – 2004 CASABLANCA – MAROC - Mongi MILED – Expert TIC – DG CIMSP

2. Video cam ISDN DEVELOPPEMENT ET EXPLOITATION Telemedecine application was identified in 1995 in the Health Telematics Plan Studies – (1996 – 2000) period. The first application was implemented in 1996 by Tunisian and French physicians working in children academic hospital of Tunis and in LaTimone hospital of Marseille France : * Exchange Medical Data Package : X Ray images, Medical documents and Informations about Patient * Remote Assistance : Telediagnosis, Teleconsulting, Teleassistance * develop research cooperation * Exchange some training Case -Supports EACH USER TERMINAL IS EQUIPPED BY : Hospital * A Basic PC with high quality screen 19" * A Network interconnexion TCP/IP Mode, using ISDN Network 128 Kb/s * Standard MS Office Tools * Internet Browser * Software Medical Document Management (Sigmacom) * Document Scanner * X Ray image scanner Scanner A3 Scanner A4 Printer Documents Video cam LAN

3. Video cam Scanner A3 Scanner A4 ISDN The second application was implemented in 1996 by physicians working in the anticancerous institute of Tunis and Lacassagne Anticancerous Hospital of Nice France * It completes the first experience by telepathology application and Videoconferencing application * Exchange complete medical data package : scans, X-RAY image , PATOLOGY ANATHOLOGY image, diagnosis, reports. * Real time monitoring of appliances (Microscope) * Medical document acces during the conference * Training and support informations • EACH USER TERMINAL IS EQUIPPED BY : • - Basic PC (Pentium) • - High Quality Scren 19" • - Standard MS Office Tools • - Network inter connexion on TCP/IP Mode : • * ISDN connxion 128 Kb/s speed for telemedicine applications (Transfer,monotoring) • * ISDN connexion 384kb/s speed for Videoconferencing • Internet Browser • - Conferencing equipment (Tv Monitor - Mobile camera, fixed camera, microphone, loudspeakers….) • - Conferencing software on H320 standard. • - Real time acquisition/monitoring Interfaces. • - Software medical document management (Mediolis). • - Image standard conversion DICOM3/JPEG - medical Peripherals (Scanners And Micoscope Medical Devices) – Telemedecine station Hospital Printer Documents Video cam LAN

4. THE TELEMEDECINE COMMITEE The Development Of Information Society over the world, The definition of a solid national policy on information technology in Tunisia The important telecomunication investment progress in Tunisia The Vertiginous growth of telecomunication technologies and multimedia systems The availability of computers capabilities. The positive telemedecine experience evaluation and sudden awarness of it benefits. Suggested to the Health Ministry to define Telemedicine policy : * For defining strategy and keeping of the plan achievement a national committee of telemedicine was constitued by minister decision on 15 May 1996. MEMBERS ARE : * General Director of Health - Public health Ministry * Representative member of Science Research and Technology secretary of state. * Representative member of Informatics and Internet secretary of state. * Representative member of Public telecommunication Operator : Tunisia Telecom Working partner is the health ministry informatics centre. Sit Expo – 2004 CASABLANCA – MAROC - Mongi MILED – Expert TIC – DG CIMSP

5. TELEMEDECINE APPLICATION : The Telemedecine network is constitueted by : 3 FRENCH SITES : Acces mic hospital - Latimone Marseille - Lacassagne Nice - CHU Grenoble 4 SPECIALISED HEALTH CENTRES IN TUNISIA : - Children Hospital - Tunis -  Cancerous Institute - Tunis -  National Neurology Institute -  National Orthopedic Institute 3 GENERAL ACADEMIC HOSPITALS -  Rabta Hospital -  Charles Nicolle Hospital -   La Marsa Hospital 3 REGIONAL HOSPITALS : -  Le Kef Hospital – Western North -  Gafsa Hospital – Western Saouth -  Gabes Hospital – Eastern Saouth THE APPLICATION ARE : TELERADIOLOGY – TELEPATHOLOGIE AND VIDEOCONFERENCING

6. Video cam Scanner A4 ISDN Technical Architectue of a Telemedicine Solution : Exemple : TELERADIOLOGY Hospital 1 Scanner A3 3x 128Kb Printer Hospital 2 Router Documents Video cam ISDN – 1x128Kb Imagery equipement RJ 45 LAN Router Imagery equipements LAN Sit Expo – 2004 CASABLANCA – MAROC - Mongi MILED – Expert TIC – DG CIMSP

7. TECHNICAL CONSIDERATIONS Adoption of commun standards : a must for cost effective exchange of any information : - Facilitate ther capturing , sase communication and structured management - TCP/ IP Network Protocol - DICOM 3 : Direct aquisition of image equipement protocol - HL7 : Direct Acquisation off Laboratory Results protocol - H320 – H323 : Videoconferencing protocol to provide voice – Data and Video - NTSC, PAL , SVGA : format Video - G711 – G722.1 Standared Audio - T120 : Remote sharing application protocol - JPEG – MPEG : Imaging Format Protocol - HTML : Document Format Protocol This to satisfy : Compatibility and Interoperability between diffirent systemS Adoption of image data and uniformed security technique - User : Profile and Institution - Content : Primarely informations and knowledge - Usage : Management and governance - Technological applicants : Computing, Networking and Telecomunication

8. APPLICATIONS REPARTING NEW STRATEGY TO HAVE PRIORITY Defined in Health Telematics plan studies for 2001-2005 period. Consist to go on national healthnet over which would cooperate on sharing patient records. 4 Academic specialized hospitals : * Tunis Children Hospital * Tunis Anticancerous Institute * Tunis Orthopedic Institute * Tunis Neurological Institute 8 General Academic hospitals: * Charles Nicole Hospital in Tunis * La Rabta Hospital in Tunis * Aziza Othmana Hospital in Tunis *Mongi Slim Hospital in Tunis *Farhat Hached Hospital in Sousse * Fattouma Bourguiba Hospital in Monastir * Tahar Sfar Hospital in Mahdia *Habib Bourguiba Hospital in Sfax

9. 2 Regional hospitals situated in Western North: *Le Kef Regional Hospital *Jendouba Regional Hospital 2 Regional hospitals situated in Western South : * Gafsa Regional Hospital * Tozeur Regional Hospital 2 Regional hospitals situated in Eastern South : * Zarzis Regional Hospital * Gabes Regional Hospital cooperation with European institute * 4 French Academic Hospitals : Marseille – Nice – Grenoble - Toulouse * 1 Belgium Hospital: ERasme Hospital * 1 Italian Hospital : ST.Rafaelle Hospital Rome All these organizations are equipped by *Teleradiology solution *Telephatlogy solution *Videoconferencing solution

10. ISDN • ERasme Hospital • Bruxelles ALGERIA { Tunis Jendouba Le Kef WESTERN NORTH Sousse Sfax { } Gafsa Tozeur Grenoble WESTERN SAOTH Zarzis Gabes EAST SOUTHERN Purpan Toulouse Hospital La Cassagne (Nice) LYBIA Latimone Marseille ST.Rafaelle Hospital Rome Sit Expo – 2004 CASABLANCA – MAROC - Mongi MILED – Expert TIC – DG CIMSP

11. SOUSSE MONASTIR 1 1 1 1 1 1 1 1 1 3 1 1 2 1 1 1 36 2 2 1 1 1 Hospital and Medecine Universities Health Map 15 Acadimic hospitals 3 Regional hospitals 1 Medecine Faculty 2 Hight School of health Science And Technologies Bizerte TUNIS 2 Acadimic hospitals 1 Regional hospitals 1 Medecine Faculty JENDOUBA BEJA NABEUL ZAGHAOUN LE KEF SELIANA 1 Acadimic hospitals 2 Regional hospitals 1 Medecine Faculty 1 Hight School of health Science And Technologies KAIRAOUN KASSERINE MEHDIA SIDI BOUZID SFAX 2 Acadimic hospitals 3 Regional hospital 1 Medecine Faculty 1 Hight School of health Science And Technologies GAFSA ALGERIE DJERBA TOZEUR GABES ZERZIS MEDNINE Regional hospitals KEBILI BENGERDEN TATAWINE LIBYE

12. OBJECTIVES : Extend professional services and uses of equipment to remote and rural areas Raise the level of diagnosis services Contribute to the equity of access by all the population to quality care services Avoid unprofitable evacuation of sick patients to academic hospital from regional hospital Increase the productivity of the daily work of health professionals or specialists Provide powerful collaboration tool for simultaneously staff work when the case concern a critical situation or a critical policy matter Improve the support on diagnosis and proposed treatment (Neurology emergencies - Orthopedic emergencies…). Provide interactive Video conferencing capabilities and teleradiological reading sending data and Images Plan the telestaff and keep practitioners and specialists in touch with the last developments. Enhance researches and medical scientific publications accompanied by Image and patient documents. Develop a large health information system. Spread the medical education to any member of network scattered over academic, regional hospitals or local care centres.

13. EVALUATION  Encourage the equity through offering same health utilities of all citizens. Telemedecine applications will : Encourage physicians, specialts and young practitioners to work in the long way region in the regional and local hospitals. Ensure a sustained training and experience for all medical sector. Avoid the unprofitable patient transport and unless examination (X-RAY, pathology, loboratory analysis) Enhance the medical research and the participation in international research programs Permit to develop training to have access to universal knowlege bases Au vu des objectifs arrêtés Partage des connaissances entre praticiens

14. Meilleur utilisation des équipements médicaux lourds par : Le Parrainage des HR par les CHU Les Télé-staffs Le Téléenseignement Il a été constaté pour les sites équipés 13 Sites de Télé-radiologie et 2 Sites de Télé-pathologie : Un Faible volume de données transférées Une Faible communication entre services hospitaliers l’organisation n’est pas au point l’aspect juridique n’est pas traité Les coûts des communications sont élevés

15. Les applications de Télé-médicine ne sont pas ciblées : le télé-diagnostic dans les cas d’urgence le télé-enseignement la télé-consultation pour avoir une seconde opinion Le téléstaff Le plan de charge prévisionnel n’existe pas Organisation projetée: Pour palier au manque de spécialistes à l’intérieur du pays et dans les zones rurales et pour développer le travail en équipe et la recherche. Créer un Centre National de Telemedecine au Service des Praticiens éloignés, dotés de stations complètes et d’un réseau de communication performant : Pour traiter et donner un avis de Senior dans le cas des urgences graves ( accidentés de la route, accidentés du travail, attaques cardiovasculaires et autres….) Pour tenir des telestaffs auquels prendront part les medecins exercant dans les zones éloignées.Ces Téléstaffs concernerait la medcine de pointe et des cas difficiles ou atypique.

16. Pour assurer un service régulier de téléenseignement. En temps réel En temps différé Pour gérer un service de Bibliothèque Virtuelle Médicale Pour assurer La veille Technologie dans le domaine de la médecine de pointe Les Pré requis Technologiques Communication aisée de Bout en Bout en large bande Echange d’information multimédia Internet - Fax - Téléphone ISDN - Fibre optique – Satellite - ADSL Utilisation des divers technologies de communication Support Technique (Installation – Maintenance – Sécurité ) Choix des équipements (état de l’art) Fiabilité des techniques de Compression

17. Les Pré requis Organisationnels Disponibilité 7x24, nuits, week ends Résolution des problèmes liés * aux Gardes * à la Facturation * à la Transmission des Comptes Rendus * à l’évaluation et à l’élaboration des Statistiques d’Activité Responsabilité Civile * Certification et Confirmation des médecins * Authentification des Comptes Rendus Réglementation des honoraires –(vacataires ou heures supplémentaires) Par acte de base Contrat annuel

18. Arrêter la méthode d’estimation des coût en tenant compte de : Des Investissements en équipements au niveau du Centre de Télémédecine et du Centre demandeur Coût de la maintenance Coût des communications Coût de la logistique administrative Evaluation de l’activité Volume des cas Types des cas Nombre d’image par cas Temps moyen nécessaire par cas Satisfaction des usagers Qualité des images (excellente, bonne, moyenne) Exactitude des diagnostics

19. Fiabilité des techniques de transmission et de réception des images Taille des images : 1 image de médecine nucléaire : 64.000 bytes = 16 Ko 1 image Mammographie : 16 000.000 bytes = 16 Mo Utiliser des techniques fiables des compressions d’images Arrêter une technique et une politique d’archivage: Au niveau: * du transmetteur (expéditeur) * du Receveur * des Deux Archivage total ou sélectif des images Pendant combien du temps * Sous l ‘aspect médical * sous l’aspect légal

20. Type d’archivage: On line (accès rapide) Sur disque: RAID Coût de l’archivage élevé Off line (accès lent) Bandes – CDS – disque amovibles Coût de l’archivage faible

21. EVOLUTION VERS LA TELESANTE

22. Internet vs Telemedicine : a Web of solutions… Content Distance Teaching Medical Data Base WirelessASP Network Platforms Rural Health Care Patient Discussion rooms Health Care Personalization Telemedicine Tele- Consultacy InformationServices Home Care Portals Medical Libraries Gaming …each with a personalized solution Tele- Radiology Doctor to Patient Messaging

23. NOUVELLES OPPORTUNITES POUR LA TELESANTE DUES AU MOBILE • LARGER DIFFUSION OF • LARGER DIFFUSION OF E-HEALTH APPLICATIONS E-HEALTH APPLICATIONS FOR E-LEARNING, EASIER FOR E-LEARNING, EASIER CLINICAL INFORMATION CLINICAL INFORMATION RECOVERY, ETC, RECOVERY, ETC, • PATIENTS TRACKING • PATIENTS TRACKING (MONITORING OF VITAL (MONITORING OF VITAL SIGNS, ANYWHERE, ANYTIME) SIGNS, ANYWHERE, ANYTIME) • PERSONAL CARE IN NORMAL • PERSONAL CARE IN NORMAL AND IN EMERGENCY AND IN EMERGENCY SITUATIONS SITUATIONS • E-HEALTH DEPLOYMENT IN • E-HEALTH DEPLOYMENT IN DISASTER AND EPIDEMIC DISASTER AND EPIDEMIC SITUATIONS SITUATIONS

24. CONCLUSION The telemedecine is a great future technology Regarding on the personnel disponibilities, the organisations capacities ,the budget ressources and quality of international health cooporations 3 Key words : * Canalizing * Guiding * Optimizing The trends of the new telecommunication technologies gives us : * More services abilities * More security * More quality in life The benefits for developping countries are largely proved by improving health care services, medical researches and reducing costs

25. Thank you for your attention