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Telemedicine & e-Health

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

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Telemedicine & e-Health

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  1. Telemedicine & e-Health Nicolette de Keizer Dept Medical Informatics University of Amsterdam

  2. 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

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

  4. 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

  5. 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)

  6. Calling names • Virtual Outreach • Hospitals Without Walls • Reaching The Unreached • Bridging the Urban-Rural divide

  7. eHealth vs telemedicine eHealth Telemedicine

  8. Quality assurance • Code of behaviour • Certificate of (trusted) third party

  9. Code of behaviour: e-Health code of Ethics • Sincerity: objectives, financial interest • Honesty: no misleading information • Quality: correct and recent information with acknowledgement • Informed consent: use of data • Privacy: carefull use of data • Professional: professional care • Responsible care provision

  10. 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?

  11. Example NL www.artsennet.nl, 20/3/05 Statement Drug prescription via the internet should be prohibited Disciplines to internet physician Agree 44% Neutral 1% Disagree 55% Minister surprised about internet development “I didn’t know it would go so fast” March 2005

  12. 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. March 2000

  13. Teleconsultation • Videoconferencing (real-time) • Store-and-forward

  14. 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

  15. Which settings benefits from telemedicine? Only large distance Also small distance

  16. 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 Telemedicine – large distances • Developing countries • Army • Places hard to reach • Disasters • Space

  17. Mobile TMU

  18. Telemedicine – small distances • Jail • Shy, socially challenged people • Pressure of work, shortage of personell • Nursing homes

  19. Impact on health care • Quality of care • Access to care • Cost of care

  20. 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)

  21. Outcome measures Quality of Care • Diagnostic accuracy • Delay in treatment • Preventable consultations • Adherence to medication • Quality of life • Mortality and morbidity

  22. 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

  23. Outcome measures Access to Care • Patients satisfaction • Timeliness disease detection • Adherence to (treatment) advice

  24. 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)

  25. 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?

  26. Other outcome measures • Physicians satisfaction • Technical aspects: quality of photo’s, performance of application • Usability of the service

  27. 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

  28. Types • Tele-Radiology • Tele-Cardiology • Tele-Pathology • Tele-Ophthalmology • Tele-Dermatology • Tele-Psychiatry • Tele-Surgery • Tele……..Anything

  29. An example of a study inTeledermatology

  30. 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

  31. 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)

  32. Conventional care versus teledermatologie info patient patient Conventional care Dermatologist GP Teledermatology GP Info + images Dermatologist advice patiënt 35% Less referals? Less costs?

  33. PERFECTD • Primary care Electronic Referrals: Focus on Efficient Consultation using Telemedicine in dermatology • Virtual consultations between GPs and dermatologists

  34. Website KSYOS TDCS®

  35. PERFECT D: outcome measures • Unnecessary referrals • Patient satisfaction • Costs savings

  36. PERFECTD methods • Multicentre cluster RCT • Randomisation GPs • Control group = conventional care / referral • Intervention group = teledermatology • All patients go to live dermatologist • Cost minimizing study

  37. Patient referred to dermatologist Control group Live dermatologist Intervention group Description signs + digital photos to derm Teleadvice + intervention GP Dermatologist decision: Consultation necessary or unnecessary Less consultations?

  38. Less costs? • 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)

  39. 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 Benefit

  40. Cost model

  41. 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)

  42. Scenario analysis Unneccesary referals >17% GP TD time <7.5 minutes

  43. Scenario analysis Distance to GP < 55km Distance to dermatologist

  44. 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

  45. …Questions?…

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