IMPROVING PREVENTION METHODS AND INNOVATING
THE DANISH TELEMEDICINE INFRASTRUCTURE BY
INTRODUCING A NEW MEDICAL PARADIGM
Table of content
Reading Instructions ........................................................................................................................................................... 5
Chapter 1............................................................................................................................................................................. 6
1.1 Introduction .................................................................................................................................................................. 6
1.2 Problem formulation ..................................................................................................................................................... 7
1.2.1 Initiating problem.................................................................................................................................................. 7
1.2.2 Supporting initiating problems .............................................................................................................................. 8
1.3 Methodology ................................................................................................................................................................. 8
1.4 Project management .................................................................................................................................................... 10
1.4.1 Why is it important to analyze Project Management? ........................................................................................ 10
1.4.2 Why are we together? ......................................................................................................................................... 11
1.4.3 Scheduling of Project .......................................................................................................................................... 11
1.4.4 Identifying Stakeholders ..................................................................................................................................... 15
1.5 Risk Management ....................................................................................................................................................... 15
Risk Management Plan ................................................................................................................................................ 15
1.5.1 Risk Identification .......................................................................................................................................... 16
1.5.2 Risk Quantification (probability and consequences) ...................................................................................... 16
1.5.3 Risk Response ................................................................................................................................................ 17
1.5.4 Risk Control ................................................................................................................................................... 18
Chapter 2........................................................................................................................................................................... 19
2.1 Introduction to telemedicine ....................................................................................................................................... 19
2.1.1 What drives telemedicine forward? .................................................................................................................... 21
2.1.2 Current projects in Denmark ............................................................................................................................... 21
2.1.3 Idea screening/idea evaluation ............................................................................................................................ 22
2.2. Model of what TeleMed can do ................................................................................................................................. 22
2.2.1 Features of TeleMed ........................................................................................................................................... 24
2.2.2 Blood pressure test .............................................................................................................................................. 24
2.2.3 Pulsoxymeter....................................................................................................................................................... 25
2.2.4 Eye vision test ..................................................................................................................................................... 25
2.3 Interviews ................................................................................................................................................................... 26
2.3.1 Interview A – Lung specialist ............................................................................................................................. 26
2.3.2 Interview B – Blood specialist ............................................................................................................................ 27
2.3.3. Interview C – Telemedicine scientist ................................................................................................................. 28
2.3.4. E-mail conversations .......................................................................................................................................... 28
2.4 Results of questionnaire overview .............................................................................................................................. 29
2.4.1 Locations: Reasons and obstacles ....................................................................................................................... 30
Chapter 3........................................................................................................................................................................... 39
3.1 Introduction to our infrastructural ideas...................................................................................................................... 39
3.2 Financial infrastructure ............................................................................................................................................... 40
3.2.1 Transaction costs ................................................................................................................................................. 40
2
3.2.2 Pilot Study........................................................................................................................................................... 42
3.2.3 Cost of final launching ........................................................................................................................................ 44
3.2.4 Investors .............................................................................................................................................................. 44
3.3 Human infrastructure .................................................................................................................................................. 45
3.4 Change Management .................................................................................................................................................. 46
3.4.1 Clarifying needs of different management groups .............................................................................................. 47
3.4.1.1 CAB ............................................................................................................................................................ 47
3.4.1.2 RFC ............................................................................................................................................................. 48
3.4.1.3 The final procedure ..................................................................................................................................... 48
3.4.2 Setting up different scenarios and needs of change ............................................................................................ 50
3.4.2.1 Change scenario: Blood chip ....................................................................................................................... 50
3.4.2.2 Change scenario: Legislation change .......................................................................................................... 51
3.5 Service Desk ............................................................................................................................................................... 52
3.6 Security ....................................................................................................................................................................... 54
3.6.1 Design and analysis of information systems – using XML as a unifying language ............................................ 54
3.6.2 Security requirements for Electronic Health Records ......................................................................................... 58
3.6.2.1 Access rights, availability and integrity ...................................................................................................... 58
3.6.2.2 Current situation of EHR in Denmark ......................................................................................................... 60
3.6.3 Object oriented programming security for web based applications .................................................................... 60
3.6.3.1 Three tier architectural approach: Client server database ............................................................................ 64
3.7 Standards/Legislation ................................................................................................................................................. 65
3.7.1 Standards that matter today ................................................................................................................................. 66
3.7.1.1 Fitting legislation in the infrastructure ........................................................................................................ 66
3.7.1.2 Legislation that matters today ..................................................................................................................... 67
3.7.1.3 Changes needed for our machine to be launched ........................................................................................ 68
Chapter 4........................................................................................................................................................................... 70
4.1 Comparison of StayHealthy ........................................................................................................................................ 70
4.2 Worldwide technical aspects related to TeleMed ....................................................................................................... 71
4.2.1 The French System ............................................................................................................................................. 72
4.2.2 The Swedish System ........................................................................................................................................... 72
4.3 Lung test ..................................................................................................................................................................... 73
4.4 RFID-patches .............................................................................................................................................................. 75
4.5 Blood Tests ................................................................................................................................................................. 78
4.6 Realistic future changes .............................................................................................................................................. 80
4.6.1 Iris laser test ........................................................................................................................................................ 80
4.6.2 Blood chip ........................................................................................................................................................... 81
4.6.3 Information offerings .......................................................................................................................................... 83
4.7 Differentiation of the market ...................................................................................................................................... 83
Chapter 5........................................................................................................................................................................... 85
5.1 Interest shown in TeleMed ......................................................................................................................................... 85
5.2 Distributor ................................................................................................................................................................... 86
3
Chapter 6........................................................................................................................................................................... 89
Conclusion ................................................................................................................................................................... 89
7.Bibliography .................................................................................................................................................................. 90
8.Attachments ................................................................................................................................................................... 96
Attachment 1: Questionnaire ....................................................................................................................................... 96
Attachment 2: Venture Cup leaflet .............................................................................................................................. 98
Attachment 3 : TELEKAT leaflet.................................................................................................................................101
List of Figures
Figure 1: How to improve the general health in Denmark? ................................................................................................ 7
Figure 2: Problem solving model........................................................................................................................................ 9
Figure 3: Tasks for accomplishing a project ..................................................................................................................... 10
Figure 4: Gantt chart ......................................................................................................................................................... 14
Figure 5: Stakeholders of the project ................................................................................................................................ 15
Figure 6: Risk control ....................................................................................................................................................... 18
Figure 7: TeleMed machine capabilities ........................................................................................................................... 23
Figure 8: Age categories ................................................................................................................................................... 29
Figure 9: Location............................................................................................................................................................. 34
Figure 10: Usage of the machine ...................................................................................................................................... 34
Figure 11: Which tests ...................................................................................................................................................... 35
Figure 12: Trust in technology.......................................................................................................................................... 36
Figure 13: Doctor's visits .................................................................................................................................................. 37
Figure 14: Comparison of Usage of the machine and doctors visit .................................................................................. 38
Figure 15: New relationship doctor – patient.................................................................................................................... 45
Figure 16: Change management for TeleMed .................................................................................................................. 49
Figure 17: Entities involved in the development of RFC’s............................................................................................... 49
Figure 18: Decision-making process regarding the blood chip......................................................................................... 51
Figure 19: Required steps for issuing a RFC .................................................................................................................... 52
Figure 20: Use case diagram ............................................................................................................................................. 54
Figure 21: Activity diagram .............................................................................................................................................. 55
Figure 22: UML example using XML code ..................................................................................................................... 56
Figure 23: Public key infrastructure ................................................................................................................................. 61
Figure 24: Timestamp infrastructure ................................................................................................................................ 62
Figure 25: Secure communication .................................................................................................................................... 63
Figure 26: Needed situation .............................................................................................................................................. 67
Figure 27: Blood chip ....................................................................................................................................................... 81
Figure 28: Blood chip infrastructure ................................................................................................................................. 82
Figure 29: Tunstall interest ............................................................................................................................................... 85
Figure 30: Blood pressure monitor ................................................................................................................................... 86
Figure 31: Automated blood pressure monitor ................................................................................................................. 87
Figure 32: Wight scale ...................................................................................................................................................... 87
Figure 33: Wireless weight scale ...................................................................................................................................... 88
List of Tables
Table 1: Sequential order of activities needed to be completed ........................................................................................ 12
Table 2: Project management Gantt chart ......................................................................................................................... 13
Table 3: Risk identification............................................................................................................................................... 16
Table 4: Risk probability .................................................................................................................................................. 17
Table 5: Risk strategy ....................................................................................................................................................... 17
Table 6:GOLD Spirometric Criteria for COPD severity .................................................................................................. 74
4
Reading Instructions
To better the understanding of the report and to achieve a red line the reader is presented with a short
description of every chapter. The chapters include the following:
Chapter 1: Concerning the scientific approach used in the report and clarifying what needed to be
answered and which obstacles needed to be overcome.
Chapter 2: This chapter offers an understanding of telemedicine and what our TeleMed machine can
contribute with. Major parts of our gathered information are shared in this chapter to lay a fundament for
the following chapters.
Chapter 3: This chapter concerns the practical procedures of running the machine - from the very beginning
until ending up on the market.
Chapter 4: This chapter makes clear in which ways TeleMed differentiate itself from competitors and
analysis’ markets.
Chapter 5: Can be seen as an ending making clear that our idea already has gained interest and an opening
for what possible investors can be.
5
Chapter 1
1.1 Introduction
At the beginning of this semester we were offered the possibility of going in depth with one area out of
cognitive radio and telemedicine. After conducting a detailed analysis on the business potential of the two
possibilities we have agreed upon choosing telemedicine as we have identified an immediate demand on
the market. During this report we are going to briefly present the different questions that we have
formulated during this semester, analyse what telemedicine is, and present current trends in telemedicine
continuing with a thorough analysis of TeleMed, finishing up with differentiating aspects and interest
already shown in TeleMed.
The biggest problem that we had to face during our work was related to focusing on only a few aspects of
TeleMed. As the reader is going to discover in the next chapters, the TeleMed concept is a really complex
project, involving different entities and skills. In order for the idea to become reality it has to be analysed
from all possible perspectives (technical, financial, legislative, etc) which we soon discovered that was
practically impossible to do in only 3 months. Analyzing every possible aspect in such a short period of time
was something beyond our reach and so we decided to make the most of our background knowledge and
skills, focusing on infrastructure issues. Even though the term infrastructure can still seem really broad,
after going through chapter 3, our approach is going to become clear. The first definition that we came
across was the following:
”Telemedicine is the delivery of health-related services and information via telecommunications
technologies. Telemedicine delivery could be as simple as two health professionals discussing a case over
the telephone, or as sophisticated as using videoconferencing between providers at facilities in two
countries, or even as complex as robotic technology” [Telemedint.net.(2009)].
The idea for our project started building on this approach – we now knew what the limits were. The goal
that we had in mind was to find a means of improving the general healthcare in Denmark and in the same
time providing help for medical professionals in their every day work. Another clarification is necessary at
this point: none of us had any knowledge about medical terms or medical tests, as our backgrounds were
business, information technology and telecommunications. This was the first connection we made –
telemedicine involves different knowledge and different skills that went hand in hand with our different
backgrounds. The missing piece of the puzzle was the medical knowledge which we have tried to
compensate by discussing with lung specialists and blood specialists (see chapter 2.3 for more information).
It is probably safe to assume that “improving general health” is again a very broad term, one that could be
questioned as we are not inventing a new medical test or a new medicine. To shed some light on the
matter, we will only reveal that telemedicine could focus on curative aspects as well as preventing aspects.
With this in mind, it will be easier to understand our point of view and our focus. We are not re-inventing
the wheel, but we are putting together technologies and medical tests already available on the market in a
new way while adding changes in regards to the infrastructure. Is not that one part of what innovation is all
about?
6
Now that our way of thinking is explained, it is easier to introduce the reader to the structure of the report.
A good business idea is one that fills a void on the market or one that fulfils a demand-side request, which
means that a problem formulation (synonym to a demand on the market) needs to be addressed.
Resolving a problem could sometime be done in a chaotic way, but this is not the case for a business
proposal. The steps taken need to be thoroughly planned and analyzed by presenting a systematical
approach – the methodology chapter. For an efficient way of working a time-schedule should be
presented. TeleMed could be facing a number of obstacles (risks) which means that risks factors need to be
considered – the project management chapter. As mentioned before, the point was not to reinvent the
wheel, so a brief analysis of already existing telemedicine projects in Denmark and in the world was
required. In order to determine if there was a market for TeleMed, we performed a questionnaire asking
200 people in Aalborg what they think about the machine, about the tests and most importantly about
their trust in technology. For the results of the questionnaire, the reader should refer to sub-chapter 2.4.
We were now able to come up with a concept from which to start working on. The continuation supposed
working on the infrastructure area, trying to answer the following questions:
1.
2.
3.
4.
5.
6.
How to finance TeleMed?
Who should be in charge of the eventual changes?
What are the costs of TeleMed?
Is there a need for a service desk?
What does the Danish legislation say about telemedicine?
How can security threats be overcome for a TeleMed web-based application?
This short introduction has prepared the field for diving into analyzing TeleMed, starting with the problem
formulation.
1.2 Problem formulation
1.2.1 Initiating problem
In order to find a problem/need that TeleMed can solve/fulfil, the following question needs to be
answered:
“How can the general health of the population of Denmark be improved by the use of technology?”
Figure 1: How to improve the general health in Denmark?
7
This way of formulating the problem is simple - maybe too simple. There are so many possibilities which
drive an innovative approach far from being the simplest decision possible. The key in the last phrase is
“innovative”. Innovation, in the Schumpeterian sense [Schumpeter, 1939] could refer to new products, new
ways of organizing businesses, new processes, or new markets. In the same time, innovation is different
from invention in the sense that it can make use of already existent e.g. technologies or products in a new
way. This could of course lead into the trap of re-inventing the wheel so we need to consider the aspects
that support our problem formulation.
1.2.2 Supporting initiating problems
In order to solve the main problem, we need to take in consideration the following guiding questions:
-
What is the current situation of telemedicine in Denmark? What are the things already done in this
direction?
How can improvements be brought to the way things are done right now in telemedicine? Is there a
need for changing the infrastructure?
What is the role that technology plays right now in telemedicine and how can we enhance the
technological role?
If a new concept is developed, what could the specifications (criteria for the constituent parts) for it
be?
1.3 Methodology
At this point, the goals for this project are set and a number of supporting questions have been formulated,
but the way in which these questions are going to be answered is not clear – we have a problem/demand
but how do we solve/fulfil it?. To shed light on the path that will be followed in order for TeleMed to reach
its goal, a methodology – a systematic approach - will be needed.
Step 1: The problem
It is fair to consider that the telemedicine approaches are of two kinds:
o A curative one – focusing on dealing with medical problems after they appear.
o A preventive one – focusing on preventing medical problems.
The problem identified during our research (meaning the questionnaires, interviews, etc) is that most
people request medical care after they identify a problem and focus less on preventing medical problems
from appearing. One way of preventing medical problems from appearing could be regular medical
appointments. Unfortunately, for a number of reasons, the number of persons that have their regular
check-ups as often as they should is very small while comparing to the number of persons that handle a
8
medical issue only after appearing. Also, we feel there is a need for a centralized point for medical
information on nutrition or symptoms as more and more people check their symptoms on the internet, on
a number of websites more or less approved and with more or less accurate information.
Step 2: Why is it a problem?
The answer to this question is relatively simple – it is easier to prevent something from happening than
dealing with it afterwards, not to mention the decreased costs – both for the patients and for the
government.
Step 3: How do we solve it?
Let us now analyze the path followed in order to solve the presented problem. This report is built upon the
Problem solving model (see figure 2 below) which suits our problem statement exceptionally well. The
starting point could be the theory block which follows after the problem formulation (figure 2). In this block
the theory is represented by the existing articles and books over telemedicine. This area is a relatively new
one with developments being carried at an amazing pace. Still the number of books on the topic is not very
large. One of the most significant guiding books in our development was the “Advanced Health Telematics
and Telemedicine” – the Magdeburg Expert Summit Textbook [Pharow & Blobel, 2003b], which presented
the situation of different projects and pilot studies in Europe as well as general security, legal, social and
ethical aspects of Telemedicine.
The problem formulation block is also connected to the empirical data block which again reflects exactly
our approach. Since the already existing articles and books were not considered sufficient for developing
our business idea, we have opted to supplement the theory with data collected by ourselves. This data
came in different forms:
o
o
Interviews with Kim Larving a blood specialist from Bloddonorene at Aalborg Hospital (The Blood
Donors), Lene Birket-Smith (a lung specialist) from Aalborg Hospital, Dr. Birthe Dinesen from
Aalborg University and discussions with lawyers and distributors.
Questionnaires – to develop a viable business idea you have to keep close to the targeted users,
identifying their needs and trying to find the best possible solution based on their requests. The
questionnaire that we have performed in Aalborg focused on determining what kind of people
would be interested in using TeleMed and where they want it to be located.
Figure 2: Problem solving model
9
All the information that was collected in these ways needed to be analyzed, interpreted and eventually
formulated under the form of conclusions and answers to our initial questions. The final point which is not
represented in the diagram above could be best formulated as a test/demo/pilot study. In order for this to
be accomplished, we have established contact to a Telemedicine Company, Tunstall Healthcare, trying to
evaluate the value of our project. The outcome of the contacts and meetings are presented in the first to
final chapter of the report.
1.4 Project management
1.4.1 Why is it important to analyze Project Management?
“Projects, rather than repetitive tasks, are now the basis for most value-added in business.”[Peters,
1992].Having a good idea and a good way of solving a problem might sometimes not lead to the expected
success unless it is accompanied by an efficient time planning resolution for the project. The task of timeplanning was not a simple one, as previous experience in working with these kinds of projects was limited.
Usually, the task of accomplishing a project can be illustrated in the following way, as presented in
[Brandon, 2006]:
Figure 3: Tasks for accomplishing a project
As can immediately be observed, there is a feedback loop – for example initial planning could lead to a
certain scheduling but after controlling (monitoring) it could happen that the results are not the expected
ones. In this case, planning could be changed, possibly leading to a new scheduling and so on.
10
1.4.2 Why are we together?
Putting together a good team is crucial to a project. When putting a team together, it is important to look
at what the individuals are good at. Unfortunately, given the small number of people interested in the
Innovative Communication Technologies and Entrepreneurship program, the choice was already made. This
came as another challenge, as no one was aware of the strengths and weaknesses of the other members of
the group. We had to discover this on the way and make the most out of what we had. It was obvious even
from the beginning that we have different skills and backgrounds, but what was not just as obvious was the
way we can put these differences together and accomplish our goals. The first task in order for this to
happen was to determine the weaknesses and strengths of each group member while trying to develop a
level of respect and friendship between us.
The aspects mentioned above are meant to somehow explain the way tasks have been given out to each
participant in the planning process. In this part of the report, we will go through the planning process, how
to break down the project and make the process manageable and well-arranged from beginning to end. We
will go through potential problems and constraints for the project and how to avoid them. In this course of
action, we will touch upon actual deviations that have happened. In the end, we will evaluate the project
and compare our plan with what became the reality.
Project Definition
A project can be defined as a collaborative or individual assignment that is carefully planned and designed
to achieve a particular aim. A well-known definition from an expert in project management, Jeffrey Pinto,
defines a project as:
“A complex one time process developed to resolve a clear goal or set of goals and is limited by budget,
schedule and resources” [Pinto & Slevin, 1987].
1.4.3 Scheduling of Project
For an efficient project scheduling, the necessary steps need to be set up. These steps can be narrowed
down further into various tasks (activities) that we need to perform in order to complete the project. The
sequential order by which these activities can be carried out is termed as project scheduling.
This will help us to make the best use of our time and resources. This being said, it is time to outline the
various activities that need to be completed in a sequential order, thus identifying which activities are
predecessors and successors.
The table 1 below shows an outline of the individual activities needed to be carried out in this project.
11
1. Considering project area
2. Problem formulation/statement
3. Methodology
4. Project management
14. Service desk
15. Human infrastructure
16. Fitting legislation in the infrastructure
17. Worldwide technical aspects related to TeleMed
5. Chosen area description
6. Current projects in Denmark
7. Idea screening and evaluation
8. Analyze existing solutions
9. Interview area specialists
10. Description of idea capabilities
11. Presentation of our infrastructural idea
12. Financial infrastructure
13. Change management
18. Security requirements
19. Security of web based applications
20. Security – PKI situation in Denmark
21. Specific tests
22. Future developments
23. Report writing - proof reading & conclusion
24. Final editing
25. Printing
26. Hand in
Table 1: Sequential order of activities needed to be completed
Choice of network diagram (AON VS. AOA, GANTT CHART)
There are two ways of representing the activities: as nodes or as arrows between activity nodes. Let us
briefly analyze the differences in approach between these two techniques.
In the activities on arrow (AOA) diagram one can show the finish-to-start relationships, the arrow
representing that the activity spans the time from the event at the start of the arrow to the event at the
end [Brandon, 2006]. In the activity on node (AON) diagrams the activity is placed on the node, while the
arrows now show the precedence and relationships between activities [Brandon, 2006]. It is safe to claim
that the AON network diagrams emphasize the tasks, which is one of the reasons we have chosen this
approach. Also, the AON network diagrams are considerably easier to construct than AOA network
diagrams, and are easier to understand than AOA for inexperienced users, this being the situation for our
group at the beginning of the project. The fact that the group lacked experience while dealing with these
kinds of projects is reflected even more in choosing the AON, as it gives the possibility of ease of revision in
case changes appear [Brandon, 2006].
After the short comparison between AOA and AON the choice of the Gantt chart for project management is
easier to justify. As you can see from the Gantt chart (figure 4) it is easy to identify which dates the
activities are to be completed, how long the activity will take and the precedence between activities. If any
activity is completed earlier or delayed, the Gantt chart allows us to update it and provides us with the
effect this early completion or delay will have on the entire project. In this context it is also important to
define the slack time – the period by which an activity can be delayed without affecting the rest of the
project [Brandon, 2006].
Duration of activities
We have to make an estimate of the duration that the various activities to be completed will take. The
experience of working in such projects was somehow missing, but each member of the group had a level of
experience with different tasks (activities). Based on these own experiences we have made qualified
estimations. To ensure that our estimations are reasonable, we will consider adding plus/minus deviation
12
of the tasks (see the definition of the slack time). The scheduling of our project has been depicted in the
Gantt chart.
Note: (+x) needs to be interpreted as a sign of the slack time. E.g. (+1) - represents a slack time of 1 day that
does not affect the rest of the activities.
Project management Gantt Chart
Tasks
Considering project area
Problem formulation/statement
Methodology
Project management
Chosen area description
Start Date
2009.09.02
2009.09.08
2009.09.10
2009.09.13
2009.09.21
Current projects in Denmark
Idea screening and evaluation
Analyze existing solutions
Description of idea (capabilities)
Specific tests
Financing infrastructure
Duration(days)
6
2
2
7(+1)
1
End Date
2009.09.07
2009.09.09
2009.09.12
2009.09.21
2009.09.22
2009.09.21
2009.09.28
2009.10.07
2009.10.09
2009.10.17
2009.10.17
3(+1)
10(+2)
2
5(+2)
10(+2)
9(+2)
2009.09.25
2009.10.07
2009.10.09
2009.10.16
2009.10.29
2009.10.28
Change management
Break due to exams
Service desk
Human infrastructure
Fitting legislation in the infrastructure
Security requirements
2009.10.17
2009.10.29
2009.11.07
2009.11.07
2009.11.09
2009.11.18
2
8
2
2
7(+2)
3(+1)
2009.10.19
2009.11.06
2009.11.09
2009.11.09
2009.11.18
2009.11.22
Security of web based applications
Client server database
Security - PKI situation in Denmark
Worldwide telemedicine technical aspects related
to TeleMed
Future developments
Distributors & Conclusion
Final editing
Printing
Hand in
2009.11.22
2009.11.25
2009.11.25
3
2
2
2009.11.25
2009.11.27
2009.11.27
2009.11.22
2009.11.22
2009.11.29
2009.12.08
2009.12.15
2009.12.16
4
5(+1)
5
5
1
1
2009.11.26
2009.11.29
2009.12.04
2009.12.14
2009.12.16
2009.12.16
Table 2: Project management Gantt chart
13
2-Sep
9-Sep 16-Sep 23-Sep 30-Sep 7-Oct 14-Oct 21-Oct 28-Oct 4-Nov 11-Nov 18-Nov 25-Nov 2-Dec
9-Dec 16-Dec
Tasks
Considering project area
Problem formulation/statement
Methodology
Project management
Chosen area description
Current projects in Denmark
Idea screening and evaluation
Analyze existing solutions
Description of idea (capabilities)
6
2
2
7
1
3
10
2
5
Specific tests
10
Financing infrastructure
Change management
Break due to exams
9
2
8
Service desk
2
Human infrastructure
2
Fitting legislation in the infrastructure
Security requirements
Security of web based applications
7
3
3
Client server database
2
Security - PKI situation in Denmark
2
Telemedicine tech. aspects related to TeleMed
4
Future developments
5
Distributors & Conclusion
Final editing
5
5
Printing
1
Hand in
Figure 4: Gantt chart
1
14
1.4.4 Identifying Stakeholders
Now that we have scheduled our tasks and estimated the duration, we have to identify the stakeholders.
These are all of the interest groups that play a part in the project either directly or indirectly.
In relation to our project, we can establish the stakeholders as follows:
Aalborg University
•Responsible for our examination
and setting the requirements for
the project. This is the
administrative part of the project.
ICTE7 group
•This includes the members of the
team: Andrei, Claus and Juras
Figure 5: Stakeholders of the project
1.5 Risk Management
Before analyzing different aspects of the risk management, a clarification over the term risk is required: a
risk has a chance/probability above 0% and below 100% of happening and could have a positive or negative
impact [Brandon, 2006].
Risk Management Plan
In managing risks, a number of stages can be determined, as presented in [Brandon, 2006]. We are going to
focus only on the following four stages:




Risk Identification
Risk Quantification (probability and consequences)
Risk Response
Risk Monitoring and Control
15
1.5.1 Risk Identification
The first point of action is identifying the risks. Risks could fall under one of the two categories:


A generic risks category - characteristic to a number of projects (e.g. users might not be available).
A standard mitigation solution can be used with this category.
A TeleMed-specific risks category. Under this category we can identify the following risks:
a.
b.
c.
d.
e.
f.
g.
h.
i.
One or more devices implied in one of the tests have malfunctions while users are performing tests
Complete system failures
Soft certificate (digital signatures) might not be sufficient from a security point of view
A change in the current legislation
Similar or even more technologically appealing machines are created by other companies
Unwillingness of doctors to accept TeleMed
Unwillingness of users to rely on the results produced by TeleMed
Impossibility of transferring the information to the user’s Electronic Health Record
Development of additional equipments for usual tests
At this stage it is not enough to identify risks; their impact needs to be asserted according to [Brandon,
2006] (note – in the following table a. represents the risk a. identified above in the a. – i. list of risks).
Cause
a. Misuse or technical problem
b. Misuse or technical problem
c. Attackers trying to exploit the system
d. New laws passed by the government
e. Telemedicine projects receive extra-funding
from the government
f. TeleMed is perceived as an extra-load
g. TeleMed is not offered enough time to build a
reputation
h. Software/hardware failures
i. Increased interest in telemedicine
Impact
a. Decrease of reputation and trust in TeleMed
b. Complete lost of reputation
c. Decrease of reputation and trust in TeleMed
d. Deployment could be delayed
e. Deployment could be delayed or canceled /
Project canceled
f. Deployment could be delayed / Project canceled
g. The project could be canceled
h. Reputation is lost
i. RFC’s need to be formulated
Table 3: Risk identification
1.5.2 Risk Quantification (probability and consequences)
The second step aims at answering the question relating to the probability of the risk: How likely is it that
the identified risk is going to occur? In order to offer an accurate answer to this question risks need to be
quantified in two dimensions while evaluating the impact of the risk and the probability [Brandon, 2006].
For evaluating these two parameters two methods are available:
 Qualitative – past data, educated guess
 Quantitative – based on formulas or statistical data
For TeleMed we chose to express the parameters on a 1(low) to 3(high) scale (even though it is less precise,
it seems a more viable option for projects as complex as TeleMed). By using a matrix as indicated below, a
priority (impact potential) can be established. If the risk has a high probability and a low impact then we are
16
dealing with a medium risk, but on the other hand, if the risk has a high impact and a low probability then it
is crucial to deal immediately with that risk.
Probability
Low
Medium
High
Impact
Medium
Low
C
A, H
B, D
High
F, G
E
I
Table 4: Risk probability
1.5.3 Risk Response
Also called risk mitigation strategy, this paragraph focuses on answering the following question: What is the
way that risks can be dealt with? There are four possibilities as described by Brandon [Brandon. 2006]:




Avoidance. Eliminate the cause
Transfer the risk. Move the responsibility to a second party (e.g. a vendor).
Mitigate the risk. The impact or the chance of the risk occurring needs to be reduced.
Acceptance. Take no preventive action as the risk is not worth it.
A risk response plan should include the strategy and action items to address the strategy.
Risk
a
Strategy
Avoidance – During the pilot study all possibilities of usage of TeleMed should be tested
b
Mitigation – Prepare a backup equipment that could immediately replace the malfunctioning
equipment
Avoidance – Test different scenarios during the pilot study
c
d
e
Mitigation – Enforce maintenance contracts
Avoidance – The introduction of smart cards should be debated
Acceptance – In this situation the risk is out of the reach of the TeleMed innovaters
Avoidance – Gain governmental support
Mitigation – Investigate new developments through RFC’s
f
g
h.
Acceptance – Developing a solution that comprises the newest technologies
Avoidance – Gain governmental support
Mitigation + Acceptance– Governmental campaigns for educating the users
Avoidance – Perform thorough tests during pilot studies
i.
Mitigation – Enforce software maintenance contracts
Acceptance – Put in place a Change Advisory Board (CAB)
Table 5: Risk strategy
17
1.5.4 Risk Control
The process of risk management should be a continual one – risks should be monitored permanently, as
they have the chance of turning into an issue. The next step after removing present risks is identifying new
risks, going through the entire process of risk management again.
Figure 6: Risk control
18
Chapter 2
2.1 Introduction to telemedicine
By definition, telemedicine implies receiving professional medical health-care, remotely, through the help
of innovative information and communications technologies Telemedint.net.(2009)]. If we try to go in
depth with the definition, we will find out that in order to receive this kind of care one has to rely on
technologies like mobile phones applications or Internet to transfer the information towards the
designated doctor, eliminating limitations related to distance. Immediately after analyzing this definition,
the problem of security as well as the problem of legal and ethical issues comes into mind. For now we are
going to focus on presenting a short insight on what telemedicine means and current developments as the
other issues are all to be discussed in the following chapters.
One of the greatest problems that telemedicine tackles is providing help to rural or damaged by
catastrophic events areas, where sometimes doctors are not able to reach or the existing staff is neither
prepared nor trained in dealing with complex problems. Nevertheless, telemedicine should be regarded as
a possibility for countries of all kinds. People in the countries referred to as more developed countries as
well as people in less developed countries should be able to take advantage of the benefits brought by
telemedicine, thus providing an increase in the overall health system. Our main focus throughout this paper
is a telemedicine service in Denmark and we are going to prove that telemedicine can serve even in a
country that, so far, does not rely on so many projects on-going in this area. Also, the applications of
telemedicine expand way beyond the simple image created in rural and catastrophic events damaged
areas.
To have the exact picture of why telemedicine is becoming one of the most interesting fields in which
research is being conducted, one meaningful example could be set. The three hour window following a
stroke is crucial for the patient. The stroke is of two types – ischemic or hemorrhagic [Hinkle, McKenna,
2007]. In the first case, administering thrombolytic drugs can diminish the probability of serious long term
damage. On the other hand, administering these drugs to a patient that had a hemorrhagic stroke could
turn to be a life-losing situation. This situation could be alleviated by use of communication technologies
like video-conferencing, for example [Pedersen, 2009].
The first definition that we have presented included the term remotely which is not, by far, a new concept.
Before the development of innovative communications technologies, the possibility of receiving medical
care from a distance imposed the usage of the usual mails. None the less, the 20th century was marked by
an incredible advance in technology which created the starting grounds for deploying new methods aimed
to help people by receiving improved medical care.
Telemedicine has evolved so much in the last years that now we are able to properly determine three
categories of telemedicine [Borkowski & Mielniczuk, 2003]:

Store and forward – the patient takes the required tests and the results are sent to a doctor for
evaluation, thus eliminating the need for physical consult. The category under discussion does not
19
involve time-critical or life-critical tests. This is in no way a method targeting to replace the usual
check-ups that people need to take periodically, but a chance for people to enhance the
possibilities for these tests (especially people who have some concerns about going to a doctor’s
office on a regular basis or people who do not find the time for this).

Self-monitoring – compared to the first category, this one involves the existence of a specific
disease that doctors can monitor remotely. The benefits of this category are the possibility of rapid
action taking and cost-efficient monitoring. Cost-effectiveness comes from the fact that patients
that use self-monitoring services are not required to go to the doctor as often as they were
supposed to, permitting the doctor to take care of more cases.

Clinician interactive – it usually involves real-time consultation of a person through the use of
video-conference or phone-conversations. This category is especially useful for regions in which
doctors cannot provide regular help. For example, in some countries in Africa, a doctor that is
located in a city, could have the responsibility of up to 70,000 people, most of which live in the
rural areas, making transport and access particularly hard [BMJ, 2000]. This category is probably
the most well known category, as the correlated applications have experienced world recognition.
Doctors and medical staff in different countries can take advantage of the different expertise
around the globe in situations that could be proving life-saving. There have been (and are still being
developed) different projects aiming at interconnecting hospitals from different countries or maybe
even continents in a virtual way, thus helping patients, increasing the expertise level in these
countries and greatly decreasing overall costs.
While categorizing the types of telemedicine, we have used the term “service”, referring to some
applications in this field. These services (having a primary focus on self-monitoring services) are intended to
be marketed in countries referred to as most developed, on a financial and technological level. Also,
another important aspect that should be held in mind is the fact that the perspectives offered by
telemedicine are not only in the treatment area, but also in the diagnosis area. The most obvious example
is related to countries that have a high number of persons that have to deal with the HIV disease [Lemens,
2009]. The treatment of this disease is an extremely challenging situation that leads to high costs. Recent
research has shown that a small sensor installed on a regular mobile phone that receives a blood test
sample can prove to be an extremely useful tool in diagnosing and preventing the HIV disease [Lemens,
2009].
Another important aspect that catches the eye is related again to the first definition – telemedicine makes
use of innovative communications technologies. Why does that definition make use of the word
”innovative” if technologies that are currently being used in this field have been around for years? The
innovative part does not mean that the Internet, the mobile phones or other technologies deployed are
new inventions that drive telemedicine forward, but simply a new way to combine all the existing
technologies. We are not denying in any way that telemedicine could involve the deployment of inventions,
but the term innovative seems the most appropriate to use, even in correlation to the following chapters,
that presents the TeleMed machine.
20
2.1.1 What drives telemedicine forward?
A possible answer could be that the current progress that telemedicine is experiencing can be correlated
with the increasing interest (and of course investments in research) of major equipment providers (such as
Cisco, Ericsson, etc). Recent work taking place in the research facilities e.g. of Cisco or in the Scandinavian
region has one more central point – telemedicine. For more references, readers are more than welcome to
document themselves on the latest Health Presence Pilot project from Cisco [Cisco’s Health Presence
(2009)]] or on the Gramjyoti Project [Gramjyoti(2009)]. The interest of companies like these is viewed as a
turning point, one that could add to the reliability and security of this field, especially if we consider the
clinician-interactive category of telemedicine.
2.1.2 Current projects in Denmark
Situation in Denmark – until 2001, no significant work of embracing telemedicine was noted. A working
group called the Danish Board of Technology determined through the use of different studies that
telemedicine could be used to decrease costs for the government and enhance the quality of health care
[Danish Board of Technology, 2001]. In one of the reports presented by this work group [Danish Board of
Technology, 2001], the problem of lacking local health staff is debated, presenting the way how
telemedicine will influence this matter. There is also a discussion over the improvement in quality of
diagnostics and treatment by centralizing the knowledge and expertise in a few centers. Overall, this has
constituted the start of reorganizing the health sector and services offered in Denmark.
The importance of telemedicine was illustrated through the example of strokes. Determining the type of
stroke is conducted with the use of a magnetic resonance imaging (MRI) machine, which involves a
radiologist with particular background and knowledge. Unfortunately, these radiologists are very scarcely
distributed, fact that proves out to be a particularly big problem in Denmark. The expertise of this type is
provided in centers like Odense University Hospital [Pedersen, 2009], which is hardly sufficient to meet all
the needs of Danish citizens. Time is of the essence in telemedicine, and the three hour window comes to
prove this. Having so few centers specialized in dealing with this particular medical condition could turn out
to be a really fierce problem in the case that patients cannot make it to the hospital in due time.
Fortunately, telemedicine comes to meet this problem making use of videoconferencing.
Another ongoing project in Denmark that is meant to solve the problem of insufficient medical staff trained
in particular medical area brings benefits to both Denmark and the Baltic states, like Lithuania and Latvia.
The project is called the Baltic e-Health and actually solves two stringent problems in the same time. First
one is the lack of radiologists in certain regions of Denmark, the second being the unemployment of these
specialists in Latvia and Lithuania, due to the insufficient work places for these professionals [Sørensen &
Svendsen, 2007]. There are also other advantages in this approach, the main ones being the timeeffectiveness (we have already stated that time is of the essence in telemedicine) and cost-effectiveness.
The latter refers to the fact that there is no need to relocate the specialists from their countries, giving
them the chance to also help in their countries, if possible.
21
The last project relevant in the Telemedicine area that we have come across is the Telekat project,
mentioned several times in the report. A leaflet from Telekat is attached to this report.
2.1.3 Idea screening/idea evaluation
The reader could ask himself/herself at this point how this is relevant in any way to the TeleMed project. By
underlining the current focus in telemedicine (the curative approach) we are actually emphasizing the need
for a preventive approach. The traditional preventive way until now was a usual visit to the doctor every 6
months (in theory), where different tests could be run in order to check one’s health condition. How many
people actually follow this approach? This is not something that could be concluded from any previous
studies, thus we have identified the need for gathering empirical data, under the form of questionnaires
and interviews.
2.2. Model of what TeleMed can do
After analyzing the current projects related to telemedicine that were or still are in progress in Denmark, it
is easier to identify the void that TeleMed can fill on the market. TeleMed should not be aimed at
enhancing the treatment methods (the curative approach) but is aimed at tackling the preventive
approach. After a period of brainstorming and intense analysis of the equipments existing on the market,
we were able to come up with a list of capabilities and tests that TeleMed should incorporate – First of all
TeleMed should incorporate general information about different symptoms and information regarding
nutrition and fitness programmes. The reason behind this choice was the increased usage of the Internet
(and sometimes unreliable sources) for finding out more information especially about symptoms. Currently,
in Denmark there is a solution in this sense, represented by sundhed.dk [Rasmussen, 2009]. Providing more
sources with authorized health information could increase the basic knowledge of the common patient.
Naming one example – while coming home, you are experiencing different symptoms and you want to find
out what could be the cause, without waiting until you get home where you allegedly have internet access.
If you are part of the category that does not want to contact the doctor first, TeleMed could be the first
source of information. We understand that speed in providing information in this case is essential for the
situation described above so no login will be required for the user, offering the possibility of determining a
possible cause in just a few minutes.
Moving on to more complex features of TeleMed, in the problem formulation we have identified a problem
in the category of people that do not perform regular check-ups as often as required by medical staff. But
what are the tests usually performed in a regular check-up? The most important test is related to blood
samples from which a list of parameters is calculated – glucose level and oxygen saturation, etc. Usual
blood test is performed by extracting blood directly from the veins, using a needle, but is in the TeleMed
machine done by finger prick tests. The list of tests also includes checking the health of the lungs
(Pulmonary function studies – e.g. forced vital capacity (Spirometry)), height and weight measurements
(useful in determining parameters like Body Mass Index), and sometime eye tests. Finally blood pressure
and pulse can also be measured by pulsoxymetry. As a more futuristic approach we decided on
22
implementing RFID-patches since these already are valid to use. All the methods for performing the
measurements are explained later in the report. In determining how these tests can be included in
TeleMed we have also set as a goal offering benefits in contrast to usual check-ups.
Including tests like these in a machine gives rise to a number of questions:





Can a patient take blood samples on his own if TeleMed is going to be placed in a location where
medical staff is not present?
If the location permits the presence of a medical staff (or specially trained staff) is there a viable
possibility of storing blood samples?
Could the mitigation of hygiene issues addressed above take place by incorporating the finger-prick
test instead of usual blood samples? Is this a scientifically accepted option?
If one-time results of tests performed within TeleMed are not concluding how can we offer the
possibility of gathering statistics, increasing reliability?
In regards to pulmonary tests, could the results be presented in just a few minutes? (this would be
a differentiating aspects in regards to usual check-ups) Are these results reliable and can hygiene
be assured even if medical staff would not be present?
To illustrate what exactly the TeleMed machine has to offer the user, see the model below:
Figure 7: TeleMed machine capabilities
23
2.2.1 Features of TeleMed
After outlining what the TeleMed machine can do, it is now possible to be more explicit on the workings of
the machine. Most features of the TeleMed machine are mentioned later in chapter 4 since they are
differentiated offers not seen in other health kiosks on the market. The features described in this chapter
are implemented in other health kiosks such as StayHealthy (See chapter 4) but are still highly relevant to
offer the users. One idea that exists in some health kiosks which we decided on not implementing is ear
test. To perform an acceptable ear test many specialist believe an otoscopy examination is needed
[Heneghan et. al., 1999]. An otoscopy test is most often picture or video coverage of the ear canal or ear
drums, which makes a more precise result than offered by simple headphone tests (Sounds playing in
different volumes followed up by questions to the listener to determine the quality of hearing) performed
at other health kiosks. Using the otoscopy test in a self-serviced machine seems unreasonable since the test
is difficult to perform, and no immediate answers can be supplied to the user, since the picture/movie
needs to be examined by a specialist – and only offering a headphone test to the user has been judge
invalid since results are related to many factors such as age, colds and the lately pressure on the ears.
2.2.2 Blood pressure test
One of the dangerous factors that can easily be measured in the body is the blood pressure. Blood pressure
can cause a threatening number of diseases/attacks, such as heart attacks, diabetes, kidney diseases [Opelz
et. al., 1998] and in general a weak immune system [Hansson et. al., 1998]. Measuring blood pressure in
the TeleMed machine might turn out as the most preventive tool offered, and it is ironically also the easiest
one to implement. Normally, a doctor would put a special bandage around the patients arm and have
immediate results, but in the TeleMed machine the user place the hand wrist in a tube which automatically
fits the wrist, and within seconds presents results. This method is already used in various hospitals being a
time safer for the nurses [A&D]. It is easy to perform the test and there are no risks involved, and the
results are fairly accurate – the only things that can blurry the results are high/low body temperature or
recent exercise (this will be informed to the user before carrying out the test).
At the moment, many patients use telemedicine to monitor their blood pressure from home (e.g. the
TELEKAT project mentioned later in the report), but it could be argued that having people tested at the
TeleMed machine will save the government money, by discovering a potential group in the public with high
or low blood pressure who were not aware of the dangerous situation they were in. Not only there are
many people in the danger zone regarding high or low blood pressure, but the people being attacked by the
consequences, can be attacked without any warning signs – The blood pressure is the result of the blood
being pumped from the heart to create oxygen in the veins, without this oxygen (or blood stream to move
blockages) immediate attacks can occur without warnings [Americanheart]. This means that people who
were considered healthy might all the sudden be seriously sick needing regular medical assistance. It would
be of great importance to have the general public tested frequently in the TeleMed machine to avoid these
insidiously setbacks, which a potentially big group is in the danger zone of.
24
After the user has received the results of the test, the user will either be proved fit or unstable. If unstable,
the user will be introduced to the many various reasons that may have caused the high or low blood
pressure, such as obesity, stress, kidney diseases etc to offer immediate guidance. If the result is alarming,
the user will be suggested to schedule a doctor appointment. Also, it could be suggested that the
government should run campaigns encouraging people in the risk of blood pressure problems to get tested
- the risk increases with before mentioned situations, but also with more natural factors like age, gender
and pregnancy [Wiinberg et. al., 1995].
2.2.3 Pulsoxymeter
A pulsoxymeter device offers an easy way of checking pulse and high/low saturation. The only thing needed
to perform the test is the fingertip of the user (without any penetration of the skin). A finger clip gathers
around the finger tip and results are presented after a few seconds. Pulsoxymeter test devices have been
for sale for reasonable prices on the ordinary market for many years, and are already implemented in e.g.
TELEKAT. Pulse measurements are important to avoid risks of fungi, heart diseases [Franklin et. al., 1999]
and vascular diseases (affecting the circulation system) [Cohn et. al., 1995] among other diseases.
Saturation tests are important to make sure the blood carries sufficient oxygen in the red blood cells
[Harvard Health Publication, 2009]. The diseases related to problems with saturation are quite similar to
the ones mentioned regarding pulse.
There should be no complications of implementing a pulsoxymeter in the TeleMed machine since costs are
low and the usage is easy. The results have been accepted for years and there are no dangers related.
2.2.4 Eye vision test
An innovative idea to be integrated in the TeleMed machine is eye test. The main idea is not new and was
developed by SoloHealth as a product called Eyesite, but their proposal is a totally separate kiosk which can
assess initial eye sight test, make appointment with a specialist and read about eye diseases. EyeSite is an
award winning self-service vision test kiosk focused on total eye health. Users can get an accurate screening
of their vision in about 3 minutes; learn about eye conditions like cataracts, glaucoma (fluid pressure inside
the eyes rises because of slowed fluid drainage from the eye [MedicineNet(2003)]), and macular
degeneration (damage or breakdown of the macular of the eye. Macula is a small area at the back of the
eye that allows us to see fine details clearly: [Macular Degeneration (2009]). And a doctor location feature
encourages users to schedule an appointment with an eye care professional to get a full eye health
examination [Eyesite, 2009]. SoloHealth has placed the EyeSite kiosks throughout its home base of Atlanta
(USA) in retail locations such as Walgreens, Kroger, Walmart and regional malls. Since September 2008,
SoloHealth has screened over 100,000 people [Gokis, 2009]. As it seems to be accepted by people, we are
offering a new approach to this system by integrating it to our TeleMed machine.
How does the user perform the eye test? First of all it is necessary to choose the eye test function in the
tests menu. Now the user can choose to see what kind of eye diseases exists or just perform the test. The
25
eye tests could be performed as SoloHealth suggested by answering some general questions in the
beginning (like gender, age, previous eye tests, use of contact lenses etc) and then the user are tested with
each eye for a near vision, which is done by displaying different sizes of text on the monitor. After each text
display, to determine the sight level, questions on how good or bad the user can see displayed text comes
up on the monitor. Afterwards the distance vision test takes place; here letters are displayed on a separate
smaller monitor placed at the eye level to imitate distance. It is more or less similar to a regular eye
checkup which determines your eyes status. When the test is done results with brief explanation are
displayed on the monitor and are saved to the user’s medical record. In the case of unclear results the
system offers to schedule an appointment with suggested eye care professionals for a full examination.
After an appointment is made, results are automatically sent to the selected specialist. Virtual eye tests do
not replace eye test examinations by professionals; these are just initial eye tests which encourage the user
to take a full eye examination by an eye care professional. The main benefits of this kind of tests are that
people will be more aware of their eye’s condition, and e.g. prevent the spread of infection which could
lead to blindness.
2.3 Interviews
2.3.1 Interview A – Lung specialist
We wanted to ask Lene Birket-Smith based on her expertise if our idea of implementing a tube for
measuring the quality of clients’ lungs was a possibility and if other lung-related attributes could be
implemented. Also we were informed that Lene Birket-Smith was working on other telemedicine projects
that we wanted to know more about.
She was for our idea of implementing a tube and could not mention any contradiction towards not using
the procedure. We mentioned possible negative criteria, like hygiene and uncertified results but both were
not problems according to her. Hygiene was can be easily solved by changing the mouth-part of the tube
which is basically just a small plastic tube and uncertain results does not occur since the lung test is straight
forward.
According to Lene Birket-Smith the lung test shows if persons using the machine have vague lungs and if
e.g. cigarettes are too harsh on the lungs – thereby preventing black smoker lungs and cancer. Lene is
working as a researcher within lungs and attached to the telemedicine-area. She explained to us that so far
telemedicine in Denmark is way behind other countries (especially United Kingdom) and therefore Aalborg
Hospital was quite unknown within the telemedicine-area and only brief tasks had been performed so far.
She explained it to be lack of knowledge in the field but made clear that it is not lack of funds being the
issue since the interest definitely is present. The only major project running at Aalborg Hospital (which she
is part of) is called TELEKAT.
Lene put us in contact with Dr. Birthe Dinesen at Aalborg University who is working partly on telemedicine
who we later on contacted to gain general knowledge. Lene’s comment about Birthe Dinesen was:
26
“Birthe is likely to be the most knowledgeable person about telemedicine in Denmark and is passionate
about developing the health sector with telemedicine techniques”.
The meeting was positive as she seemed very interested and had no arguments of not implementing lung
measurements in our machine. Lene has expressed her desire to see further information later on about our
project to gain knowledge about the possibilities for her own research.
2.3.2 Interview B – Blood specialist
A lot of questions needed to be clarified within the sphere of blood. Naturally, contact was made to Aalborg
Hospital which delightfully made one of their most knowledgeable resources available, Kim Varming. Kim
Varming is a medical director at Department of Clinical Immunology and director of Aalborg Hospital’s
blood bank. Kim Varming is an experienced and acknowledged doctor with expertise within blood
transfusions.
At the beginning of the meeting Kim Varming was introduced to our idea in general and to a list of blood
measurements. We wanted to know if a blood sample could clarify thoroughly these tests. Also we wanted
his point of view on either using ordinary blood samples or finger needle tests in our machine. And lastly
we wanted to know if he agreed on the legislation we had been informed earlier on by our two law
educated sources (Anna Murphy and Mikkel Dybtved Andersen).
It soon became clear that the blood specialist was skeptical about our idea regarding blood samples
included in the machine. Neither blood samples nor finger needle tests would be appropriate regarding Kim
Varming while more than one test is often needed to clarify a final result of only one parameter – like e.g.
cholesterol. A few tests could be performed but would contribute to results that can only be used as signs
of problems, but not finally conclude that something is necessarily wrong. One of many examples given by
Kim Varming was:
“It is common for a doctor to have patients worried about having HIV and the first test performed might be
positive, but the following two deny the first by being negative”.
Another problem arising, according to Kim Varming, was that maybe only 1 out of 10.000 people have a
problem regarding e.g. hemoglobin, so why should perhaps 500 people then be tested? We questioned
this statement by the interest of a more healthy country and were informed that each blood sample
performed by an ordinary doctor has a cost range between 40 – 300 Danish kroner. As a group we still find
this a question of interest but Kim Varming disagreed.
Regarding the legislation part Kim Varming agreed with our law sources, he did not see the need of
performing blood samples outside of a doctor’s office. He was a fan of the idea of performing other tests
such as lungs, heart-rate etc but believed that blood measurements are only suitable for a doctor’s visit.
27
Lastly we asked Kim Varming if he saw any future possibility making our machine work regarding blood
measurements. His short answer was no (though scientific papers shows otherwise (see sub-chapter 4.6.2).
In the same time, Kim Varming referred to future medical developments such a scanning the iris (eyeball)
which can show signs of sickness but is not accepted as a medical method by now.
Overall, Kim Varming was against our idea of performing blood samples or finger needle tests and did not
see future aspects as a solution. As a group, based on what we have learned from our research, we decided
that the future looks brighter concerning easy performable blood sample tests than what Kim Varming
states. This stand point will be proven later in this report, especially in the Blood chip section 4.6.2.
2.3.3. Interview C – Telemedicine scientist
Grounded information on telemedicine and information about ongoing projects was given by assistant
professor Birthe Dinesen from Department of Health Science and Technology at Aalborg University.
Throughout the project contact was being kept with Birthe in order for her to give feedback on the
TeleMed project and as a whole she had no objections against the idea.
Birthe Dinesen, alongside with engineer Bernhard Ege, is in charge of another Danish telemedicine project
called TELEKAT (mentioned several times in this report). A leaflet on the TELEKAT project can be found
attached in the appendix. The TELEKAT project is cooperating with Tunstall Healthcare which we contacted
regarding telemedicine equipment.
The only obstacle with the TeleMed project that Birthe Dinesen and Bernhard Ege could find was the usage
of digital signature (Bernhard Ege claimed that the process of digital signatures will be going under
modifications in the following years, without offering further information). Besides from that, Birthe
Dinesen found the TeleMed project interesting and is interested in the final outcome.
She made it clear that it is rather easy to achieve economical support for telemedicine-projects in Denmark.
She predicted our project to be a major step within Danish infrastructure in the sense that currently
integrated telemedicine is on a more basic level, referring only to features installed in private homes.
Putting a variety of telemedicine products into one machine and making it available for the wide public
would show a major improvement in Danish telemedicine in her opinion.
2.3.4. E-mail conversations
A large variety of professionals were contacted in the working process of the report. All of these are
mentioned in the report when appropriate, but here is a list of the most relevant sources made use of to
make sure our project is possible to launch:
- Business Developer at A&D Frank Downing – to gain information about distribution options of
telemedicine equipment, to get technical knowledge on A&D’s equipment and to get a list of prices.
28
- Information Chief John Collins at StayHealthy – to get knowledge about the technicalities of StayHealthy
and knowledge about possible tests.
- Lawyer Mikkel Dybtved Andersen working with legislation at Bloddonerne in Frederiksberg – to make
sure our idea of the legislation of collecting blood samples was correct.
- Lawyer Anna Murphy head of department at Sundhedsstyrelsen – to make sure our idea of the legislation
of telemedical usage was correct.
- Managing Director Bjarne Flou from Tunstall Healthcare A/S – to obtain information about telemedicine
equipment and because Tunstall Healthcare A/S showed interest in our product.
- Head of Section at Faculty of Engineering, Science and Medicine Kenneth Stenkjær Pedersen – to compete
in Venture Cup 2009 (entrepreneurial academic competition) and to receive feedback on our ideas.
- Associate Professor Anders Henten – to gain knowledge about transaction costs.
2.4 Results of questionnaire overview
The questionnaire was build upon Steinar Kvale’s ‘Interview – En introduction til det kvalitative
forskningsinterview’. 200 people were interviewed (111 female and 89 male) and counted enough to
illustrate a clear picture of the population’s point of view. The interviews were carried out in various places
of Aalborg city that we considered as being places with diverse segments of people – such as a main library,
train station, market squares and malls. It was important for us not to put words in the mouth of the
people being interviewed and to seem neutral about our ideas presented. We have interviewed people
from a variety of age categories and as a result the average age of the participants was 35.76 years old. The
age differences are categorized to give a clearer picture of the interviewees:
Age categories
70
60
50
40
30
20
10
0
15 - 25
26 - 36
37 - 47
48 - 58
59 - 69
70 +
Figure 8: Age categories
29
One of the first things to mention is the reticence of most people in talking about the specific chronic
disease that some were experiencing. After questioning 50 persons only 4 admitted facing chronic diseases
and only one mentioned the nature of the disease – a pulmonary disease. It was becoming obvious that
people are feeling somehow embarrassed about speaking about their diseases and this did not come as a
surprise. To avoid unpleasant situations, after interviewing 50 persons, the decision of eliminating this
question was taken. The point of this question was to determine if people that are already facing different
medical conditions are interested in using the TeleMed. Because of this reason we are going to analyze the
responses of the specific person separately.
The respective person was a 25 years old female which claimed to have a pulmonary problem due to
smoking (as to her own words). This person seemed enthusiastic about the perspective of using the
TeleMed, especially if the location of the machine would be in a hospital. Regarding how often this person
would use the machine, the answer was “every six months”, while the answer for the question “how often
do you do your usual check-up?” was less than once per year. These two answers correlated could present
a somehow intriguing situation. While asked to list the tests that might be useful for her use, all the
available tests were selected, emphasizing the lung tests.
2.4.1 Locations: Reasons and obstacles
The first aim of the questionnaire was to determine which location for the TeleMed would be preferred by
the interviewed people. We had four locations in mind and these are going to be explained in the following
paragraph.
The list of locations was created having in mind attractiveness and comfort ability for people who should
not feel e.g. embarrassment while using TeleMed. It was assumed that places referred to as being more
populated (crowded could be used just as well) would represent a more suitable option as they would give
people the possibility of additional services alongside the usual needs that they fulfill in the analyzed
location. Here, there is a need of differentiating between people that planned to use TeleMed and people
that could use TeleMed only because they were in that location. It is imperative to consider that the list of
locations should not include places where people usually find themselves in a hurry. There was another
category of locations eliminated from the lists and that was the category of locations where people do not
want to spend a lot more time than needed or places where mood is questionable. The examples for this
last category could be a Court house, or a police station, while an exception is represented by a hospital
(maybe even schools).
Moving to the list of locations that people were to be interviewed about, that list included several places
considered as best options for TeleMed. At this point it is important to bring into discussion the fact that
people had the freedom of expressing new locations that were not included in our lists, locations that were
more suitable regarding their needs. The following paragraphs are analyzing the initial list:
30
1.
2.
3.
4.
5.
Fitness center
Doctor’s office
Entrance of a hospital
Pharmacy – this one appeared as a possibility after suggestions
Shopping center – this one appeared as a possibility after suggestions
1. Fitness center
The first location that seemed to check all the above mentioned requirements, in our opinion, was a fitness
center. First of all, a fitness center and the TeleMed would have in common the prevention characteristic.
This location was classified as a good idea for carrying out simple or ordinary health tests while the
emphasis would be on the nutrition and symptoms information. It is claimed that in this kind of location the
TeleMed services could complement the services for which people came there in the first place (let us
assume that people take the tests provided by TeleMed and are unhappy with the results presented e.g.
pulse rate. One immediate option that they have at their disposal is to start exercising programs, for
example, exercises offered by the fitness center). This means that in a location of this sort, TeleMed could
target people that planned to use it, as well as people that found it by accident (assuming the early days of
deployment, where reputation is an issue).The other requirement checked by this kind of location would be
“providing an alternative for people who are afraid of hospitals for different reasons (e.g. the environment
or lack of time)”, as stated in the previous chapter. The downside of a fitness center would be lack of
medical assistance while performing the tests and the category of age for the people that usually attend a
fitness center – this would lead us to consider only a younger category of people. Also, not being able to
receive medical help from a qualified e.g. nurse/medical assistant has the possibility of creating legal issues.
On the other hand, the nutrition information (and exercising programs) presented on TeleMed might be
very useful for people who attend fitness center, as TeleMed could complement their training program
according to their needs.
What are the obstacles that could be encountered in a fitness center? The first obstacle could be related to
the willingness of the fitness center of accepting TeleMed. Second obstacle is related to one of the
disadvantages – because medical staff cannot be present in the fitness center, the management should
make sure that the staff members are properly trained in using all the facilities of the machine (aimed at
alleviating some of the hygiene issues and giving assistance to persons when needed). One of the
requirements for TeleMed is that it should not pose an embarrassment on people. This requirement could
find its solution in using a separate room for TeleMed (compared to the alternative of having it in the lobby,
it is assumed that people would choose the alternative with more privacy), which could in turn lead us to
reticence from the fitness center management, as they would have to free up important space.
When considering the fitness center, it is believed that all reticence should be eliminated while analyzing
the advantages. Probably the main advantage for the fitness center would be increased reputation (which
later on could be translated by increased number of users), obtained by additional advertising. TeleMed
could be advertised by commercials (in television, radio or other media) which would also give the
possibility to the fitness center to be also known as “the fitness center that holds the TeleMed”. If the
31
fitness center proves to be the option chosen among the persons interviewed, then the possibility of
setting up means by which only one fitness center could host the TeleMed should be found (this would
increase the desire of the fitness centers to own it).
2. Doctor’s office
The second option on our list was a doctor’s office. When reading about this option, the first question that
comes into mind is “wasn’t TeleMed supposed to help people that are afraid of going to a doctor and that
prefer going there only when really necessary?” The answer is yes, but in the same time this location does
not put under discussion the above requirement. Being afraid of seeing a doctor might have nothing to do
with going to his office, if that does not necessarily involve interacting. On the other hand, for people that
do not feel comfortable in going to see a doctor, this location could seem ideal, as in the case of
unsatisfactory results, a doctor appointment can be immediately made. In the same time, the hygiene issue
could be easily alleviated as medical staff could be around the TeleMed all the time, helping people with
tests or offering indications.
But what would the benefits for the doctors be in this case? As a primary observation, this approach could
lead to saving time and becoming more efficient. The usual check-ups could be compensated by the
TeleMed tests, while the doctor would be dealing with the more serious cases, focusing on treatment
rather than prevention. Another possibility might be formulated in the following way: while waiting to
enter into the doctor’s office you could take some tests available. The question here is if this kind of
approach would be a redundant one or a more efficient one, as the doctor would already have some
indicators when beginning the tests.
3. Entrance to hospital
The third location is somehow similar to the second one. The same question of fulfilling the initial
requirements is also in place, while the benefit of having medical staff like nurses or medical assistants
around to help persons with tests and eliminate the hygiene issue is also present. One of the main
differentiation points would be that in the second case it could happen that only a small number of doctors
adopt the TeleMed in their offices. A normal question regarding this approach would be if it is a viable
option, thinking that only people with serious problems would go to the hospital. A possible answer for this
could be related to the time saving feature. Performing tests with TeleMed is aimed at returning the results
in just a few minutes, feature that could be also used by the medical staff when dealing with complex cases.
But would people be interested in using TeleMed if they did not have to be in the hospital? Is it safe to
assume that e.g. while returning home from work, a person would stop at this location just because he/she
knows about the TeleMed? This is one question whose answer should be revealed by the questionnaire.
4. Pharmacy
This location is one of the places indicated by one of the interviewed persons. Even though it was
suggested only by one person, we feel that an analysis should be performed. After analyzing the EHR
National Report for Denmark [Rasmussen, 2009], we have discovered that all pharmacies in Denmark make
use of IT (100%). IT is used here as a mean of communicating with the general practitioners and hospitals.
32
Thus it could be argued that by placing TeleMed in one of these locations, the possibility of setting up an
immediate appointment with the doctor would be made easier by the existing IT infrastructure. Another
advantage would be the help that could be received while performing the tests from the persons working
in the pharmacy (there is no need for a further employment) and dealing with the hygiene issues. As this
location seems to further reduce the costs, in the same time has the disadvantage of requiring building a
new facility in the pharmacy.
5. Entrance to shopping center
This location was suggested by a number of 10 people interviewed. While asked to indicate a better
location alternative, more suited to their needs, these persons have asked why this kind of location has not
been taken into consideration. They argued that in this way TeleMed would have a bigger market, as the
number of people going each day in a shopping center could prove to be significantly higher than the
number e.g. going to a fitness center and people could take a few minutes before starting the shopping to
perform the tests. While asked to present their opinion about hygiene issues in this kind of location, 6 of
them claimed that the reputation of TeleMed could be “inherited” from the shopping center’s reputation,
and while there is precise indication about the tests, hygiene should not pose a problem. The remaining 4
were not able to present a clear opinion. While thinking about strengths of this location, the most
interesting one is the way TeleMed could complement everyday shopping. As this is not an obvious
situation, it should be somehow explained. As TeleMed offers weight tests (and calculating the bio mass
index) as well as offering nutrition information under the form of e.g. diets, it is a possibility that TeleMed
could influence your shopping habits, turning to the so-called healthier food. In the same time, it makes
sense to question the efficiency of including tests involving blood in a shopping center. Here, TeleMed
would be dealing with similar issues like in the case of the fitness center. The shopping center’s
management should be convinced of the advantages of having TeleMed there and maybe allocate persons
to help out with the tests. As there are a number of persons employed in the shopping center, this
eliminates the need of employing new personnel, but does not eliminate the need of investing in training
some of the staff members. These persons will not have to be around the machine the entire day, but
he/she could be called by a simple button press, soliciting help. Other similar features involve increased
reputation – increased number of persons going into the shopping center, which can easily be translated
into increased revenues, revenues that could be used in building the separate room for the TeleMed. If you
are just planning to use the TeleMed, while not make some shopping after that? And if you just came there
to do your shopping, why not see what TeleMed has to offer?
Let us now analyze the answers and the graphical representations. The graph below shows the
attractiveness of different locations. The locations indicated in the charts are only the initial locations,
presented in the questionnaire. From the graph we can conclude that the most popular location among all
participants was at a doctors’ office (115 persons interviewed approved this location). When asked about
the reasons behind this choice, the responses included trust, trained professionals, the possibility of
contacting a doctor immediately if something is wrong and the help that could be provided by nurses. The
second choice as a location was the hospital, with very similar reasons as in the case of choosing a doctor’s
office. The questionnaire revealed that 74 participants were interested in this location, but in the same
time they have indicated the doctor’s office as a second best option.
33
Location
140
115
120
100
74
80
56
60
40
20
0
Fitness Center
Hospital
Doctor
Figure 9: Location
It is also important to mention some of the reasons presented by the interviewed persons regarding the
unwillingness of placing the TeleMed in a fitness center. Younger persons (in the 20-30 and 30-40 category)
accused the lack of hygiene in this location, while older persons (above 50 years old) stated that by not
usually going to a fitness center, they would not start going there only because of TeleMed. Another aspect
that is worth mentioning is related to younger persons that do not usually attend a fitness center. Some
even claimed that “going to a fitness center is stupid while you can just start running”, while others stated
they would feel rather uncomfortable in going to the fitness only for TeleMed.
Unwillingness of seeing TeleMed in a fitness center is also reflected in the graph above, having only 56
persons indicating interest in this location (mostly only young people-from the categories defined above).
Among the reasons presented when choosing the fitness center the most popular was unwillingness to go
very often to a doctor/hospital.
The graph below shows the results for the question “How often would you use TeleMed?”
Usage of the machine
70
61
60
50
36
40
30
26
35
22
20
20
10
0
Weekly
Monthly
Every third
month
Every half a
year
Once a year
More rarely
Figure 10: Usage of the machine
34
The differences in responses concerning this question were somehow hard to pin-point. The differences are
not so big between alternatives, the biggest difference being between the “every half a year” and “more
rarely” (41 votes in favor of the former). Nevertheless, the majority of people stated that they would
consider using TeleMed every half a year (61 persons), not far being situated the number of people that
would use TeleMed every third months: 36 people and the number of people that would use it once a year
(35 persons). What was somehow surprising was the fact that 26 people claimed they would use it weekly
and 22 people would use it monthly. Analyzing the category that stated that they would use TeleMed more
rarely, out of 20 persons, 10 would use it when they would experience some kind of medical condition.
Analyzing the presented data could lead to the possible hypothesis: depending on the reputation that
TeleMed gains, people would immediately move from one category into the other, which makes it
increasingly hard to present a qualified guess.
Which tests
120
112
108
104
105
100
80
80
60
40
20
0
Blood samples
Test of lungs
Height/weight
Information on
nutrition and
training
Infomation on
symptoms
Figure 11: Which tests
The next graph to be analyzed is the one that presents choices concerning the kind of tests people would
feel comfortable taking when using TeleMed. The tests were explained as detailed as possible without
trying to influence the outcome. What the graph above shows and might be interpreted as a surprise is the
willingness of people of using the TeleMed for blood samples. Actually, most of them claimed they would
use TeleMed for this feature (112 persons).
It is fair to observe from the graph above that people are interested in all suggested tests and there are
only slight differences between options. More than half of the interviewed people showed interest in
taking all tests available in TeleMed. 108 persons were interested in the lung tests, 104 were interested in
checking their height and weight, while 105 would check for information about nutrition and training. The
capability that seems somehow as least appealing to people was the possibility of reading about symptoms.
One reason would be the vast information already existent on e.g. the Internet even though that
35
information could prove to be insufficient or insufficiently controlled and checked (excluding sundhed.dk).
Trust in technology
100
92
90
80
70
60
47
50
44
40
30
20
14
10
3
0
Completely
Above average
Average
Below average
None
Figure 12: Trust in technology
Telemedicine relies on communication technologies for dealing with medical conditions. This short
definition leads us to another question: Are people willing to trust technology and the outcome of the tests
performed in TeleMed? In order to find out the answer, we have asked people this question allowing them
to choose from the following options: completely, above average, average, below average and none. A
short explanation over the possible answers is therefore required, explanation that was also presented to
the persons interviewed. By choosing completely, a person admits that he/she would regard the results
returned by TeleMed with complete confidence, using them as parameters of their medical condition. An
above average answer suggests that the results are to be taken into consideration, but in the same time
having in mind that they could be wrong. The “Average” option is to be understood as an option of a
person who would use the machine but not take the results seriously; relying more on a classical doctor’s
appointment. The “below average” answers suits a person that would use TeleMed out of curiosity more
than for the benefits provided. The interview showed that the majority of the interview participants, 92 to
be exact, do not have any kind of problem in trusting the results of the tests, taking them as serious as
possible.
The results showed that there is a thin line between average and above average which could again be
related to the reputation that the machine builds. 47 persons stated an above average trust while 45
persons have an average trust in TeleMed technology.
The results of this question are in strong relation with the economical situation of the country, admitting
that the citizens of a more developed country (like Denmark) would be more willing to embrace the
36
possibility of using TeleMed. Only 15 people would prefer a usual doctor’s appointment instead of
TeleMed, considering using it just out of curiosity, while 3 persons claimed resilience in accepting that
technology of this sort could ever replace or complement the regular check-ups. One of these 3 persons
offered additional reasons: the conversation with a doctor cannot be replaced by heart-less technology. It
is important to mention that these answers were given out of free-choice, as at no moment in time did we
try to suggest that TeleMed could replace the check-ups.
Doctor's visit
120
100
80
60
40
20
0
Weekly
Monthly
Once every half a
year
Once a year
More rare
Figure 13: Doctor's visits
The last question addressed to people concerned how often check-ups are being performed. We have
decided to ask this as a final question, as there was no intention in giving the impression that TeleMed is
aimed at replacing the regular check-ups, but more at providing a complementary alternative. The
questionnaire revealed that close to 50% of the interviewed persons perform the check-ups as often as
considered sufficient (every 6 months) while the rest waits for a year or more.
Out of the interviewed persons, 43 admitted they set up a doctor’s appointment only after they are
becoming aware of a medical condition that they are experiencing. On the other side lay the persons that
are extra-cautious about their medical condition, setting up appointments weekly (1 person) or monthly (9
persons). To illustrate the patterns of how TeleMed can improve the check-up rate in the Danish society the
comparison beneath has been made. The second half of the illustration (“once every half a year” – “more
rarely”) shows similar patterns, but the first half of the illustration (“weekly” – “every third month”) shows
a considerable increase in the number of people willing to use the TeleMed machine compared to ordinary
doctor check-ups. The conclusive matter is that the TeleMed machine can improve the intended prevention
of the general health by more regular check-ups.
37
70
60
50
40
Usage of the machine
30
Doctor's visit
20
10
0
Weekly
Monthly
Every
Once
Once a
third every half year
month
a year
More
rarely
Figure 14: Comparison of Usage of the machine and doctors visit
Overall:
The point of this questionnaire was to determine first of all if there is a market for TeleMed and if people
would show actual interest in it. There were issues concerning location (which is tightly connected to
hygiene), trust in technology and willingness to perform tests available in TeleMed. Overall, we feel the
results of the questionnaire are favorable, as from 200 persons only 3 seemed truly pessimistic and
questioned the future success of this kind of machine. We are convinced that people understood the
message that TeleMed is not aiming at replacing the usual check-ups, but is aiming at complementing
them, making life easier for people while contributing to the improvement of their health. The
questionnaire reflected that the short period after deployment of TeleMed would be critical for the future
success (as this would be the period in which reputation could be gained or lost, which in turn would lead
to an increase or decrease in the number of people using TeleMed and relying in the results). As it can be
concluded from the answers given to the question related to location, people are aware of the hygiene
issues and expect an overcoming of these issues before starting to use TeleMed. It appears people are
convinced that by deploying TeleMed in a doctor’s office or a hospital many of the presented issues could
be overcome. Also, the questionnaire reflected one aspect that the team was not expecting – even people
that could be experiencing medical problems would use TeleMed (this could be interpreted as an
unexpected result as TeleMed focuses on a preventive approach rather than on a curative one).
Furthermore, another very important question that got answered after this questionnaire was the
willingness of performing blood tests in TeleMed. The answer was more than positive, as the blood tests
were the category most indicated as “to be used” by the interviewed persons. One reason for this could be
the speed of presenting the results to the users.
38
Chapter 3
3.1 Introduction to our infrastructural ideas
In chapter 2 the current status of telemedicine in Denmark was presented, the void that TeleMed could be
filling has been identified and the perspective of potential users has been analyzed through the help of the
questionnaires. There is a demand for TeleMed on the market, but this is not enough in order to assure the
success of this project. A successful project means being able to offer proper answers to the questions
formulated in the following lines - A complete and thorough analysis includes, in the first place, considering
the financial aspects – what is the cost of TeleMed? Is a pilot a viable alternative before deploying the
actual TeleMed and who could play the role of the investors? There are some that claim that introducing
more and more telecommunication technologies into medicine will have a major impact on the human
infrastructure and on the role that the patient is going to play in this new paradigm [Itkonen, 2003]. How
does TeleMed change the standard relationship between doctors and patients? If we can conclude that this
relationship is going to go through modifications, will the medical staff be willing to accept the new
situation? One of the worst possible scenarios is the one related to doctors not accepting TeleMed as a
viable solution in their work.
It would be wrong to assume that once deployed all the problems and issues that TeleMed could be
undergoing until then are over. There is a need of constant change in order to keep up with the demands
from the market side. This leads us naturally towards the change management sub-chapter, where the
focus is going to be on the way that a request for change comes to life and the steps taken all the way
towards the Change Advisory Board (CAB). A change could be triggered by a number of causes – new
technological developments, legislation change or issues signalled by customers. All these possibilities need
to be addressed in the form of a Request for Change (RFC).
The TeleMed project is focused on users/patients which mean that their opinions should always be taken
into consideration. Before deploying TeleMed, customers needs have been determined by a questionnaire.
How can a similar approach be accomplished after deployment? This will be the role of the Service Desk –
assuring the users/patients questions, uncertainties and demands are listened to and further on, taken into
consideration by the CAB.
TeleMed is going to be a telemedicine application that will deal with personal information from a number
of patients – the need of assuring the best security needs to be addressed. Questionnaires have revealed
that the citizens of Denmark have an above average trust in technology and for this trust to be maintained,
TeleMed will need to incorporate strong security policies. Patients, as well as doctors, will have the right of
checking their information remotely, from any computer, over the Internet – security threats need to be
mitigated and a viable web-based solution needs to be determined. All the points mentioned before would
have no value without a thorough analysis of the legislation – is TeleMed going to need laws being changed
or does the present law system permit immediate deployment of our project?
39
3.2 Financial infrastructure
Innovative ideas are often built upon a good portion of optimism. An idea may often seem to be brilliant in
the beginning but then get shut down due to expenses that were not foreseen. The gap between coming up
with a good invention and becoming an entrepreneur is often the ability of financing and understanding the
investments needed [Manove, 2000].
Performing an exact calculation of the investment needed in order for a project like TeleMed to get started
is difficult. Many indirect costs need to be kept in mind (costs that are not directly connected to
technology). Only estimations can be introduced and many unexpected expenses will be facing the board in
charge of the project. This chapter introduces the way the financial infrastructural part of the TeleMed
machine will be planned and approximately how much money is needed. This chapter shall be looked upon
as drawing a picture of the financial matters and explaining the economical constraints, but not as a
detailed economical calculation. For further economical details the project needs more time and many
numbers are therefore build on assumptions. The chapter is nonetheless interesting to make clear how the
project is planned to be run economically and clarify what the board needs to keep in mind.
First of all, it is important to emphasize that the economy will build a lot upon transaction costs. A lot of
information is needed, technical components needs to be purchased and further research which already
exist should be used, and the cost related to making these deals are all transaction costs. Other areas are
completely new and need to be build from the ground – e.g. pilot studies, maintenance and development
of a database-system. The different expenses are described step by step.
3.2.1 Transaction costs
Transaction costs is a term derived in 1937 [Coase, 1937] but might still need some explanation in this
context while the term have different definitions. The definition in this report is as explained below by
Demsetz [2003]:
“A transaction cost is the cost of making an interaction when an economic exchange between parties takes
place. It differentiates from production costs by only dealing with information necessary to coordinate
processes”.
Put in other words, the transaction costs cover all costs regarding making business with use of agents and
employers workforce. There are different kinds of transaction costs that TeleMed needs to keep in mind:
Search and Information costs:
This cost relates to browsing the market for needed products and comfortable prices, a
natural action from a company looking to keep costs down. In more details, it can be costly
to acquire information, searching for a longer period of time for information, understanding
the information [Smith et. al., 1999] and to discover bounded rationality (limitation of
40
decision-makers’ knowledge) [Williamson, 1981]. It is often the first step before going
further to bargaining costs;
Bargaining costs:
This refers to the costs spent making an agreement with other companies or interests, and is
often combined with contractual bindings. It can be seen as an exchange of demands of two
(or more) interests [Hessel, 1981]. Bargaining costs are also referred to as decision making
costs.
Policing and Enforcement costs:
Policing costs refer to the costs making sure that an agreement (contract) is being kept,
which is done by safeguarding against opportunism (people acting after own interests), while
enforcement costs are the ones of the action taken if the agreement is not being kept [Dyer,
1997] (by engaging rightful legislation).
After having clarified transaction costs it is now possible to analyze examples of how TeleMed is ought to
use the different types. Many different scenarios can be put up where the company deals with transaction
costs, but here three different scenarios have been chosen:
1. Scenario: TeleMed has information stored in the machine about nutrition advices.
TeleMed will then have to use resources on where to gain the information needed. After the
information source has been found, it would be feasible to keep the connection because of
updates and therefore policing costs are needed to make sure the deal made is being kept.
Naturally this demands a contract which has bargaining costs to make an agreement. This
scenario shows three different types of transaction costs besides the cost of the information
product itself.
2. Scenario: TeleMed needs another company to perform a one-time pilot study of the product.
Again TeleMed will need to consider the money spent on identifying the right company to do
the work. Bargaining costs will also be needed this time, but the policing costs will probably
be low since it is not a continual process.
3. Scenario: TeleMed found the company to perform the pilot study, but the study was not fulfilling the
contract.
In this case most of the earlier mentioned previous costs are not needed, but enforcement
costs are needed to go to court.
It is difficult to calculate overall transactions costs since it is a very dynamic area with unsuspected turns.
Therefore it is more feasible to make a fund available that should make sure the amount is covered. At
least three persons will be needed (Three persons are needed since many deals will have to be made at the
same time and different business educational backgrounds are needed) having a Danish average educated
persons wage of 30.000 DKK each month for one year, making a total of 1.080.000 DKK.
41
3.2.2 Pilot Study
A pilot study is vital before launching a product like TeleMed accessible for the wide population, to
eliminate chances of fatal errors ruining the machine’s reputation and gambling with a patient’s health. The
study tests the machine and tries to erase errors and find possible improvements [Altman et. al., 2006]. The
pilot study will undoubtedly perform many RFC’s for the CAB in change management. It can be argued that
parts of the pilot study have already been performed producing this report.
The extent of the pilot study depends on the number of investors and how much they are willing to fund.
Having said that, an economical limit should be stated which symbolizes the point at which the funding is
enough to perform a thorough test, to make the machine suited for the launch on the market. To calculate
the cost of the pilot study, it is necessary to point out what the study includes:
-
-
Research from professionals (e.g. market analytics, lawyers, doctors) to have a second
opinion besides the developers’ idea and to make a list of critical criteria’s, coming up
with new ideas.
Technical test pilots need to be performed to exclude all errors within the machine and
the machine’s technical infrastructure.
The machine needs a test period on the market. Normally in this period the machine will
only be placed in one location in the country and be monitored for possible errors.
To try to specify the price of a pilot study further it will be reasonable to describe the proceeding of the
studies in details.

Different juries will be established to perform check-ups:
o A jury consisting of different types of lawyer specialists will be established trying to
challenge the machine while making sure TeleMed encompasses all legislation.
o A jury consisting of different types of specialist doctors will clarify the validation on the
performance of the machine – and contribute with possible future implementations.
o A jury consisting of different specialist technicians hereby gaining knowledge on the
performance of the database and well as components reliability and make sure the
machine is reliable enough for daily regular use.
o A jury consisting of economists/researchers to make sure the machine stays within the
financial limits (budget).

The machine will be tested for various diseases and usage by medical personnel and one month per
area tested is needed:
o Month 1:
Test of ordinary fit patient and RFID-patch.
o Month 2:
Test of patient with lung disease.
o Month 3:
Test of diabetes patient.
o Month 4:
Test of patient with a heart disease.
o Month 5:
Test of more minor diseases (e.g. high cholesterol and symptom information).
42
A board in charge of the pilot study needs to be established consisting of professors at a Danish University
having knowledge in medical research but who are neutral regarding the project. The two parameters
mentioned above (the juries and tests) can run at the same time having duration of six months. After the
six months obstacles will be lined out, the machine might have to undergo changes – and if so, depending
of the size of the change - another pilot study might need to be enabled or small changes might need to be
conducted. Assuming that the TeleMed machine is being approved after the first pilot study the price of
performing the test will be approximately:
-
-
Given that the medical personnel for the monthly tests cost 80.000 DKK (two doctors attached) for
each month, the price will be 400.000 DKK for the monthly tests.
Given that the different five juries need six months to make a conclusion and that each jury consists
of three persons attached having an average monthly wage of 30.000 DKK the overall price will be
2.700.000 DKK.
Persons being tested will need a fair price of 10.000 DKK for participating (giving a 10 person test
group being paid 1.000 DKK each).
This calculation makes an overall price of 3.110.000 DKK. After this comes an estimation of the prices for
performing the tests technically. Materials needed to build TeleMed, facilities, transportation etc is
estimated at 500.000 DKK. The estimation of 500.000 DKK is based on an average of 30.000 DKK for rent of
facilities (e.g. warehouses) each month during half a year, transportation costs including drivers, trucks and
gas costing 50.000 DKK for half a year and finally 250.000 DKK for materials bought from telemedicine
distributors, legal rights and test equipment. This calculation is making an overall price of 3.590.000 DKK.
Nevertheless, to be economically responsible a reserve poll needs to be established for unsuspected needs
being 500.000 DKK making an overall price of 4.090.000 DKK. The estimate of the reserve pull of 500.000
DKK is to keep risks of closure down. Unsuspected errors, obstacles or need of new material always pop up
in the working process. The reserve pull should of course be refundable for the economical contributors.
But before it is possible to test the machine it will be necessary to build to machine. Transaction costs,
software developers and components producers need to be taken into consideration. Estimation of the
prices is made below
- Transaction costs have been estimated to 1.080.000 DKK mainly due to wages (see 3.2.1 for
calculation).
- Software developers will need six months period working alongside with the monthly tests earlier
mentioned (having two employees working with an estimate of 360.000 DKK (given a monthly
wage of 30.000 DKK)). The production will cost an estimate of 300.000 DKK by use of materials and
cooperation with a software company giving an overall price of 660.000 DKK
- The machine with its design and production should be possible to be done by four month with an
estimate price of 560.000 DKK. The estimate is built on a design architectural agency paid
approximately 100.000 DKK for the design, and a final production of the machine (after the several
above mentioned steps) costing 460.000 DKK (based on three persons working for four month with
an average salary of 30.000 DKK plus a fee of 100.000 to their company).
43
This leads to an overall price of 6.390.000 DKK. Finally the board needs to be paid. Three actors would be
enough to be in charge over a one year period with an estimate of (giving a monthly wage of 30.000 DKK)
1.080.000 DKK. This leads to the conclusion of a final pilot study price of 7.470.000 DKK.
In general, it will be important for TeleMed to make clear economic strategies keeping transaction costs in
mind. It should also be included in the business model which types of partners TeleMed makes transactions
with.
3.2.3 Cost of final launching
The pilot study incorporates all fees for having a final product. In worst case scenario, the pilot study is
being shut down due to major mistakes, but in that case it will hopefully be possible to change and perform
another pilot study. But if the pilot study shows successful the product is ready to be launched. Therefore
the before mentioned 7.470.000 DKK is the final calculation. However, the final calculation does not take
future costs into account, such as maintenance costs and costs of implementing future supplements. These
costs are hard to predict since it is a question of how intense the future owner wants to interact.
3.2.4 Investors
The TeleMed project can only be launched by big funding but that is not necessarily a problem. According
to lung specialist Lene Birket-Smith (participating in telemedicine projects) and telemedicine specialist
Birthe Dinesen (according to sub-chapter 2.3.3), there are a lot of companies willing to fund telemedicine
projects. The TELEKAT project actually had back-up investors according to Lene Birket-Smith.
The TeleMed machine can expect funding from both the state and private companies. The state because it
is a natural interest to keep the health of the population at a good level, and Denmark would get a good
reputation introducing a ground breaking system like TeleMed. Private companies can have various
interests. Some may have built up a foundation over the years to improve health care. Others may have
commercial interests - or if being a major investor, getting percentages of the revenue achieved by the
system. Others may invest with their knowledge or development of technical aspects of the machine.
To give examples of companies that could have interest in the TeleMed machine, three possible examples
are given:
-
-
Ericsson: The Company mainly known for producing mobile phones makes a lot of
different devices. E.g. heating systems which are one of many technical components
needed in the construction of the machine.
Aalborg University: Naturally the university has an interest in bringing ideas to life from
its own labs.
44
-
Rambøll: This Company helped financing the TELEKAT project and is one out of many
companies that at first glance does not seem like a potential investor. But Rambøll works
in many spheres and one is innovation of IT and telecommunication.
3.3 Human infrastructure
Dealing with a complex system, one of the most important aspects that need to be analyzed is the
underlying framework that enables it to work in a certain way. However, by using the term “infrastructure”
in regards to TeleMed, as seen before, the purpose is to analyze all the different “pipes” that create this
new telemedicine system. This now leads us to the analysis of the ways in which a patient and doctors
interact and how this interaction is going to be changed in regards to TeleMed.
By implementing TeleMed, there are two main groups affected; the medical staff and the users of TeleMed.
It can be argued that because of the technological development, the standard doctor-patient relationship
will undergo some radical changes. In [Itkonen, 2003] it is claimed that “the knowledge gap between
patient and doctor is so wide that diagnostic reasoning is inherently opaque to the patient”. This could be
further understood as a minimal impact or participation from the patient side in the diagnostic process. Can
TeleMed shorten the gap while involving more the user in this process?
Digital documents in health care
EHR
e-Signature
Results need advanced knowledge
Contacting specialists
Changing the standard relationship doctor-patient
Patient needs to be informed
about the contacts made
Patient should be allowed to
present their opinions
Figure 15: New relationship doctor – patient
At the current moment, only the personal doctor has the right to view the records of a patient (for the
legislation issues, the reader is welcome to read the 3.7 sub-chapter). But TeleMed encompasses a number
of tests and the results provided by the respective tests could turn out to need specialist knowledge (e.g.
the lung test). At that moment, the user needs to accept the fact that the doctor is going to ask for a
second-opinion and maybe present parts of the problem (meaning parts of the patient’s records) to a
45
specialist. If this is the case, the current procedure needs to be changed, as the doctor should inform the
patient about contacting a specialist. In turn this means that the patient should be entitled in discussing the
proposed action points with the doctor, thus gaining an active role in the diagnosis and treatment
procedures. In [Itkonen, 2003] it is actually claimed that the autonomy will be moving to citizens by
technology deployment, but this could be argued. One of the reasons presented is that by developing at
the current rate, technology will provide new means for the patients in receiving information – this could
be the case for TeleMed as patients can receive symptom related information, nutrition programs as well
as immediate results for e.g. lung tests, blood tests, etc.
It is only fair to admit that this approach could pose different problems, as doctors might be reticent. The
success of TeleMed relies, among others, on the ability of the doctors of accepting this new paradigm. In
order for this to happen, doctors need to be convinced that the benefits on their side could overcome this
possible obstacle.
Also, for the doctors the introduction of TeleMed could lead to changing some of their routines and
procedures as they will have to take into account the time allocated to the TeleMed patients. What will the
priority granted to them be? A straight answer to this question seems to be somehow out of reach as it
depends on a number of factors like how many users are going to access the system and how many tests
are actually performed. A possible way of handling this is to create an automated system that sends out
notifications to the doctor after tests are performed. In this notification the results should be present, as
well as other important indicators. At the end of the day, the doctor could analyze all the tests performed
during one day and check if any of the cases needs detailed analysis during the next days.
What changes does this new paradigm involve on the user side? Could a patient use efficiently the
autonomy that [Itkonen, 2003] speaks about? Again, this question cannot be granted a straightforward
answer. It is in the first place debated if the patient should have the right of not sending the results of the
tests to his/her electronic health record. This leads the discussion towards the capability of the users of
determining which information is of high importance. The safest way is to send all the information to the
EHR, even if this means an increase in the work load for the doctors. As illustrated in Figure 15, when the
test performed with TeleMed are followed by a consultation, the user will and should have the possibility of
presenting their opinions, based on the information received on the screen of TeleMed.
To conclude, we can state that one more important issue that will determine the final success of TeleMed
will be related to the willingness of doctors in overcoming the obstacles of giving an increased autonomy to
patients and the responsibility that patients are willing to assume.
3.4 Change Management
After the illustrations of TeleMed’s infrastructure it is natural to look at what happens if changes occur in
the infrastructure – especially in relation to the changes that already look appealing due to future
inventions not yet on the market (See sub-chapter 3.4.2) When a machine like TeleMed is launched it is
46
vital to reassure the investors and the public that the machine is prepared for a range of obstacles and
challenges and it is therefore necessary in this chapter to clarify who will be in charge and how a variety of
situations will be dealt with.
“Not every change is an improvement, but every improvement is a change” [Van Bon, 2005].
The term Change Management derives as a part of ITIL (Information Technology Infrastructure Library) and
is not directly bonded to our field, but is still a term needed to keep in mind in this project to make sure
who has the responsibility of decision-making. Change Management is a working function which clarifies
the procedure of changes and performs agreed standards for the system to stick to. The standards (defined
as the level of excellence required) followed ensures which groups needs to accept the change, dictates
who should tests the consequences of the changes and who is kept responsible [Chapman, 2004].
Change Management can contain a variety of different strategies and be structured very simple as well as
very comprehensively [Aladwani, 2001]. If a minor company launches a simple product the change
management strategy should be kept simple (maybe only one director in charge of decisions) while major
systems like introduced in this project needs thorough strategies encompassing all possible situations that
may confront the system. Also, the TeleMed project will be sponsored by private interests, which makes
standards for the boards decisions vital to avoid disagreement.
3.4.1 Clarifying needs of different management groups
To clarify which actors are needed to keep a system like TeleMed running, the different groups needed are
specified below.
3.4.1.1 CAB
A change advisory board (CAB) needs to be established before launching the product. This body
encompasses different employees who have the knowledge to analyze and predict the outcome of changes
[Van Bon, 2005]. Generally, the CAB should be able to brainstorm and foresee the reaction given by change.
The CAB should be able to eliminate wrong decisions and to keep a standard which excludes decisions
contradicting policies of interest groups (e.g. the population’s interests, investors’ interest, the medical
spheres’ interests, the governmental policies and legislations). To incorporate all interests the CAB for the
TeleMed project should be established by the given actors:



Change manager: This leading actor will be described later.
Service desk: The group needs a representative from the service desk in order to make sure that
given changes are appropriate to the service offered.
IT: To clarify the technical criteria being introduced by a change an IT responsible needs to be
incorporated.
47





Business manager: This will be more than one person. All actors who invested money in the project
need to have their saying and also persons with economical background are needed to predict the
financial aspects.
Politician: At least one politician is needed to represent the policies given by the government.
Medical advisors: A group of specialists within their own professional area should be established so
a specific specialist can be asked for advice given a specific task.
Lawyer: A lawyer is needed to make sure legislation is followed.
Users: It is important to know the populations attitude and interest towards an upcoming change.
The given actors above can reassure a decision-making process in favor of all concerned parts and stick to a
standard which enables agreement and makes the highest chances of successful changes. The CAB is
established to make sure major disagreement is avoided and to exclude fatal errors due to changes [Van
Bon, 2005]. The change manager firstly mentioned in the CAB is naturally the person in charge of making
the board-cooperate. Also the authority and responsibility of a functional board must be put on someone’s
shoulders. Therefore it is vital that the person in charge is neutral and has leading capabilities. It is also the
change manager’s job to decide when and how a change is implemented since the change manager has the
overview of the project. Another aspect partial to the change manager’s job description is Request for
Change (RFC).
3.4.1.2 RFC
RFC is a serious matter that needs clear proceedings. In the future a lot of request and proposals for
changes regarding the TeleMed machine are inevitable and it is the change manager’s job to filter these
ideas, and decide whether or not the ideas should be proposed to the CAB. In order not to put all of the
responsibility on just a person, and to avoid rejecting useful innovative ideas, a minor board of change
coordinators of entrepreneurs has to assist the change manager in this area.
3.4.1.3 The final procedure
So far, the change management for TeleMed can be illustrated as in this model:
48
RFC
Change management and
change coordinators
CAB: Capable of accepting, planning,
testing, predicting, evaluating and
debating RFC's
Figure 16: Change management for TeleMed
But the model above only illustrates the internal level at the higher hierarchy in the TeleMed organization.
RFCs are not just offered voluntarily or by coincidence and in order to obtain RFCs the organization will
have to be aware of the sources offering RFCs, as illustrated in the model below:
Incident
Management
Problem
Management
Service Level
Management
Availability
Management
Customers
RFC’s
Change manager and
change coordinators
CAB: Capable of accepting,
planning, testing, predicting,
evaluating and debating RFC’s
Figure 17: Entities involved in the development of RFC’s
49





Incident Management corresponds to the technical descriptions of the machine in two ways. Errors
while using the machine are identified through incident management, but incident management
also covers identifying future possible errors and is therefore a flexible ability that naturally offers
RFCs. E.g. Errors in the database.
Problem Management is closely related to incident management but concentrates on problems
occurring and not exact errors. E.g. could be problems regarding opening hours.
Service Level Management (SLM) is often a kind of analysis consultancy in close contact with the
customers in order to make sure the product offered is still interesting. Often the CAB will send
reports of their judgment upon RFCs and then SLM will perform an analysis. So SLM is also an entity
with requests both to - and from the CAB.
Availability Management is performing market research and researching new possible capabilities
of the machine. It also works to improve the service offered and can be seen as a sort of idea
developing faculty making sure than TeleMed does not surpass any opportunities.
The Customers are in this case the patients and their opinions are of course of big importance for
the changes being made. Yet again the information goes both ways since patients can make their
opinions clear but the CAB can also draw contact with relevant questions [Van Bon, 2005].
Overall, all the above mentioned entities are not only built to suggest RFCs but they are also question
answering entities that help the CAB choosing the correct decisions. The employees working in the
different entities will not be full time employees but will mostly be governmental paid professors (or other
professions with a relevant scientifical background) or ordinary citizens.
3.4.2 Setting up different scenarios and needs of change
The earlier chapter defined the organizations behind the change management; now examples of how
TeleMed would react in a situation where changes are inedible, examples in which changes the TeleMed
machine are very likely to undergo (changes due to the future developments) need to be presented.
3.4.2.1 Change scenario: Blood chip
The first scenario given is a situation that already is known to be a matter the management needs to decide
whether to use or not in the future (See sub-chapter 3.4.2.1). The way in which the change management in
the decision-making process will work regarding the blood chip is illustrated below:
50
Incident
Management
Problem
Management
Service Level
Management
Availability
Management
Customers
RFC’s
Request for
information
Change manager and
change coordinators
CAB: Capable of accepting,
planning, testing, predicting,
evaluating and debating RFC’s
Figure 18: Decision-making process regarding the blood chip
In this case the product/idea that needs analysis is an RFC which is already known, and the CAB does
therefore not rely on RFC-making entities. Therefore the process starts at the CAB and at the change
manager. It will most likely be the change manager asking the CAB to work on the blood chip. The CAB will
then make use of the problem management entity, service level management and question the customers
in order to make their decision. The request flow is therefore the opposite way around than if the product
discussed was not known. This illustrates that change management is a flexible tool with the different
stages of a process working together in all directions. In the case of blood chip implementation Availability
Management is not needed since the CAB already knows the market regarding the chip as well as Incident
Management can be excluded in the beginning since the product already is tested.
3.4.2.2 Change scenario: Legislation change
But how about new criteria’s which are unexpected? Let us imagine that the government declares a new
law changing the legal usage of finger needle tests, a change that demands TeleMed to change technical
aspects of the tests performed in the machine. The process is illustrated below:
51
Incident
Management
Problem
Management
Service Level
Management
Availability
Management
Customers
RFC’s
Request for
information
Change manager and
change coordinators
CAB: Capable of accepting,
planning, testing, predicting,
evaluating and debating RFC’s
Figure 19: Required steps for issuing a RFC
The identification of the problem is most likely to be discovered by problem management and thereby
made into a RFC. The change manager and CAB will then have to take actions, and by doing so they need
advice from all the management entities to perform a justified change. This is the organizational process
that will be most common since only a few RFCs derive from the beginning in the CAB, but are most often
identified in the management entities. The flow of information in these cases starts from above in the
model and goes down to the CAB (maybe stopped by the change manager), and then to make a proper
answer the CAB consults the management entities that again answers back.
3.5 Service Desk
It is impossible to design a service that proves to be flawless or a service that can please everybody. This is
the reason why we are considering developing a Service Desk for TeleMed. The Service Desk is going to
take care of the client queries, acting as a middle point between the clients and the IT administration. This
way we are assuring that the specialized personnel does not receive low-level questions or service related
questions and, on the other hand, we are assuring that the right IT person is assigned to take care of
specific problems. It is because of this that the service desk is considered on its own a support provider.
When considering all the entities presented in the Change Management chapter, we can establish the
connections to the Service Desk. The first relationship that we need to take into consideration is the one
between the Service Desk and the incident management. People that are using the Service Desk could
present incidents or problems that they have encountered while accessing the services offered by the
machine. One step that the Service Desk could take is to pass the information on to the incident
management for analysis, under the form of written report. In the case that the incidents turn out to be of
a serious nature, the incident management could consider formulating a RFC to pass on to the change
52
manager and change coordinators. In the Change Management the close relation between Incident
Management and Problem Management has been underlined making it easier to conclude in this subchapter that the technical incidents signaled to the Service Desk could lead to formulations towards the
Incident management and the non-technical incidents could lead to formulations towards the problem
management. In connection to the role presented earlier on for the Service Level Management, the way to
ensure that the product/service offered is still interesting could be achieved through the help of the Service
Desk. People could receive different questionnaires about the services offered as well as they could receive
information about modifications in the services [Van Bon, 2005]. Other questionnaires could be targeting
the overall satisfaction offered by the TeleMed which brings us to the last relation – the one between
Service Desk and the Availability Management. By deploying a service desk, the task of doing market
research for other enhanced capabilities becomes easier. This responsibility of the Service Desk is not
intended to be an annoying one, which can be assured by contacting only those users that explicitly allow
this. For this to happen, in the moment of creating a new user account, the user is going to be explicitly
asked if he wants to be notified of the newest changes or if he wants to participate in the future
questionnaires with the perspective of symbolic offering of prices.
The Service Desk could be a useful tool for the regular users as well as for the medical professionals. This
last statement brings up a new question – is there a need to offer a differentiated Service Desk for regular
users and for doctors? We tend to give a negative answer to this question, because of the communications
media through which this Service Desk is going to perform its daily activities. The goal is to use
communications technologies like the e-mail and phone which also makes the location of the service desk
irrelevant. For example, there could be a number of different service desks placed in different cities, but
because of the used model – a virtual service desk, they could appear to form a single unit. A type of
Service Desk can also be incorporated in the TeleMed. While accessing the menu, a list of frequent asked
questions and the answers for those questions will also be at the disposal of the user. If the user does not
find the answer he is looking for, he will be encouraged to contact the service desk for any type of support.
The goal of the persons working at the Service Desk should be to keep the satisfaction level of all the users
the highest possible, a goal that could be accomplished by making use of procedures based on standard
responses (scripts) [Van Bon, 2005]. We envision the requirements for the service desk as requirements for
a call center, with personnel that is not highly skilled, having more of a dispatching function rather than an
“any problem solving approach”, representing a middle layer between all the management entities and the
customers. The reason behind not choosing highly skilled personnel is that we anticipate that most calls or
e-mails sent to this Service Desk will not be related to the technical infrastructure, but more to the service
experience.
One of the last roles of the Service Desk is to take care of proposals for approving the maintenance
contracts. Hardware and software, referring to the software patching (updating) or hardware replacing is
also included in the Service Desk management.
How can the overall effectiveness of the Service Desk be evaluated? For this question to be answered one
must have in mind some performance indicators – the number of calls answered and the rapidity in
answering, the number of calls that were dispatched to the IT administration and finally the number of
53
reports for the management entities in regard to the relations underlined in the first part. The Service Desk
will be evaluated using predefined evaluation schemes [Van Bon, 2005].
3.6 Security
3.6.1 Design and analysis of information systems – using XML as a
unifying language
When designing a system like TeleMed, we have to always keep in mind some aspects – what are the
specifications, how it is going to be implemented and who is going to make use of it. For a short reminder,
the following Unified Modeling Language (UML) can be used:
Figure 20: Use case diagram
And a corresponding use case diagram can also be presented:
54
Figure 21: Activity diagram
There are a number of constraints that we come across during this process, constraints that can be of
different nature. We can come across constraints related to rules or maybe constraints related to structure.
When designing a complex system, we are addressing different categories of people. We could be receiving
questions from business professionals or from system developers which means that we need to develop a
common language for everyone [Blobel, 2003]. First of all, the viewpoints involved need to be separated.
Each viewpoint has a specific vocabulary and meaning for the audience that it is targeting. Even though the
viewpoints are separated, the viewpoints are not completely independent from each other because of
some common terms that they could be using. To analyze a complex system, such as a telemedicine
system, the ISO Reference Model Open Distributed Processing (ISO RM ODP) can be used [Blobel, 2003].
The ISO RM ODP divides the viewpoints in 5 categories:
 enterprise viewpoint
 information viewpoint
 computational viewpoint
 engineering viewpoint
 technology viewpoint.
The five viewpoints just provide the concepts that should be used and not the way to use them.
As presented in [Blobel, 2003] the enterprise viewpoint focuses on the business specifications, business
models and how revenues can be generated. The information viewpoint has as focus the information
managed by the system as well as the structure and content of data. The computational viewpoint provides
the means for dividing components into sub-components that interact over the specific interfaces. These
sub-components that could be referred to as objects and need to be processed in a distributed way, which
leads us to the next layer in the ISO RM ODP – the engineering viewpoint. The last layer in this so called
stack of viewpoints is the technology viewpoint which presents the technologies used in designing the
system. Providing an abstract overview of this type can prove to be very valuable considering that we just
55
need to instantiate each viewpoint for the design of TeleMed. To accomplish the task of illustrating these
viewpoints, UML 2.0 could be used [Blobel, 2003]. Still, even if we use UML 2.0 we still need a way of
connecting the different vocabularies used in the different viewpoints. The medical professional use a
certain vocabulary characterized by usage of narrative text while UML just provides a means for graphical
illustration. This is the reason that leads us to consider the Extensible Markup Language XML for connecting
the viewpoints [Blobel, 2003]. But how can UML and XLM work together? The answer is considering the
classes from UML and the relations between those classes as being paths and nodes in XML documents.
In order to prove the connection between UML in XML while analyzing TeleMed, the following example was
imagined – The UML portion shows four classes and the connection between them. A patient could access
the tests (which lead to results), while the doctor class has the right to see the results of the test (as
mentioned previously this is only an example, based on a small portion of the UML drawing, not taking into
consideration all the possibilities).
Figure 22: UML example using XML code
XML sample for the above UML portion above:
<?xml version="1.0" encoding="UTF-8"?>// Setting xml version and Unicode Transformation Format-8. It is
an octet (8-bit) lossless encoding of Unicode characters.
<schema xmlns:xs="http://www.w3.org/2001/XMLSchema" // In the schema we use the standard
namespace (xs), and the URI, associated with this namespace, is the Schema language definition, which has
the standard value of http://www.w3.org/2001/XMLSchema.
<complexType name="Client" >// A complex type element is an XML element that contains other
elements as we see below. The element’s name is Client.
<sequence> // The following sequence denotes the characteristics of the client, as name (of type
string, city, country and CPR.
<element name="name" type="string"/>// Creating element Name for User full name input which
consists of text (String).
56
<element name="street" type="string"/> // Creating element of street containing textual
information of user street.
<element name="city" type="string"/> // Creating element of city containing textual information
about user city
<element name="country" type="string"/> // Creating element of country containing textual
information of user country
<element name="CPR nr." type="NUMERIC"/> // Creating element of CPR nr. containing numerical
information of user CPR number.
</sequence>
<complexContent> // The complexContent element defines extension on a complex type that contains
mixed elements – we need to specify what are the rights of the client and the connection with the other
classes
<extension base="Tests"/> // The extension element extends an existing complexType element and
“base“ specifies the name of a built-in complexType element. – in other words, the class Client has a
connection to the class Tests.
</complexContent> //this format marks the end of a tag
</complexType>
//this format marks the end of a tag
<complexType name="Doctor"> // The following steps are performed again – we are creating a class
called Doctor, class that has a number of attributes
<sequence>
<element name="name" type="string"/>
//We are defining the name of the doctor and his
profession (his profession is the one that gives him the access to the results of the tests
<element name="Profession" type="string"/>
</sequence>
//this format marks the end of a tag
<complexContent>
<extension base=" Process/results "/>
// The connection between the Doctor class and the
results of the tests
</complexContent>
//this format marks the end of a tag
</complexType>
//this format marks the end of a tag
<complexType name="tests">
//The final class is defined – named Tests.
<sequence>
<element name="Lungs" type="Process/results" //the class tests defines the list of tests: blood
tests, lung tests, height and weight. The results are sent to the process/results class.
<element name="Blood" type="Process/results"
<element name="Height/Weight" type="Process/results">
</sequence>
//this format marks the end of a tag
<complexContent>
<extension base="Process/results"/> // the connection between the tests and the results of the
tests
</complexContent>
//this format marks the end of a tag
</complexType>
//this format marks the end of a tag
<complexType name="Process/results">
//Finally, the last class is defined – the results of the tests,
where a client could see his results.
<sequence>
<element name="Description"
<element name="Results"
</sequence>
//this format marks the end of a tag
</complexType>
//this format marks the end of a tag
</schema>
//this format marks the end of a tag
57
The Client class is containing elements from the user’s personal information such as name, street, city,
country and CPR number. This class is able to communicate with Tests class which is composed of tests
such as lungs, blood and Height/Weight where 1.* indicates that one or more clients can access the Tests
class, (there could be more than one TeleMed machines used at the same time). Furthermore, the Tests
class is composed of Process/results class, which comprises the description of the selected test, how-toperform instructions and results of tests. The Process/results class can process one or more operations as
indicated by the sign 1.*.
3.6.2 Security requirements for Electronic Health Records
3.6.2.1 Access rights, availability and integrity
Until recently, ICT has been used in healthcare only for administrative and financial purposes. The change in
the presented ecosystem has occurred in the last decades, when people realized the huge potential of
including the health-oriented functionality of ICT in telemedicine and health care. Combining the two
sectors is thought to have a number of advantages over traditional systems. But, if we are to be correct all
the way in our statement, we have to consider the threats that this combination poses. One of the biggest
problems of ICT is inherited security, which is accentuated if we take into consideration that health systems
(and implicitly telemedicine systems) that use ICT are handling valuable information regarding patients.
These systems involve the usage of Electronic Health Records, which contain sensitive patient data, data to
which only intended professionals should have access. In the following paragraphs we are going to analyze
the security issues related to TeleMed and the current situation of the Electronic Health Records in
Denmark.
To give an even clearer view of the formulated problem above, we are going to formulate the ICT
requirements when using technology in the health sector. First of all, the problem of availability comes into
place. In order to discuss this term one should in the first place define availability. One of the most
comprehensive definitions seems to be the one provided in the Babylon Dictionary:
“The degree to which a system, subsystem, or equipment is operable and in a committable state at the
start of a mission, when the mission is called for at an unknown, i.e., a random, time. Simply put, availability
is the proportion of time a system is in a functioning condition”.
The task of providing a relatively accurate proportion of time in which TeleMed should be in functioning
condition is not by far an easy one – claiming that 100% availability can be achieved would be a total
overstatement. On the other hand, TeleMed will be dealing with data that are to be put in the electronic
health record of the patient meaning the standard (threshold) cannot be set too low. One of the worst case
scenario would be the following – after taking a number of the tests available in TeleMed, you might
discover that a further appointment with a doctor could be necessary. Thus, you contact the doctor and set
up an appointment expecting him to know about the alleged problem from the information submitted
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through TeleMed. You had no idea that in the moments when you thought the information is being
submitted the system was down. This is not an acceptable situation, as it leads to a time waste (you will
have to take the tests again in the doctor’s office) and puts a stain on TeleMed reputation – there goes one
user that is probably not going to use TeleMed ever again or at least, not any time soon. In the best case
scenario just an estimate can be presented, estimate that could be changed during the pilot study. As
reflected from the questionnaires, the best location for the TeleMed is in a doctor’s office. This means that
TeleMed is available to the users in the working hours of the respective doctor – if needed, maintenance
could occur in the evenings, after closing hours. The availability of the system refers to both hardware and
software. One of the most used approaches while providing hardware resiliency is duplication of
equipment. As this method leads to increased costs, we are not going to consider this as a viable solution
for TeleMed, at least for the pilot study. If the pilot study proves the need for this kind of backup,
duplication is going to be considered. In regards to the software availability, the situation here appears to
be more acceptable as only copies of the software need to be kept. Mechanisms of backup need to be
available for the valuable information with emphasis on the information stored in the databases. Backup
mechanisms are of two types: full combined with incremental or differential [Preston, 2008]. In the full
combined with incremental a full copy of the data is stored and successive incremental backups are
performed. To recover in case of a failure, first the full copy needs to be restored and second, the
incremental backup until the time of failure. In the differential backup, day to day modifications performed
are saved. These mechanisms provide the means to protect against human errors or software failures.
The second requirement is user identification and authentication. There are a number of ways through
which this can be accomplished. First of all, there should be two categories of users – the patients (regular
users) and the doctors. For the moment we are going to analyze only the login that takes place in the
TeleMed room and return later to the login requirements over the Web interface. In the case of first time
users, for logging into the system, the user will be asked to enter his CPR number and choosing a password
afterwards. Referring to the password’s strength, different rules can be agreed upon e.g. choosing a
password with more than 6 letters which also needs to have one of the following characters – numbers or
special characters (?,.’ etc). The possibilities of logging into the system might be extended in the future
depending on the progress of biometry (e.g. face recognition, finger-print recognition). One problem that
could arise while using this system is related to forgetting to logout after using the system. This situation
could lead to this problem – a user forgets to logout, the second user wants to use the machine and does
not notice that the previous session was not properly ended. A possible mechanism to prevent this
situation is the following – because the TeleMed is going to be placed in a special room, mechanisms like
automatic logout can be installed as the door is opened. Of course, simpler mechanisms related to timeouts
can be easily used from the technical perspective.
The third requirement refers to integrity – this is related to the last aspect presented in the user
identification and authorization. The worst case scenario presents a user filling up the EHR for another user
by accident. The mechanisms presented above should be enough to avoid this situation.
Last, but not least, the problem of access rights needs to be discussed. Who has the right to view the
Electronic Health Records of patients and how much of these records are doctors allowed to view? This is a
matter of critical issue that should be discussed after analyzing the existing policies in Denmark.
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Each user that accesses the system needs to be granted a role which determines the amount of information
that he is entitled to see. It will be assumed that only the assigned/personal doctor will have the right to
view the information submitted through TeleMed. In case of emergency (e.g. the patient needs to be
treated in a different region or by a different doctor), these rights have to be overwritten, with the doctor
having immediate access to the records. For overwriting of these rights, the new doctor needs to present
the reasons. The problem behind access rights becomes more critical when discussing a medical audit in
case of a lawsuit concerning the EHR. The doctor needs to be able to prove that he has considered all the
existing information and that his actions were justified. At first hand, this implies that all data needs to be
time-stamped and that the possibility of recreating a situation from the past exists. In the same time, the
possibility of keeping track of each and single access to the system should be provisioned.
3.6.2.2 Current situation of EHR in Denmark
After going through one the European Union reports over the EHR implementation in Denmark, it is clear
that a compromise regarding the standardization of EHR has not been reached [Rasmussen, 2009]. In the
period January 1st 2003 – December 31st 2005 a number of initiatives were started in order to achieve
implementation and development of the electronic health records. The primary focus was to develop
standards and to achieve the integration of EHR with other IT systems available in the health care service.
What was the outcome? Implementation of a Danish standard for EHR failed and this aim was moved in the
2008-2012 strategy [Rasmussen, 2009]. Given the present situation of uncertainty we can only present an
ideal situation for adding the results provided by TeleMed to a future Electronic Health Record standard
that is going to be modified depending on the outcome of the new Danish strategy.
3.6.3 Object oriented programming security for web based applications
In designing a web-based solution there are several important requirements that need to be addressed in
order for the TeleMed to be a success [Georgoulas et. al., 2003]:
1. The need for confidentiality – this is the first requirement for a secure communication over an
unsecure environment like the Internet. Encryption could be accomplished e.g. through the use of
protocols like Hyper Text Transfer Protocol Secure (HTTPS) and Transport Layer Security (TLS).
2. The need for traceability – as stated previously, in case of a medical lawsuit or medical audit, a
doctor needs to be able to prove that his actions were justified by the situation at that given time
so the problem of time-stamping arises.
3. Integrity – integrity refers to the possibility of discovering, before accidents happen, that the
information at hand has been tampered with by unauthorized persons. Integrity also deals with
reliable communication between server and client in terms of Digital Signatures.
4. Authentication – Before any communication of any kind can be conducted, there is a need for
authentication. This is where the digital signatures (again) prove to be of the highest level of
importance.
60
After analyzing the four points, we can go on to prove that the framework provided by the Public key
infrastructure (PKI) is the one required for TeleMed. The PKI (which is more a security framework than
merely a technical solution) with Trusted Third Party services is analyzed in the following paragraphs as a
valid option for secure deployment of the web-based solution for TeleMed. The framework of PKI relies on
the existence of certificate authorities (CA) or Registration authorities (RA) [Pharow & Blobel, 2003a], which
register and issue certificates (digital signatures) for organizations, validating their public keys or which
uniquely identify users. In simple words, the CA proves that organizations and users are who they say they
are by performing some checks over their identity. A regular user of TeleMed would have to register with a
Public Key Registration Authority while a doctor would have to register with Professional Registration
Authority, assuring that after login they have the correct access rights [Pharow & Blobel, 2003a]. The Public
Key Certificate Authority is the one that certifies the correspondence between the certificate and the user’s
public signature, while the Professional Certification Authority has the same role for the professionals.
Figure 23: Public key infrastructure
So far, we have offered a possibility of determining the roles that users and doctors should play. The next
step would be determining the access rights that each professional should have based on his specialization.
This could be accomplished by issuing professional attribute certificates, even though the situation is far
from being resolved because of existing discussions about how to describe specialties [Pharow & Blobel,
2003a]. The last requirement formulated above was related to traceability of different actions taken so that
individuals cannot repudiate the existing information at one point, thus meaning that no one can change
the creation date on the specific data. This task is accomplished through the use of trusted time-stamping,
provided by third parties. How does this trusted time-stamping work? First of all, the requester of trusted
time-stamping needs to calculate a hash from the data that he has at his disposal. The hash is sent further
on to the trusted third party who calculates a new hash, by combining the submitted hash with a timestamp. The authentication comes by signing the new hash with the private key of the third party and
sending it back to the requestor, who has to store the new data alongside the original data [Georgoulas et.
al., 2003].
61
Figure 24: Timestamp infrastructure
After performing tests available in TeleMed, the user might want to verify that the correct results were
uploaded to his Electronic Health Record or he might want to go through the results again. How would
users and medical professionals get access to these Electronic Health Records? One way of verifying these
EHRs can only be accomplished with the help of a Web interface. In the following paragraph we are going
to focus on modalities of overcoming the threats of conducting medical communication over the Internet.
Security can be implemented in different layers but here we are going to focus on the application layer.
This layer supports a number of protocols with vulnerabilities that could be exploited, while combined with
the fact that the most valuable information resides here make the application layer a desired target for
attackers. One possibility of mitigating security threats would be to consider the benefits of object oriented
programming (with focus on Java). What are the reasons for choosing Java? The primary features that have
influenced this selection are interoperability and transferability, since programs can run on every operating
system, without having to write the source code more than once [Deitel, 2004]. The Java platform allows
the system users to define the rules that Java applications and applets (Java code that resides on the server
and gets downloaded on to the browser whenever the client sends a request for the specific page [Deitel,
2004]) should comply with when running on their machine. Additionally, Java benefits of already
implemented classes that accomplish the functionality required by PKI - in the case of the TeleMed webportal, an applet can consist of graphical user interface depending on the access right granted to the user,
smart card controller (as an enhanced method of authentication), XML signing, XML processing and finally
the communication using the TLS feature of Java and the data processing components as described in
[Polemi et. al., 2000].
Let us analyze some of these components: A secure connection to the server can be established by using
the TLS protocol which has a predefined API in Java – the secure socket extension [Deitel, 2004]. The TLS
protocol establishes a secure connection between the client and the server providing strong authentication
62
and confidentiality using cryptography. TLS offers the possibility for unilateral authentication where only
the server gets authenticated while the client remains anonymous as well as the possibility of mutual
authentication – where both the server and client are authenticated by the corresponding side, which
proves to be of greater value in this project. When using TLS, the client can validate the digital signature
provided by the server.
What to use XML signing for? Before we go into XML signing analysis we need to mention the servlets - the
feature of Java that permits dynamic content on a website [Blobel, 2003]. The servlet could make use of the
JDBC – the Java Database Connectivity API that defines interfaces and classes for writing database
applications in Java by making database connections to almost any relational database – database that
use tables to store information. The standard fields and records are represented as columns (fields) and
rows (records) in a table to access remote databases and dynamically present content on the server web
site (exactly the way we envision the Electronic Health Records to be). The next security aspect that needs
to be taken into consideration is the communication between applets and servlets. A secure way of
handling this communication could make use of the XML set [Blobel, 2003], including digital signatures,
which provide the means of signing several messages at a time (this feature could prove to be extremely
valuable while considering accountability issues – archiving the messages). Security can be enhanced by the
so-called authenticode – which also uses the digital signature technology. Authenticode could be used to
certify the origin of the software (having in mind that applets are downloaded from the Internet –
unreliable sources) [HARP, 2000]. By signing code, the developer simply generates a digital signature string
that is attached to the code. Summarizing the steps presented so far:
Figure 25: Secure communication
1. The user uses his browser to connect through a secure connection (HTTPS) to the server.
2. Both the user and the server are authenticated using the TLS protocol
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3. By accessing the web page, a personalized applet from the server side is downloaded into the
browser of the client. The applet is personalized according to the credentials of the user, and
implicitly his role.
4. The user authentication and the attributes provided will insure the fields in the database that the
user will have the right to see only the right fields in the database.
3.6.3.1 Three tier architectural approach: Client server database
By analyzing the proposed architecture of the TeleMed one can immediately see that we are proposing an
server-client architecture, completed with databases. The difficulties of this three tier architecture clientserver-database relate to the way the information is presented to the client and the way the server
accesses the database. The two things in question need to sustain a certain level of flexibility required for
the best user experience because in the end it all sums up to the way the users have access to the
information behind the database.
In the previous subchapter we have seen how XML can be used as the unifying tool for the different
viewpoints implied by the ISO RM ODP and how the Digital Signature feature of XML can be used in
archiving and auditing messages, as well as facilitating secure communications between the applets and the
servlets [Vlachos & Stassinopoulos, 2003]. When considering the OSI reference model, XML is one of the
protocols used in the presentation layer and, in standard web applications architecture, it would be used
for the representation of data in the client side. The capabilities of XML need to be “exploited” even further
to the server side in order to obtain the desired flexibility [Vlachos & Stassinopoulos , 2003]. In the client
side XML can be used to display the information, capability which could be translated in the server side as
being able to locate information in a database. The desired flexibility that we have been talking about
comes from unifying the two aspects under a common component.
The web server is the one responsible for collecting information from the databases and presenting it to
the web client, according to his profile. As mentioned before, in the client side an applet is downloaded in
the browser while accessing the desired web page. In this presented scenario, the server needs to be able
to obtain information from the various fields in the database and associate it with information provided
from the client. To summarize things, whenever the user is logging in to the web applications
(authentication performed in some of the possible ways mentioned before) the server needs to be able to
access the correct fields in the database in order to present the correct information to the user, the user
being a medical professional or a simple patient. A security aspect that has not been mentioned so far is
the use of HTTPS while accessing the server. HTTPS makes use of the HTTP protocol while providing
encryption and authentication through the use of TLS.
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3.7 Standards/Legislation
In this section, the Danish laws that could impact the final outcome of TeleMed are being analyzed. Since
the word standard has different meanings, depending on context, it should be explained that in the
following sub-chapter it is used in the legal way – referring to the standards established by law.
It became clear after meeting blood specialist Kim Varming at Aalborg Hospital that blood samples were
considered somehow a too radical innovation for TeleMed, because of the obstacles that blood samples
could be facing. Nevertheless, it is still possible and we therefore needed to look into the prospects of
blood measurement as a part of the machine and in that occasion make sure legislation could not turn
down the project.
After reading thoroughly through the Danish legislature concerning healthcare, which is influenced strongly
by the rules of the European Union, it became clear that a lot of laws regarding this issue are not explicit
and are substance for judgment in specific cases [Frank & Bix, 2008]. The next step was therefore to make
contact with lawyers working with these specific tasks we needed information about.
Two contacts were made; first contact made was to Anna Murphy who is a lawyer at Sunhedsstyrelsen in
Copenhagen. Second contact was to Mikkel Dybtved Andersen working with legislation at Bloddonerne in
Frederiksberg. Both persons agreed that performing a blood sample or finger needle test is easy and not
much training is needed – nevertheless a doctor needs to authorize the person performing the tests, and it
is therefore necessary to have a doctor included in the team (at least part-time) in order to follow the laws.
This might sound too comprehensive for finger needle tests since no assistant is needed to perform the
test, but the law clearly states that all kind of penetration through skin demands authorization from a
professional doctor. In the case that e.g. a fitness instructor wants to perform blood samples the company
behind needs statutory power and still a professional doctor assigned. As the Danish law (European Union
law) is stated at the moment, the one being authorized by a doctor to perform blood samples is only seen
as an assistant and not as an employee who is meant to perform several tests. This is due to the
authorization law paragraph 17 which states that a doctor only gives authorization to an assistant if the use
is limited, careful and is being kept on a fair level of use. For private companies like fitness centers to bend
this rule special statutory power, which will be very hard to obtain, is needed. If the machine is located at a
doctor’s office or hospital the doctors can obviously perform the blood samples and educated nurses are
allowed to perform the tests as well.
In general, due to the authorization law paragraph 74 part 2 which states that penetration of skin only
should be performed by authorized doctors, the idea of locating the machine at a fitness center is hard to
transform into reality. It will need special statutory power which will be difficult to obtain. The location of a
doctor’s office is possible in the sense that the doctor finds the time to perform the tests himself or pass
the assignment to assistants or hired nurses. There are no laws declining the nurses at a hospital location to
perform blood samples. In the case of finger needles, there seems to be no serious preventions for any of
the locations as long as a doctor is regularly connected to the place.
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3.7.1 Standards that matter today
3.7.1.1 Fitting legislation in the infrastructure
It is vital before launching a product like the TeleMed machine on the market to make sure laws are being
followed. Within the infrastructure of the product it is important to make sure policy, privacy and
authorization matters are not contradicting the legislation or Danish standards as well.
Looking back at former Danish telemedicine projects proves that some of the biggest obstacles to
overcome for the designers behind the idea were related to changing the current legislation. It is not
always difficult to come up with new innovative ideas but the reason why it some do not get launched is
often the country’s legislation. Examples of projects having a more or less simple idea where the main
obstacle that needed to be cleared was legislation are:
TELEKAT: This project aims to change the Danish legislation regarding who is allowed to get access to
information stored from telemedicine patients, and legislation about who owns the data retrieved (See
Attachment 3).
MedCom: This project made it possible for the first time ever for patients to log on to their own medical
record online. The project started in the county of Viborg in Denmark but is today available for the entire
nation, and is a clear example of pushing the regulations [IT-borger, 2007].
This illustrates that not only does the TeleMed machine have technical innovations but also produces the
need of innovative legislation. In order for TeleMed to be successful regarding legislation and standards,
two different strategical approaches can be used:
-
Strategy 1: TeleMed is being launched encompassing the current legislation and is therefore
possible to be launched immediately after the technicalities are cleared. This has the benefits of
simplicity and certainty of usage, but its weaknesses are not to use the full capabilities technically
possible.
-
Strategy 2: TeleMed is produced with features that currently do not follow the legislation and
standards, but by political and medical debate hopefully will be approved for. This has the benefits
of a more universal product possibly obtaining all the goals the design group aims for, but has the
disadvantages of not being launched before the product is reproduced to be suitable for the given
legislation.
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3.7.1.2 Legislation that matters today
In order to choose one of the two possible strategies given above, it is necessary to analyze if there are any
laws challenging TeleMed. Due to the long list of various laws it is inconvenient to describe and clarify all of
them; therefore this chapter only mentions laws which might raise problems for the implementation of the
TeleMed machine.
Law 1:
As explained in chapter 2.3.1 the project has no issues regarding the medical procedures itself (unless
ordinary blood samples (not finger prick samples) are performed), but the infrastructural information
sharing related to privacy may confront the system. Basically all the information deriving from the patient is
transferred to the patient’s medical record. The Danish legislation (dictated from EU directives) describes
the medical record as a confidential document between the patient and the patient’s personal doctor
[Søndergaard, 2008]. This law is not appropriate for the database-system ideas in TeleMed since it should
be possible for the user of the machine to consult specialists directly, and these specialists will need the
information given at the machine. This is a problem while the patient is showing his/her medical record to
both the personal doctor and the specialist. In the real world it would not be a complicated matter while
the doctor in an ordinary meeting would make contact to the specialists and give the information needed
only.
Figure 26: Needed situation
This should nevertheless not be seen as a major problem while the currently running TELEKAT project is
working hard to change the current legislation regarding this issue. Both the legislation but also the
infrastructure in the hospital, because at the moment it is only possible to use one specialist from the
TELEKAT machine, but with organizational and legislature changes, this can easily be solved – and the
process of changing the law is already in progress.
Law 2
Another law worth mentioning is a law which leads to a lot of sensitive cases regarding insurances. It is
stated in the Danish declaration number 1373 of 16th of December 2006, § 8, topic 1, number 2b that the
doctor needs to write a journal containing:
-
The reason why there has been a contact between the doctor and the patient.
67
-
A description of the patient’s medical history.
A description of the patient’s current condition.
An explanation of the treatment given.
This is not directly a problem, but is as mentioned a sensitive case in the meaning of authorizing the
information. If a doctor stores the information in the database it should be kept certain by surveillance that
the information is not changed, and authority should be given to law authorized personnel to enter the
information during law suits, insurance questions and if a doctor in general is being claimed of performing a
wrong treatment.
Law 3
Some users of the TeleMed machine might find that they need treatment and through the machine make
contact to a doctor. This is an infrastructural change decreasing bureaucracy and saving time for
middlemen normally unnecessarily included in the ordinary procedure. One law defines a minor hurdle
regarding the permission from the patient to perform a treatment. It is in the Danish legislation vital that
the patient makes an approval either oral or by letter (for major treatments). But for the patient to give his
or her approval in the TeleMed web-based application, it is needed to add digital signature to prove the
interest of the patient. This can easily be implemented but is nevertheless important to keep in mind.
3.7.1.3 Changes needed for our machine to be launched
It is of great importance to understand how medical records are proving materials for court trials etc and
therefore needs to be handled with great care. But to look back at the before mentioned two strategies it
becomes obvious that strategy 2 is the path to choose. It is not many laws that TeleMed does not follow
regarding the infrastructural aspects. Only three laws restrict and one of them is already being challenged
by another project while the later two are only a matter of few implementations in the infrastructure. It can
be argued that we by the two implementations in law 2 and 3 follow strategy 1, but as long as law 1 is not
followed, then strategy 2 is being used. The strategy to choose is therefore to believe in the importance of
the product, meaning believing that the law system will show flexibility taking into account the many
possibilities offered by the machine.
An aspect worth mentioning that is not written in any law books is the ethical aspect. Ethical believes are
hard to predict but when the machine has been launched there will undoubtedly be people with contempt
towards the machine [Veacth, 1983]. These people may or may not have some correct ethical point of
views, especially regarding privacy of people’s medical conditions, and if their believe is to be shared by the
wider public – new laws against the TeleMed machine may arise. Naturally, the whole design process of the
machine tries to eliminate the chance of this situation to occur, but it is still a possibility that needs to be
kept in mind.
Many telemedicine projects are “playing” with the legislation because a doctor is being kept responsible for
the use of telemedicine products in private homes (e.g. TELEKAT). But with the TeleMed machine a doctor
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is not attached to the machine unless the patient wants an appointment. The patient makes its own
decision of using the machine and is therefore being kept responsible which eliminate many of the earlier
known telemedicine obstacles, which shows to be a great advantage of the TeleMed machine.
Currently telemedicine is a rather new subject in Denmark and the law is therefore not well defined which
makes a product launch within the telemedicine field flexible in general. The most important law regarding
telemedicine in Denmark is that the doctor offering telemedicine assistance finds the treatment reasonable
and that the treatment is being given with care [Dons, 2005].
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Chapter 4
After making the framework for the TeleMed machine it became clear in which areas the machine can
differentiate itself from competitive health kiosks on the market. The following are various techniques and
market aspects that differentiate TeleMed positively compared to competitors.
4.1 Comparison of StayHealthy
After researching in detail similar solutions offered by different competitors, we have reached the
conclusion that the teaming between IBM and Stayhealthy seems the most powerful competitor. IBM and
Stayhealthy have developed the so-called health-kiosk which we are going to analyze in the following subchapter.
By analyzing the competitor’s approach there are some aspects worth mentioning:

Available tests: Stayhealthy and IBM – they are granting their users the chance to monitor weight,
blood pressure and body mass index (BMI), as well as receiving information on fitness related
products and services. The other tests offered are Blood pressure and pulse measurement,
temperature, eyesight and hearing. Stayhealthy and IBM are also considering using in the future
blood tests through the help of blood meter (e.g. blood glucose meter which is useful in
monitoring a patient’s diabetes condition, requiring only 0.3 micro liters of blood).

Available tests: TeleMed - Currently the proposed architecture for TeleMed is incorporating all the
aspects of IBM and Stayhealthy, having the advantage of a number of innovations. An innovative
approach is represented by the blood tests performed with the finger prick (needle), as well as the
lung test (Stayhealthy and IBM are considering this approach for a future implementation). It is
obvious that both categories of tests need further clarification of hygiene issues before becoming
feasible ideas, but while considering the finger prick this possesses the advantage of also offering
information about hemoglobin and mononucleosis, and not only diabetes (blood glucose) still
using a very small quantity of blood. The last innovation in available tests deals with the
development of the RFID technology. Currently, RFID patches (e.g. glucose-monitoring skin patch,
cardiac-monitoring skin patch, UV-monitoring skin patch, biomarker skin test patch) are available,
patches which can be useful for persons desiring to gather statistics on their medical condition
over a specific period of time.

Futuristic approaches – TeleMed is considering also incorporating the blood chip, also known as
the lab-on-a-chip device. The current development in nanotechnologies must not be ignored. In
the future, by using this blood chip, the waiting until results time will be decreased from days
(normal blood samples) or weeks to only a few minutes [Genuth, 2006].

Location – the issue of locations is related to national and regional preferences as well as
legislation. The results of our questionnaires indicate that places like hospitals and doctor’s offices
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would be the option of choice for the majority, while shopping malls and fitness centers would be
the last option. Stayhealthy and IBM claim that their solution can be deployed in a multitude of
locations, but after asking them directly about the public places in which this health kiosk can be
deployed free of charge, they have mentioned universities and shopping malls. The innovation of
TeleMed relies this time on the Danish system. By providing free medical care (which countries like
USA do not), this permits our machine to be placed in locations like the doctor’s office or the
hospitals, feature that the Health Kiosk from Stayhealthy and IBM cannot possess, as the intention
of these manufacturers is to experience the highest profit possible. The kiosks available in
universities are free for the users, but are paid by the universities, while the kiosks in malls are
filled up with advertisements, which assure that the services are delivered for free (the
StayHealthy approach).
4.2 Worldwide technical aspects related to TeleMed
Infrastructure was the main focus of chapter 3 and it has been presented from a number of different
perspectives – security, change management, finances and costs, service desk, human infrastructure and
none the less standards and legislation. One can see, from reading what has been presented so far that the
focus of TeleMed is within Denmark’s territory. In spite of this fact, there is a need to learn from
telemedicine projects developed or being developed in other parts of the world. It is self evident that the
focus of analyzing these projects is on a technical level, trying to understand the technical approach,
regardless of other important aspects e.g. legislation that might not apply in Denmark’s case.
To begin with, the first presented project is going to be the RESHEN project, a project that is incorporating
regional networks from three different countries, namely Greece, Finland and Germany. The network in
Greece consists of hospitals, health centers and infirmaries connected through a network, making the
electronic prescriptions and referrals possible. The network in Finland includes several hospitals connected
to a central hospital with the aim of exchanging electronic health records, while in Germany the involved
entities have a focus on treating cancer patients by taking advantage of different knowledge levels. These
three networks are inter-connected, thus permitting the medical professionals to exchange opinions in
order for the patients to receive the best possible care.
By analyzing the proposed architectures, it is becoming obvious that in RESHEN the Public Key
Infrastructure has been chosen as a security framework. It is also worth mentioning that the certificate
authorities chosen are accredited, national ones and secure databases have also been deployed. If one is to
refer to the security chapter, one would find a number of other things that the proposed infrastructure of
TeleMed has in common with this international project. XML- security is one of the aspects in common,
mainly because of the world wide accepted standards. For a brief description of how the XML-security (e.g.
digital signatures) is proposed for TeleMed, the reader can refer to the Security chapter (3.6). In a project
that tries to make possible the interconnection of three networks from different countries, the issue of
making use of widely available standards, which ensure interoperability, is of critical importance. Thus, the
protocols being deployed in these networks fall in this category – the TLS protocol, XML digital signatures,
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etc. While presenting the proposed security architecture for TeleMed, smart cards are mentioned as a
possibility for enhanced authentication mechanisms. The viability of this idea is proved by the current
deployment in the three debated networks.
4.2.1 The French System
In chapter 3.6 the possibility of authentication by the use of smart cards has been brought under
discussion. One of the countries that have adopted a model which includes smart cards is France. Even
since the beginning of 2003 50 million cards have been issued [Kleinebreil et. al., 2003]. The mentioned
cards confirm e.g. the social rights of the user. In regards to the health professionals, at the same date 0.5
million cards had been issued having encrypted information about the medical professional on it. The
French model made use of specialized entities which certified the information on the cards and the level of
specialization of the medical professional making use of it (physician, primary care or specialist) [Kleinebreil
et. al., 2003]. One major disadvantage of introducing a similar system for TeleMed would be the high cost
while the most prominent advantage would be overcoming security threats that are characteristic to digital
signatures.
4.2.2 The Swedish System
The deployed model (security wise) in Sweden was somehow different from the other models presented so
far. The security of information was the main concern just like in the other projects, but in Sweden the
government took advantage of the existing security infrastructure already deployed for banks. The starting
premise for this approach was:
“With no attractive eServices available there was no motivation for people to acquire means for eIdentification. With people not having means for e-Identification there was no motivation for government
agencies to develop more advanced services” [Ribbegard, 2003]. Authenticating users could be a major
problem (correct identification and costs) when it comes to a large population and since the banks in
Sweden had an already existent solution the natural approach of the government was to take advantage of
an existing infrastructure. Thus, one of the important healthcare projects that was going on in Sweden was
the Secure IT for Healthcare Systems (SITHS) whose focus was the PKI for healthcare application, trying to
determine, among other aspects, if a national agency should be chosen or several regional ones [Ribbegard,
2003]. As described in [Ribbegard, 2003] the outcome of SITHS was that users and healthcare professionals
could be e-Identified by secondary certificates without the need of issuing special healthcare cards, taking
advantage of the existing means of identifying users on-line by banks. The problem with choosing this
solution was how to offer PKI services in an interchangeable way, delaying the process of introducing
secure healthcare applications.
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4.3 Lung test
Another test which is considered to be integrated in the TeleMed machine is the lung test. In this part main
aspects concerning how the test is performed are explained, what kind of diseases can be detected, and
what devices could be used starting today to test the user.
First of all it should be made clear what lung tests are used for. Lung function tests (also called pulmonary
function tests) examine how well the user’s lungs work. The test determines how much air the users’ lungs
can hold, how fast the user can breathe air in and out of the lungs, how well the users’ lungs receive oxygen
and remove carbon dioxide from the blood. After the test the user gets an estimate on the lung’s volume.
Lung volume is measured by the total amount of air the user can breathe out after a deep inhalation (The
average pair of human lungs can hold about 6 liters of air and only a small capacity of this is used during
normal breathing). Lungs volume can vary due to a lot of reasons; first of all, the best result is usually
shown for 20-25 years old people and it also depends on sex and height as well. Secondly, men usually
have bigger lungs than women and taller people have larger lungs than shorter people. Also factors like
smoking or not and fitness make a difference in the volume [Booker, 2007]. So to keep these criteria in
mind during the calculation, the user should be asked specific questions before, in order to assure a valid
test.
The primary device used in lung tests is the spirometry which will be integrated into the TeleMed system.
Spirometry is always considered the first option when testing lung functions. For this kind of test the user
breathes into a tube with a mouthpiece which is attached to a recording device. The user simply inhales
deeply, closes the mouth tightly around the mouthpiece and exhales through the tube while measurements
are taken. There are some tests where measurements are obtained by normal breathing, but some other
tests require fast and forceful inhalation and/or exhalation. The volume of air inhaled or exhaled, and the
length of time each breath takes is recorded and analyzed. In view of the fact that some patients may be
sick, and for purposes of general hygiene, spirometer mouthpieces are designed for single patient use and
are therefore disposable. They are manufactured and used in quite large numbers. Furthermore,
mouthpieces should be in various sizes to make more suitable for e.g. children to use, to make sure the test
is performed properly. As for lung tests performed on the TeleMed machine the user should after the test
remove the mouthpiece and the next user puts on a new one - in case of the user forgetting to remove the
mouthpiece, instructions before performing the lung test will be available, notifying the new user to put on
a new mouthpiece on the tube if it is not new. Tests might be taken several times to make sure of the
results correctness. Information is given on how to produce more accurate results before the test – E.g. the
user should not eat heavy food or smoke for 4-6 hours etc. before the test [Bellamy & Booker, 2004].
Most common lung function values measured with spirometry are [Bellamy & Booker, 2004]:


Forced vital capacity (FVC). This measures the amount of air you can exhale after you inhale as
deeply as possible. This is the volume of air which can be maximally exhaled out of the lungs until
no more can be exposed. Usually results are expressed in liters.
Forced expiratory volume (FEV). This measures the amount of air you can exhale with force in one
breath. The amount of air you exhale may be measured at 1 second (FEV1), 2 seconds (FEV2), or 3
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
seconds (FEV3). FEV1 divided by FVC can also be determined, providing an important parameter in
diagnosis COPD, as can be seen in table 6 below.
Forced expiratory flow (FEF). Measures how much air can be exposed from the lungs. The quartiles
are expressed as FEF25%, FEF50%, and FEF25%-75% of FVC. It is measured as liters/second or
liters/minute.
a) FEF25%: Shows the amount of air that was expelled in the first 25% of the total forced vital
capacity test.
b) FEF50%: Shows the amount of air expelled from the lungs during the first half of the forced
vital capacity test.
c) FEF25%-75%: This parameter measures the air flow expelled between the first 25% and
75% through an exhale.
The pulmonary function tests represent a viable method in measuring the chronic obstructive pulmonary
disease (COPD). COPD manifests when there is a limited airflow in the lungs and represents a chronic lung
disease that includes two main illnesses: chronic bronchitis and emphysema (the air in the lungs is exhaled
with a slower rate and smaller amount compared to a healthy person). The disease develops and worsens
over time and COPD is not curable, but therapy can slow its progress. To make clear exactly how serious
this disease is, it can be mentioned that in USA 12 million people are diagnosed with COPD and the disease
develops over many years and is often caused by cigarette smoking [COPD, 2001].
When testing for COPD, the test results will be compared with normal value-tables with variables such as
age, gender, body size to set the severity. The following table shows spirometric criteria for COPD severity
recommended by Global Initiative for Obstructive Lung Disease (GOLD) [Bellamy & Booker, 2004]:
GOLD Spirometric Criteria for COPD Severity
I. Mild COPD
* FEV1/FVC < 0.7
* FEV1 >/= 80%
II. Moderate * FEV1/FVC < 0.7
COPD
* 50% </= FEV1 < 80%
III.
Severe * FEV1/FVC < 0.7
COPD
* 30% </= FEV1 < 50%
IV.
Very * FEV1/FVC < 0.7
Severe COPD
* FEV1 < 30% or FEV1 < 50%
At this stage, the patient is probably
unaware that the lung function is starting to
decline.
Symptoms during this stage progress, with
shortness of breath developing upon effort.
Shortness of breath becomes worse at this
stage and COPD exacerbations are common.
Quality of life at this stage is gravely
affected. COPD exacerbations can be life
threatening.
Table 6:GOLD Spirometric Criteria for COPD severity
From the table we can see there are 4 stages to be concerned with. At first stage when showing mild
airflow limitations which usually causes chronic cough, mucus production, and the beginning of damage to
lungs, the patient may not notice the symptoms. The main advantage of using the TeleMed machine for
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lung test is that the machine can detect the first stage of COPD. The second stage called moderate COPD is
when the airflow is getting worse. The patient will notice symptoms like dyspnoea (difficult or shortness of
breathing). At this stage the patient would usually go see a doctor for the first time. The third stage which is
called severe COPD is when the patient has a very limited airflow. At this stage even simple physical activity
as leaving the house or going upstairs can cause dyspnoea. And finally the fourth stage called very severe
COPD is most critical in which complications such as respiratory failure and heart failure begins to develop.
As an insight of what future developments in the lung feature of TeleMed can offer, here is listed a few
alternative existing lung tests devices able to perform and detect diseases mentioned above. There are a lot
of portable lung test devices available on the market, e.g. the below mentioned portable spirometers:

First one is called MiniSpir which is a portable USB spirometer [Medshop, 2009]. The most
interesting thing about this device is that it can be connected to a personal computer through a
USB port and it is using spirometer provided software giving the user the possibility to perform a
large variety of tests. Some of the possibilities are measurement of lung age estimation. This device
can also be integrated in the TeleMed machine quite easily as a future development; the only thing
needed is software integration and a USB port.

Another lung test device which is more expensive and more powerful is called “SpiroLab III”
[Spirolab, 2009]. This device offers FVC (Forced vital capacity), SVC (Slow vital capacity - amount of
air you can slowly exhale after you inhale as deeply as possible [Bellamy & Booker, 2004]) and MVV
(Maximal Voluntary Ventilation - the greatest amount of air you can breathe in and out during one
minute [Bellamy & Booker, 2004]) tests with real time curves, high resolution color screen, fast but
silent thermal printer and a digital turbine flow meter.
4.4 RFID-patches
Including RFID applications in the TeleMed machine can raise different questions related to scalability,
effectiveness and efficiency [Vilamovska et. al., 2008]. These aspects are closely connected to the following
question: What is the biggest problem that could appear due to missed use or inappropriate use of the
RFID application? Can the information provided this way be reliable and is it possible to offer RFID patches
for free use? All these questions are going to be analyzed in the following chapter.
One key feature of using the RFID technology is the possibility of automatic data collection and transfer.
This could prove time-saving and error diminishing [Vilamovska et. al., 2008], considering a usual form
processing time.
The RFID tags could be classified in different ways, but the most usual classifications rely on:
1. Active, semi-active, passive tags.
2. Data storage/memory: read-only, read-write systems.
3. Frequency classes.
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The RFID technology differentiates itself from other technologies by the capability of non-line-of-sight – the
propagation of waves between the readers and tags even if there are obstacles on the direct path between
them – in certain frequencies. One of the most used distinctions made between passive and active RFID
tags is between active and passive tags, referring to the way the tags are powered. The passive tags have
no power source of their own, requiring an external source e.g. the electromagnetic waves from the reader
so that they can transmit signals [Vilamovska et. al., 2008]. This feature translates in long life but in the
same time in a decreased range of communications (up to 5 m). To compensate this, the active tags make
use of a battery which increases the range of communication but decreases the long-life capability, as the
battery will eventually finish. In [Vilamovska et. al., 2008] it is claimed that although passive RFID tags are
smaller and cheaper, active RFID systems are actually cheaper and easier to install. As it is going to be
explained in the following paragraphs, our choice is going to be related to passive tags, as the cost-efficient
solution could be achieved by using a reader-capable mobile phone. The second classification debated is
related to the working frequencies. Long range, lowest cost, fast speed applications and highest
susceptibility to interference (requiring line of sight communication) are features of ultra-high frequency
tags (888–915 MHz) while high-frequency tags (13.56 MHz) have a medium range, a slower reading speed
and are more expensive. The last category is the low frequency (<125 kHz) tags used for the most
expensive, the least prone to interference and for the longest-range [Vilamovska et. al., 2008].
There are alternative radio frequency solutions like bar codes, Infra Red (IR), but without practical value in
telemedicine. A viable alternative to RFID in telemedicine could be ZigBee, based on IEEE 802.15.4 wireless
communication standard. ZigBee has a similar functionality to Bluetooth, allowing each node to relay the
traffic from all other nodes (zigzagging from one to another). This capability proves its utility in a number of
applications but in regards to the TeleMed solution, it adds no value. A kit for a person is going to be
composed of just a small number of tags that are going to communicate directly with the reader,
eliminating the need for every tag to relay the traffic from all other nodes. In the introductory chapters we
have formulated the requirement specification for the so-called RFID tests. But what enables the wide-scale
RFID implementation in telemedicine? The most important enablers are, as presented in [Vilamovska et. al.,
2008]:
1. Better healthcare delivery - this can be analyzed from a number of perspectives. One perspective is
the prevention feature, which leads to decreased costs. A second perspective could be the
paperwork and manual activities which the RFID technology can address in a more efficient way. By
incorporating RFID in TeleMed, the benefits of patient self-management at home appear alongside
the possibility of collecting biometric data over a specific period of time.
2. Government support – our project is intended to be sponsored by a governmental force (alongside
private money for pilot studies), thus in order for it to succeed, this support is regarded as an
enabler of highest importance. The support from the government can be assured by promulgation
of standards involving the RFID applications or by adoption of quality standards in national
healthcare systems, which in turn can lead to scaling up capacity [Vilamovska et. al., 2008].
How can the RFID be implemented in a so-called “smart-way”? The smart implementation, as stated in
[Vilamovska et. al., 2008] is associated with:
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

A well planned and successful pilot/demo
Understanding of implementation costs - It appears to be a common belief [Vilamovska et. al.,
2008] that the prices of RFID tags, both passive and active is dropping and will continue to follow
this trend, alongside the complete RFID applications. The issue that is not agreed upon is the size of
the cost decrease and the timeline, both being best characterized by uncertainty. In the present,
the cost of RFID tags varies from 7 to 12 US cents, depending on capabilities and order size [RFID
Journal (2009)], while the prices of the reader, accordingly to the RFID Journal “cost from $500 to
$2,000, depending on the features in the device” (for UHF readers) and “High-frequency reader
modules are typically $200 to $300” [RFID Journal (2009)].
Advantages of RFID tags – advantages are especially obvious for active tags (greater power, versatility and
range), but we claim that the benefit of having a cost-efficient solution is greater in TeleMed, which means
passive tags should be used. Also, in our view, already having a mobile phone that is able to act as a RFID
reader leads to cost diminishing, as the RFID reader could be integrated in the mobile phone, with the cost
of losing a part of the user-friendliness. This solution is very similar to the approach of Gentag, the
company that has patented the use of RFID skin patch with a mobile phone reader. The other advantages of
RFID tags refer to real-time data availability, ability to store more and encrypted information and userfriendliness.
The next step after analyzing the enablers for using RFID in TeleMed is to analyze the possible obstacles
that this solution could be facing. Costs play an important role in this paragraph, as well. We claim that the
costs of deploying a RFID system can be decreased by using a mobile phone with reader capabilities, but
this implies the respective patient already having the phone. This capability is not yet a very spread feature
between mobile phones in the present, or at least among the usual category of phones (excluding smart
phones), but according to Gentag’s forecast [Gentag (2009)], in the future one out of two mobile phones
will be RFID-enabled.
Another obstacle could be related to legal issues – without a legal standard that supports the RFID
applications deployment could be made even more difficult. The security obstacles that could come across
while using these tests are no different from the ones debated in the security chapter. The mobile phone is
used in our scenario as a “middle layer” between the RFID patches and the machine, which eliminates the
need for the mobile phone to send the information stored directly on the Internet and to the database. This
means that no extra security patches should be incorporated in the mobile phone application, relying only
on the security features provided by TeleMed.
The third possible obstacle relates to technical issues like interference, reliability and interoperability
[Vilamovska et. al., 2008]. By using passive tags, the range of communication between the phone and the
tags is decreased which reduces the chance of interference. Reliability is accomplished by using a statisticslike gathering of data, like mentioned before. The interoperability issue seems the most problem-posing
one, as the mobile phone of the patient should be able to read the information sent by the tags,
independently of the tags manufacturer.
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The last mentioned obstacle in the way of deploying RFID application for TeleMed concerns the patient’s
acceptance (cultural and ethical concerns) as mentioned in [Vilamovska et. al., 2008]. For example, because
of misunderstood security and privacy in some cultures and religions, a number of anti-RFID initiatives have
already formed in different regions of the world, where RFID are considered “the sign of the Beast”,
referred in the Apocalypse of John. Another misconception regarding RFID is the fear of ubiquitous
surveillance, no matter what application is being deployed. Fortunately, this kind of reaction is not frequent
in Denmark but still needs to be taken into consideration as a potential obstacle as it has the possibility of
delaying the large scale deployment of RFID solutions in TeleMed. Patients need to be convinced that the
data is not going to be misused and in the same time patients/users need to have trust in technology.
Again, referring to the results of the questionnaire from chapter 2.2.1 the population of Denmark has an
above average trust in technology which could lead to a rapid adoption of the RFID applications in
telemedicine. In regards to the misusage, it is our belief (also confirmed by the results from the
questionnaire) that for this to happen, TeleMed needs to gain reputation. This process can be hurried up by
governmental standards for RFID applications and as well by public information campaigns, which could
also help overcoming obstacles like citizens not being aware of the benefits of RFID. The security issue
related to interception of the information stored on the RFID or phone by unauthorized parties can be
addressed by encryption and authentication methods (explained in the security chapter).
4.5 Blood Tests
Penetrating the skin of the patient without surveillance of a doctor is a sensible matter, but nevertheless it
is a possible differentiation of the TeleMed machine. At the moment StayHealthy is not performing invasive
tests but in the future they are planning on using blood meters – meaning finger prick tests. Which tests
exactly is being kept a secret.
The blood tests represent the most difficult subject to tackle. From a usual blood sample, a doctor could
test a very broad list of possible illnesses. The blood is composed out of red cells, white cells and platelets
[Boryczko et. al., 2003]. From red cells the hemoglobin concentration can be deducted which is useful in
conducting investigations related to anemia, for example.
Research in this field is an on-going work and thus the possibilities of diseases tested or maybe even
prevented by blood samples is expanding each day. A simple blood sample could be taken in a few minutes
in a doctor’s office and it’s the first thing that is tested during a usual check up. But what about those who
are afraid/ashamed or maybe don’t have the time of going to a doctor for a simple check up? Our idea is
targeting exactly those people, but is facing a big problem – the hygiene and legal issue (described in the
legislation part). Think of a machine that could take your blood sample in just a few seconds – without
having to wait for 2 days to set up a doctor’s appointment and provide results almost instantly. As
interestingly as it may sound how can the hygiene issue be taken care of? It appears that Aydogan Ozcan,
the head of the Bio and Nano photonics Laboratory at UCLA, came up with an innovation that bypasses
these issues [Lemens, 2009]. Aydogan Ozcan states that most HIV patients are either in India or Africa and
they do not have the resources (you can just replace “resources” by time in more developed countries) of
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taking blood samples, sending them to a central lab and getting the counts back. His invention refers to a
usual cell-phone to which a tiny glass slide that holds blood sample was added [Lemens, 2009]. This could
be clear evidence that hygiene can be fixed in the short term future. But hygiene is not the only problem of
ordinary blood samples. One sample is rarely enough to state clearly if a disease has spread in a body. E.g. a
test for diabetes sometimes shows alerting values whereas the next two tests show normal values. Also,
performing ordinary blood samples will be a major expense due to storage, at least if it will be possible for
all of the public to perform the tests. Nevertheless, if future developments are being carried out in this
field, it may show itself as a future prospect.
For this project, we have searched the help of a blood specialist, Kim Larving. We have discussed the
possibility of including finger prick tests in our machine but we were confronted to a very skeptical position.
We feel that blood tests could be conducted by the use of so called rapid tests – like finger needles, tests
that require several times less amount of blood. The problem with usual blood samples taken at a doctor’s
office is due to the perspective of having a patient bleed too much or even having him/her faint. This is not
a viable alternative if the machine is to be placed in a different place than a doctor’s office. With this in
mind we have presented the idea behind the finger needle but the skeptical position was due to the
supposedly lack of accuracy of these “rapid – tests”.
Although this could be interpreted as a sign of shutting down the perspective of including finger prick
samples and, further on, tests in the machine, the specialty literature tends to contradict this perspective.
In the paper called “Finger-prick blood samples can be used interchangeably with venous samples for CD4
cell counting indicating their potential for use in CD4 rapid tests” by [Calman et. al., 2005] it is proved that
the accuracy of these rapid tests is getting better and they point out the possibility of replacing venous
blood tests by these rapid tests after the latter ones become more widely available. It is true that this
research was conducted for tests over HIV and our project has nothing to do with this kind of diseases (we
don’t have in plan a machine that could provide you with these kinds of results simply because of the
psychological effect) but we should keep in mind the perspective or rapid tests that could add value to our
innovative idea.
Considering the finger-prick test, the level of blood sugar could be measured (helpful in the treatment of
prevention of diabetes), the hemoglobin level that could be an indicator if someone is allowed to donate
blood, and the mononucleosis test could be conducted with the obvious advantage of needing a small
amount of blood – usually less than 500ug. These are the most acknowledged tests on the market of blood
meters and other measurements seem unreliable. One other measurement that can be performed with a
useful result is blood poisoning, but it does not seem feasible to spend money on testing something so rare.
When blood meters at the TeleMed machine are being used, it is important to stress for the patient that
the results given should be seen more as indicators than final results. Blood tests are complicated matters
which often demands more than one test. E.g. diabetes patients (or people who want to find out if they
have diabetes) often use glucose blood meters three times a day in order to find clear results. If patients
want to test glucose values with TeleMed they will have to test themselves at least once a day and by use
of the database (which could help in calculating statistics hereby making curves only giving indicators if the
patients glucose is within the danger zone) the diabetes test can only be seen as a warning sign and final
conclusions can only be drawn by making contact to a doctor, if the values gathered are critical.
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Nevertheless, it is an important preventing test while the patient may not get tested before it is too late
otherwise.
By making contact to StayHealthy’s information manager John Collins it became clear that their main hold
back for using finger prick tests is the hygiene. It is obvious that it is a major problem for their machine
since it is located e.g. in malls where no medical assistants are available. With the TeleMed approach,
having the machine at the doctor’s place, medical assistants can easily exchange the small needles from the
tests and make sure no danger of transmission of diseases occurs. Naturally the patients using the tests
may have their concerns of trust but it is a core intention of the machine to have a high reputation.
Within the telemedicine field many papers stress the need for further availability of especially diabetes
help. It is definitely a major improvement of the TeleMed machine compared to the StayHealthy machine
with the usage of blood meters.
4.6 Realistic future changes
4.6.1 Iris laser test
During the meeting with Kim Varming we were introduced to the possibility of performing laser iris-tests
(Iris being the eye-ball). As clarified in this report eye-tests will be performed in the TeleMed machine but
only traditional tests (stated in sub-chapter 4.3). The possibility of scanning the iris with laser exists and is
already on the market [Diytrade, 2009] but has not yet been scientifically approved (though it has been on
the market since 2004). Scanning the eyes with laser can show signs of black pigment, problems with blood
veins in the eye, problems with tissue and other criteria’s, but as such lasing the iris does not produce
results of the users visibility. The test can identify problems with the pupils but these measurements can be
influenced by the density of light in the location where tested (A few iris laser test instruments can
calculate the density of the light in correlation to the pupils, but the results are not detailed).
Looking at other health kiosks on the market only dealing with eye tests such as SoloHealth, it became clear
that other providers do not implement the usage of scanning the iris. It has been concluded that TeleMed
will not make use of the option since it is not scientifically approved and therefore will be troublesome to
launch while it will be time consuming to get a permission and maybe not even possible to offer to the
public. Also, if a decent laser iris test should be performed an assistant is needed to make sure the user is
placed correctly in relation to the laser. Dealing with laser can also give problems with injuries of e.g.
diabetics (not able to handle the lights). An iris laser test show no more than what can be seen by an eye
specialist by just observing the patients eye and it has therefore been decided that for the more detailed
eye problems the iris-test deals with, a practical eye doctor is more convenient. Maybe future
developments of laser testing will improve but at the moment it is not convenient as a tool for persons
performing the test themselves.
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4.6.2 Blood chip
Starting from 2006 [Boothby, 2006] it became possible to perform tests by handheld microchips stating to
which kind of blood group the patient belongs. This was especially convenient for patients who needed
immediate treatment not being at a hospital in order for the surgery not to fail. It only took three seconds
to perform the test and only demanded three microlitres of blood. As a follower the same year a new
invention could show how many red and white blood cells the blood contained as well as showing
infection, anemia, allergies and immune system deficiencies [Genuth, 2006].
Nevertheless, to be useful for the TeleMed machine more measurements than only which blood group the
user belongs to and few other measurements are needed. This became possible last year (2008) by a new
invention by James Heath [Jablonksi, 2008]. He, alongside with more professors, invented a new chip that
within ten minutes can measure a variety of results. Some predict that the chip will even be used in
ordinary doctor offices because of the fast result instead of having to perform a blood sample that needs to
be analyzed and takes days. It only takes a single drop of blood to get results from the chip. Here is how the
proceeding is explained:
“…Starts the analysis process with some simple microfluidics. A drop of blood is pulled down a microscale
channel by the application of a small external pressure. This first channel branches off into narrower ones,
which exclude blood cells and admit the protein-rich blood serum. In typical blood tests, this separation step
requires a centrifuge. The narrower channels are patterned with what Heath calls a protein bar code — lines
of DNA bound to antibodies that capture proteins of interest from the serum. After the serum and cells are
flushed out, antibodies bound to red fluorescent proteins are flushed in, lighting up captured blood proteins.
The protein bar codes can be read under a fluorescent microscope or a gene-chip scanner. The identity of
the captured blood proteins can be determined by the location of red lines in the bar code relative to a
green fluorescent reference line” [Jablonki, 2008].
Figure 27: Blood chip
[Svitil, 2008]
If the possibility of performing blood chip tests at the TeleMed machine is offered, a scanning device is
needed for the results to make sense for the user. Compared to an ordinary blood sample test a doctor
would perform, the blood chip takes care of the following in the process [Toner & Irimia, 2005]:
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Figure 28: Blood chip infrastructure
Identification, separation and analysis are what is time consuming with ordinary check-ups which with the
blood chip can be achieved in 10 minutes. It saves personnel and time and is a significant decrease of costs.
This, alongside with showing more specific results, is what differentiate the blood chip from finger prick
samples [Genuth, 2006]. As a whole, the idea of blood chips opens a gap of treasures of wide information
on the body’s health since blood carries various information. The concentration of a dozen of proteins can
be measured by the chip and signs of e.g. cancer and heart diseases can be detected. Nevertheless it would
be more convenient to introduce in the TeleMed machine after the blood chips have been accepted as
common use in hospitals, doctor’s offices and ambulances (needing immediate blood samples). Also ethical
questions arise with the usage of the chip regarding TeleMed since the result may e.g. show cancer, and it
can be argued that such a statement is not suitable to be informed at a machine – also one result showing
cancer is not a certainty of cancer, more tests are needed according to blood specialist Kim Varming. It
should also be mentioned, that even though the chip currently is working well it is still undergoing
improvements being able show more results (up to 100 different proteins) and the scanning device needs
to be more user friendly for an ordinary user to understand the information given [Svitil, 2008]. The blood
chip has received confrontation since analyzing blood cells are a complicated matter, but critics seem to be
unable to deny the usefulness of the chip. Nevertheless, being a ground breaking implementation for
82
medical treatment both for prevention and lower costs it will still be most appropriate to wait
implementing the chip in the TeleMed machine.
4.6.3 Information offerings
After a meeting with telemedicine specialist Birthe Dinesen we became aware of the importance of
interviewing the users at the machine prior to a test. Before a user for example gets tested for lung
diseases it would be important for the end results if the user is a regular smoker. Birthe Dinesen showed us
telemedicine equipment which by a menu asked the user several questions before the tests were
conducted. It all builds up to more valid results and better the users’ understanding of which criteria’s
influences the health of the concerned matters.
As earlier mentioned, the TeleMed machine contains information regarding the tests and information in
general on e.g. nutrition, training programs and symptoms. At the moment, the biggest portal on the
Internet in Denmark containing this type of information is Sundhed.dk. Sundhed.dk is owned by the
government and since we expect TeleMed to be owned by the government as well, we recommend trying
to make an agreement on information sharing as an effort to keep production costs of new information for
the TeleMed machine down. This might be considered a setback for Sundhed.dk since it will decrease the
portals importance, but TeleMed will only need very specific information whereas Sundhed.dk has many
more offerings such as debates, archives and chat. Collaboration between Sundhed.dk and TeleMed can
easily be engaged, but other Internet sources should be kept in consideration as well as alternatives.
4.7 Differentiation of the market
We believe launching TeleMed in Denmark gives advantages. These advantages are difficult to state with
sources since it is mostly assumptions of market mechanisms and cultural differences, but nevertheless it
has been found an important improvement of the TeleMed abilities.
One major difference between the Danish and American market has been mentioned in sub-chapter 4.1
clarifying the possibilities of making TeleMed free of charge not being possible in America. Current
American president Barack Obama wishes to change the American healthcare system being rougher on the
insurance companies and making it easier for the citizens to purchase insurance, but there are no signs of
healthcare being free of charge [BBC, 2009]. But other criteria’s also influence the difference of having
freely used options. E.g. Danish clients would most likely hesitate more on using a health care machine with
commercials (which is the case with StayHealthy located in malls). This is a criteria making it easier for
American distributers to make money, but it leads to a Danish advantage – the government would be likely
to contribute mentionable on the production and maintenance of the machine, and therefore commercials
83
are not needed to the same extent, and the TeleMed machine can be located at places where commercials
are not being as eye-catching, like at a doctor’s office.
Denmark also has the advantage of being a small country, making it easier to build up a good reputation
and to spread out information about the machine. This differentiation is of course only set in relation to
larger countries.
After having the meeting with Bjarne Flou (see chapter 5) it became clear that a quite similar project to the
TeleMed project had been running in 2008 in Germany but had to close down due to lack of investors.
Bjarne Flou nevertheless found the possibilities bigger in Denmark due to a rise of economical investments
in telemedicine. At a political point of view many investments have been made building new hospitals etc,
and it seems likely that the Danish government would be more eager to invest more compared to many
other countries. Another factor is the TELEKAT project finding many private investors building up a secure
economical base.
Reviewing the Danish legislation it became clear that no major obstacles were endangering the project. It
will be fair to assume that some other countries have privacy, medical or security boundaries making the
project difficult to launch. Other factors e.g. insurances (or traditions of health care payments) makes
Denmark easier to handle when it comes to launching a free of charge medical supplement. The only
analogous machine to TeleMed, StayHealthy, deals with insurance difficulties on the American market. In
Denmark no such factors are playing a role.
Overall, Denmark has shown itself a country willing to take the first step globally in various areas, also
within the medical sphere – and going on by having the first public freely available health care system does
not seem unlikely. As mentioned, above information is build on assumptions and knowledge of market
indicators, but it seems reasonable to have in mind.
84
Chapter 5
5.1 Interest shown in TeleMed
Following the e-mail exchange with Bjarne Flou, managing director, interest from Tunstall Healthcare A/S
has been shown in the TeleMed project. At the moment, Tunstall Healthcare offers a list of personalized
solutions – medical kits for diabetes patients, COPD patients, etc. Apparently, Tunstall is receiving requests
from places like nursing homes asking for a multi-user solution; requests that Tunstall feels could be met by
TeleMed as our solution is not focused on a personalized list of test, but on a multitude of tests. A graphical
representation would help to understand the interest of Tunstall better:
Home with Diabetes patient
•Kit with blood pressure, heart rate, blood
oxygen level and glucose measurement test.
Home with COPD patient
•Kit with blood pressure, heart rate, blood oxygen
level and spirometry
Nursery home with TeleMed
The solution here should not be personalized
anymore and be able to meet the requirements of
all users.ent
Figure 29: Tunstall interest
Why would this location be interesting? Because of the advantages offered –nurses in these facilities have
to take care of patients, which means that the issue of performing the tests in the safest way and in the
most hygienically way is being resolved through this approach. The deployment of TeleMed could take
place faster as demands already exist for this solution. Our initial approach was aimed at obtaining public
owners (meaning the government) but, if deciding to accept this offer it would mean that the investment
would come from the private sector, turning TeleMed into a commercial solution.
As discussed so far, the possible contribution from our side in the Tunstall project is going to also take care
of integrating the hardware with Tunstall’s existing platform and is going to extend beyond the time this
report is going to be presented. The first step for this collaboration would be finding equipment distributors
in order to build TeleMed so the following sub-chapters will focus on distributors (e.g. A&D) and
equipments.
85
5.2 Distributor
In the search for a distributor it became clear that a variety of distributors are needed. Products like
monitors and the skeleton of the machine can be whoever is willing to offer the smallest price. Many
factories can offer these products and the choice will most likely be an option of price. E.g. the monitors
can be from Samsung, Daewoo, Sony etc. but it does not make a big difference which company is chosen
therefore the lowest price is decisive – if the quality is acceptable. This strategy was proposed by
StayHealthy in e-mail conversation with John Collins.
After browsing for companies distributing telemedicine components the most suitable company is A&D.
The company is multinational and well-established since 1977. The company is a producer of advanced
measuring, monitoring, controlling and testing instruments. The company offer a lot of the components
needed in the TeleMed machine which have been clinically validated before sale. Other alternative
companies, such as TelcoMed, are possible alternatives, but no one else seems to offer as many relevant
components as A&D. StayHealthy are also using some components distributed by A&D – e.g. the TM-2655
showed below.
Contact was made to business developer at A&D Frank Downing who provided information about the
components functionality and gave some price examples. Here are some examples on components known
to be relevant for the TeleMed machine:
UA-767PBT-C40 – Blood pressure monitor. Price 810 DKK per unit.
A minor device called UA-767PC is priced at 722 DKK per unit.
Figure 30: Blood pressure monitor
Features of UA-767PBT-C40:
Bluetooth Class 1
CE0700 compatible
128bit encryption of data for protecting patients' privacy
Higher compatibility with various Bluetooth receivers
Built-in real time clock
Irregular Heart Beat Indicator
Extra large 3-line display for easier reading of results
One-touch measurement
SlimFit comfortable cuff
TM-2655 – Fully automated blood pressure monitor. Price 9.824 DKK per unit. This machine is commonly
used at hospitals and on the StayHealthy machine. It only takes few minutes to perform a test.
86
Figure 31: Automated blood pressure monitor
Features of TM-2655:
Compact size
Light weight and either arm measurement
One-touch measurement
Large LED display
Quick printout (on TM-2655P model only)
Dual RS-232C ports
UC-321PL – Weight scale featuring suitable software. Price 745 DKK per unit.
A minor device called UC-321PC is priced at 581 DKK per unit.
Figure 32: Wight scale
Features of UC-321PL:
50g resolution
Maximum capacity of 150kg
Target weight setting
31 built-in memory function
BMI Value Calculation
Very low profile so easy to step onto scale
UC-321PBT-C40 – Weight scale with wireless connection and a weight capacity of 200 kg (compared to the
before mentioned 150 kg). Price 1.005 DKK per unit.
87
Figure 33: Wireless weight scale
Features of UC-321PBT-C40:
Bluetooth Class 1
CE0700 compatible
128bit encryption of data for protecting patients' privacy
Higher compatibility with various Bluetooth receivers
Built-in real time clock
100g resolution up to 200kg capacity
Very low profiles
Rugged construction
Motion tolerance
Kg / lb selection
Regarding distributors it is a disadvantage with the relatively few distributors available on the market which
may cause a rise in retail prices. As a strategy TeleMed should nevertheless always consider new
distribution channels to keep costs low. Nevertheless the prices of A&D components seem reasonable, and
if TeleMed make large orders from the beginning, the prices might even lower.
88
Chapter 6
Conclusion
TeleMed represents a complex project, one that deals with a multitude of different aspects (e.g. medical,
financial, technical, etc). Throughout this report, the need for TeleMed as well as the void that TeleMed
could be filling on the market have been identified. Moving from the current curative approach that
Telemedicine seems to be embracing towards a more prevention-oriented one is synonym to introducing a
new medical paradigm. Following this path is not an easy task – questionnaires have revealed, among other
things, that the success of TeleMed (measured by the number of people using it and number of times to
use it during e.g. one year) will be conditioned by e.g. first of all, the reputation that TeleMed will be able to
achieve and second of all, the security achieved in setting-up the web-based application.
Reputation is going to be directly connected to the way hygiene issues will be mitigated (throughout the
report, solutions have been presented) while the security issues have been dealt with, referring especially
to the object-oriented programming sub-chapter. On the other hand, patients will not be the only users of
TeleMed. Judging by this category of users, the success is going to be conditioned by the way TeleMed will
be perceived by the medical staff – either as an extra burden or as a method of making everyday’s work
easier. It has been shown that by combining telecommunications with telemedicine, the autonomy of users
will grow which could prove a hard to accept situation by the medical professionals.
The success of TeleMed will also be influenced by the way it is going to differentiate itself from present and
future competitors. At the moment, the biggest competitor is Stayhealthy, which offers the so-called
“health-kiosk”. Differentiating aspects in regards to the medical tests performed can be briefly mentioned –
RFID skin patches, blood tests (performed by the finger-prick), lung tests alongside the advantage of placing
TeleMed in Denmark – the Danish healthcare system (where patients do not have to pay for health care) is
totally different than the e.g. American system. Reputation, security, acceptance by medical professionals
and differentiating aspects are issues that can only be evaluated after deployment of TeleMed.
At the moment, the financial and legislative aspects are of greater importance. After analyzing different
costs directly related to TeleMed (with the focus on transaction costs) we have established as viable
solution a cost of 7.470.000 DKK for a pilot study (for the detailed calculation, the reader is advised to read
chapter 3.2.2) and we have identified potential investors e.g. Aalborg University.
In regards to legislation, TeleMed is aimed at using existent legislation (taking advantage of work already
done by projects like Telekat), without requiring new laws which could delay the deployment.
The field of medicine, in general, is a field marked by continuous research and developments. In order to
address this trend, TeleMed will benefit from a change management board whose first tasks will be
analyzing incorporating developments like the blood chip and the iris tests (tests not accepted at the
moment but still worth considering on a long-term situation).
The overall conclusion is that the TeleMed innovators feel that this project could lead Denmark in a
dominant position in the telemedicine field, given that a number of essential factors join forces towards a
common goal - “Improving the general health in Denmark by the use of telecommunication technologies”
89
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93
Acronyms
AON - activity on node
AOA - activities on arrow
HIV - Human immunodeficiency virus
EHR – Electronic Health record
CAB - Change Advisory Board
RFC - Request for Change
IT – Information technologies
E-Signature – Electronic signature
ITIL - Information Technology Infrastructure Library
SLM – Service Level Management
ISO – International Organization of Standardization
RM - Reference Model
ODP - Open Distributed Processing
UML – Unified Modeling Language
XML – Extensible markup Language
ICT – Information and Communication Technologies
HTTPS – Hyper Text Transfer Protocol Secure
HTTP – Hypertext Transfer Protocol
TLS – Transport Layer Security
CA – certificate authorities
RA – Registration authorities
PKI – Public Key Infrastructure
OSI - Open System Interconnection Reference Model
BMI – Body Mass Index
RFID - Radio-Frequency Identification
RESHEN – Regional Secure Healthcare Networks
FVC – Forced Vital Capacity
FEV – Forced Expiratory Volume
FEF – Forced Expiratory Flow
PEF – Peak Expiratory Flow
MVV – Maximum Voluntary Ventilation
SVC – Slow Vital Capacity
TLC – Total Lung Capacity
FRC – Functional Residual Capacity
94
ERV – Expiratory Reserve Volume
COPD - Chronic obstructive pulmonary disease
GOLD - Global Initiative for Obstructive Lung Disease
VC – Vital Capacity
UCLA – University of California, Los Angeles
CD4 - cluster of differentiation 4
DNA - Deoxyribonucleic acid
95
8.Attachments
Attachment 1: Questionnaire
Beskrivelse af vores projekt:
Vi er kandidatstuderende på Aalborg Universitet indenfor Innovativ Kommunikationsteknik og
Entrepreneurship. Vi har udviklet en maskine der skal danne besparelser omkring sundhedssektorens
infrastruktur samt forebygge sygdomme.
Maskinen har udseende af en pengeautomat, men tilbyder i stedet at få testet sin krop samt indhente
information. Maskinen tilbyder, at der bl.a. kan foretages test af blod (hvilket kan vise kolesteroltal og
andre vigtige parametre), lunger kan blive analyseret, blodtryk kan undersøges samt andre parametre som
kan give prej om ens sundhed. Information om kost, træning samt kontakt til læger kan også indhentes i
maskinen. Maskinen står frit tilgængeligt i det offentlige og anvendelse kræver ingen kontakt med
personale. Informationer fundet frem af maskinen kan videresendes til patientens læge, men der er også
mulighed for en komplet anonym undersøgelse. Det er naturligvis gratis for borgerne at anvende maskinen.
I udviklingen af denne maskine, er der en del brugerkriterier som vi vil være yderst taknemmelige hvis Du
vil hjælpe os med at finde svar på.
Personlige informationer:
A:
Deres køn?
B:
Deres alder?
Lider De af en kronisk sygdom? (Marker med understregning)
A:
Nej
B:
Ja
Hvis ja,
hvilke(n):________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________
Lokalisering af maskinen:
Vi vil bede Dem om at sætte disse lokaliteter i rækkefølge efter hvor De ville foretrække at anvende
maskinen. 1 er Deres foretrukne sted, mens 3 er stedet De vil være mindst villig til at anvende maskinen:
1.
2.
3.
Ved indgangen til et centralt liggende fitness center:
Ved indgangen til en centralt liggende læge:
(123)
Ved indgangen til et hospital:
(123)
(123)
Er der andre steder du ville foretrække:__________________________________
96
Anvendelse af maskinen:
Hvor ofte vil De formode at anvende maskinen? (Marker med understregning)
A: Ugentligt
B: Månedligt
C: Hvert kvartal
D: Halv-årligt
E: Årligt
F: Sjældnere
G: Aldrig
Hvad vil De formode at anvende maskinen til? (Marker med understregning, vælg gerne flere)
A: Blodprøver
B: Test af lunger
C: Højde/vægt
D: Indhente information om næring og træning
E: Læse om symptomer på sygdomme
F: Booke tid hos egen praktiserende læge
Troskab i teknologi:
Hvor stor tiltro har De til at lade en maskine vurdere Deres helbredsmæssige tilstand? (Marker med
understregning)
1: Meget
2: En del
3: Middelmåddigt
4: Ringe tiltro
5: Ingen tiltro
Deres normale lægebesøg:
Hvor ofte tager De henvendelse til deres praktiserende læge? (Marker med understregning)
A: Ugentligt
B: Månedligt
C: Halv årligt
D: Årligt
E: Sjældnere
Yderligere kommentarer:
Hvis De har yderligere kommentarer til denne maskine som De gerne vil dele, vil vi være taknemmelige:
Tak fordi de fandt tid til at besvare spørgsmålene
97
Attachment 2: Venture Cup leaflet
Introduction:
Telemedicine is a well-known concept but yet not being used to
its fullest on the Danish market. As it is, only basic telemedicine
equipment is being used even though hospital scientists are
welcoming a more extended use of telemedicine as seen in e.g.
United Kingdom. TeleMed is offering the Danish society free
use of a range of telemedicine components as well as
introducing a new innovative infrastructure not yet seen on the
world market, as well as the incorporation of new futuristic
medical treatments.
Team:
We are three students of different nationality currently enrolled as master students at Aalborg
University on the Innovative Communication Technologies and Entrepreneurship (ICTE) course at
the Center for Communication, Media and Information Technologies (CMI).
Andrei Lucian Stefan (09.11.1986)
Holds an engineering BsC in Telecommunications achieved at Faculty of Electronics,
Telecommunications and Information Technology at Bucharest University, Romania. At the
faculty Andrei was employed as an assistant teaching seminars and performing lab assignments
for students at third-year-level. Overall his main experienced is concentrated around networking.
At Aalborg University he is employed at the CTIF Easy Life Lab as Student Helper working on a
specific 3D localization project in the RFID field. Andrei holds a Cisco certificate – CCNA.
Claus Ladefoged (18.09.1985)
Holds a BsC in Library and Information Science from Royal School of Library and Information
Science, Aalborg. The last two semesters of this degree Claus was accepted to join the Information
Studies course at Faculty of Computer and Information Studies at Sheffield University, England.
Claus holds honors for his academic achievements by scholarships. Overall his experience is within
information retrieval, information systems and Internet technologies. Former working experience
counts consultancies work performing statistics in own company.
Juras Klimasauskas (11.06.1985)
Holds an engineering BsC in Informatics at Siauliai University at Faculty of Technologies,
Lithuania. Afterwards Juras took one year of master studies in Management and Business
Administration at Faculty of Economics and Finance Management at Mykolas Romeris
University, Lithuania. Also, he completed one Erasmus semester at Faculty of Computer
Engineering at Yildiz Technical University, Turkey. Juras’ main experience is within
computer/database systems, informatics engineering, software systems and electronic services.
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This group has been established since we have three different backgrounds and on a wide scientific
field as telemedicine, where a variety of knowledge is needed, we are able to contribute with our
personal knowledge. We hereby learn from each other but also broaden our possibilities.
What is telemedicine? The term telemedicine covers medical treatment outside ordinary locations like hospitals,
doctors etc. E.g. on telemedicine is an isolated doctor in rural areas of Africa obtaining information on how to perform a
surgery via Internet or elderly people performing blood pressure test in their private homes. Overall, telemedicine is
bringing medical treatment to other suitable locations.
The project objectives:
Our TeleMed project is a semester-project with the option of continuing the work process in later
semesters. The tasks given at the beginning of the semester was simply to introduce something
innovative within the telemedicine sphere and as so the objectives are not predefined but forces the
group to implement innovation and become knowledgeable with entrepreneur skills.
Innovation:
The innovation offered with the TeleMed project contains both product and service innovation. As a
starting point the product is designed for the Danish market while Denmark is lacking behind in the
telemedicine field (though funding and interest is available) and the Danish citizen is ready for a
product as technical reliant as TeleMed (questionnaires have been made to clarify the publics
intentions of usage and to gain ideas).
The most basic product innovation is gathering a variety of telemedicine components into one
single machine. The machine has the look of an ATM-machine but offers the client to perform
various health care check-ups such as measuring blood pressure, pulse, eye-test, weight/height,
temperature, lungs, oxygen saturation and offers information on nutrition, symptoms and training
programs. So far telemedicine components measuring these data exists but has only once been
incorporated into one machine (StayHealthy Health Kiosk from USA), while our machine offers a
wider variety of tests and new possibilities of being tested – in more efficient ways. First major
differentiation is an RFID-patch. The patch is simply collected at the machine, being placed on the
client’s body for however long the client wants to be tested. Afterwards the
client returns to the machine and a reader collects data from the RFID
showing statistics on the machine regarding the client’s blood pressure,
temperature and more having the benefit of showing highly approved
information. A second major differentiation is the usage of finger prick
tests. This enables possibilities of showing indications on a large variety of
RFID-tag
diseases. So far hygiene has been the only obstacles preventing finger prick
tests to be performed, but with our new service innovation, the solution has been found:
The TeleMed project features infrastructural changes in the medical sector. The machine in freely
available for the public at pin-pointed doctor offices making it possible having assistants making
sure hygiene is in order, and making it legal to perform finger prick tests penetrating skin. Placing
this universal machine free-of-charge at the doctor’s office will prevent diseases and give new
possibilities never achieved before.
Another innovative idea within the main idea is a database system making it possible, if approved
by the client, for the doctor to obtain information on the patient gathered in the machine. This
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makes it easier for the doctor to suggest a diagnose having data to base decision upon, and not only
in-the-moment information based on test doing an ordinary doctor appointment.
Other future prospects of possible implementations to the TeleMed machine are listed in
confidential documents, but overall TeleMed seeks to be in front of technological advantages.
Having questioned the public, it became clear that many people avoid regular ordinary doctor
meetings, while the anonymous test with TeleMed would be preferable and that the public would be
interested in using the advantages of TeleMed as prevention and frequent check-up.
For problem solving and facing obstacles before launching the product thorough research of
legislation and cooperation with relevant lawyers has been produced, and currently no Danish laws
are against implementing TeleMed to the market.
Market
Having searched the telemedicine market, it became clear that especially the need of telemedical
options for diabetes, lung and heart diseases are matters with severe problems – and we believe our
idea prevents/helps all of these diseases. TeleMed has a clear business model and a final calculation
of a pilot study costing 7.470.000 dkr. This number arrives from calculation of wages, final
development of software and the distributor of telemedicine components being the company A&D.
A market research has been produced stating the big opportunities of our project
to work. The pilot study can be financed by private companies (as seen with
other Danish telemedicine projects, like TELEKAT) while final launching and
maintenance is a governmental issue (the state being interested to invest due to
savings on less sick people because of the prevention). In this sense, TeleMed is
not a project to earn money, but to save money. The main idea surrounding
A&D component TeleMed can be launched at other national markets, but will find hurdles in e.g.
for blood
USA with insurance companies.
pressure tests
Already now, after only three months progress in the project, Tunstall Healthcare has shown interest in being
possible investors. Especially in a specific designed edition of the machine made for nursery homes – another
open market for telemedicine.
Summary
In the research/development process the team has used a variety of sources to make sure the idea is
possible and to make sure the need of the machine is alive. By questionnaires, interviews (with
lawyers, blood specialists, lunge specialists, telemedicine professors, doctors, competitors,
distributors, supervisors etc) and getting to know the electronic components, we are confident that
the TeleMed machine can show a success. Denmark, at first, can show major improvements in
preventing diseases and by the end of the day safe capital on hospital beds.
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