Case study:
Telemedicine
IN 364
19. mars 2003
Margunn Aanestad
What is telemedicine?
A wide variety in technologies, use areas,
organisational complexity, criticality, etc.
Telemedicine ranges from:
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second opinion on digital images attached to
an e-mail message
to real-time advice during emergency surgery
Examination, treatment, monitoring,
care and administration of patients, and
education of staff and patients
using technologies that allow access
to expertise regardless of where the patient,
expert or the information is located.
Examples
General practitioner in Alta communicates with ENT
specialist in Tromsø, using ISDN videoconference +
endoscopy (since 1992)
Teleradiology: Troms Militære Sykehus transmits all
images to Tromsø (in 1997: 7857 patients)
”Born on Broadband”: pregnancy controls, ultrasound
images transmitted from Gravdal (Lofoten) to Bodø.
Patient-oriented and homecare services, e.g. parents to
children with echsema may communicate with specialist.
Babies with ”murmurs” on the heart sound, digitalised
sound transmitted and evaluated by specialist.
Specialists’ network (pathologists, oftalmologists etc.)
Interesting issues
Screening of patients, reduce no. of referrals,
reduce waiting time and resource use.
Transfer of competence (often from center to
periphery).
Distribution of risks and responsibilities (general
practitioner or the expert who advices?)
Confidentiality of sensitive information
Integrity of information (e.g. quality of
transmitted images)
Which country’s law applies in a cross-border
consultation?
Challenges and barriers
Practical issues, e.g. technical competence,
availability of support personnel, building space
etc.
Legal issues (security, confidentiality, risk)
Organisational, how shall these services be
organised? Dedication of resources, payment for
services etc.
Professional standards, e.g. what is a safe level
of image quality?
Economic, who will pay for equipment, network
usage and manpower?
Status
Some well-working applications
Many ”dead” pilot projects
Concern about how to go from pilots and
research projects into routine use and
mass deployment of the technology.
Relevance for Systems
Development?
A complex and challenging case where the
technology is new (immature) and open
(generic). The goal is not well defined, and so
the prospective use areas and users are not
defined. The health care sector & organisations
are large, complex, and demanding. Resource
constraints and criticality of work tasks makes it
unsuited for experimentation. Still radical
restructuring and improvement is expected. How
can one approach such a task?
Evolutionary and experimental
In such cases: iterative development is the only
way forward
Must be learning-based:
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Learn from experience, see new problems and new
opportunities, further developing technology and
organisation
Design and re-design in use, by users.
Design encompass much more than the
technology itself (changed work practices,
expanded professional knowledge, new
organisational forms, new legislation etc.)
”The uphill battle of evolution”
Dilemmas
Disadvantaged starting point
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Lacking ”proof” of effects
Scarcity of resources (time, money, devotion)
Little management support
(for some use areas:)no perceived need
Low tolerance for disturbances and faults
Today:
Two telemedicine case that illustrates this
dilemma and how it can be handled:
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MobiMed (ambulances in Østfold) (Master
thesis, Nina Mikkelson, feb.2002)
Surgical telemedicine in Oslo (RH – US)
(From my own PhD work 1998-2002)
The DIMedS project
”Development of Interactive Medical Services”
Telia, Ericsson, Rikshospitalet, Ullevål and UiO
(Informatics): cooperation 1997-1999.
Exploratory development of broadband network
technologies for surgical telemedicine (minimalinvasive surgery)
34 Mbit/s ATM network between the two
hospitals, MPEG2 (realtime) video/audio trx.
Starting surgical telemedicine
Planned usage: demonstrate new
procedures to other surgeons
Initial interest, but constraints on viewers’
participation due to local workload. Result:
not very much use of RH-US link
Wanted to increase no. of transmissions
Wanted to get experience with use (learn)
Wanted to build support within hospitals
for later purchase/extensions
Detours and stunts
Not just surgical telemedicine:
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Radiologists , medical students and teachers,
ear/nose/throat specialists, nurses
Not just clinical procedures, but also lectures,
discussions, meetings, seminars and demonstrations)
Such transmissions might be perceived to miss
the target, be deviation from the project plans.
We argue that they were necessary and useful
”detours” in order to reach the goal (which in
turn were changed and influenced by the
detours and the new participants)
Mobimed – Østfold county
The need for telemedicine
For myocardial infarction (hjerteinfarkt)
treatment should be given within one hour
Time delays:
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From patient becomes ill until ambulance
arrives
Transport to hospital
Time spent within hospital before treatment is
started: transport from ECU to Heart ICU.
(”Door-to-needle time”)
The Mobimed ”project”:
Some milestones (1)
1996: PW (a doctor) hears of MobiMed
(transmission of ECG from ambulance) and in
1997 he goes to Falun to see the system in use
February 1998: a pilot study starts in Halden,
with two ambulances + cardiology ward at F.
(Aim: to bypass ECU, take patient directly to
Heart ICU)
January 1999: anaesthesia nurse administers
thrombolytic medication during transport
July 2000: >400 ECGs transmitted, ”call-toneedle time” reduced by 50-60 minutes
The Mobimed ”project”:
Some milestones (2)
1999: Askim looses its ECU (emergency
care unit)
April 2000: Mobimed in Askim ambulances
October 2000: > 200 ECGs transmitted,
nurse administers medication.
Ambulance personnel reaches level 3 in
their training (allowed to give medication)
2001: Sarpsborg, Moss and Fredrikstad
The success of the Mobimed project
Started with enthusiasts
Visible and tangible benefits
Started small (one site), incremental
growth, not all in one go
Low cost, simple solutions (no heavy
investments necessary before benefits
could be demonstrated)
”Bootstrapping”as strategy (1)
Start with the simplest and cheapest
solution that satisfy the needs of most
users in their least critical and simplest
practices and which doesn’t require a
large network
Use this technology as far as possible,
enroll more users
Use the same solution on more innovative
and beneficial ways
”Bootstrapping”as strategy (2)
Use the solution for more critical tasks
Use the solution for more complex tasks
Re-design/improve the solution so that
new tasks can be carried out
(Repeat from start)