Updated: Sep 17, 97
TELMED

3.3.2 How are telematics applications implemented?: Distribution patterns

i) The level of coverage

ii) Geographical distribution

The cross-national pattern masks considerable regional variations in applications distribution. Three main clusters can be distinguished:

1. Integrated community health care 'packages' - focusing mainly on telesurveillance and community health monitoring, and remote telediagnosis connecting primary and specialist care networks. These are mainly found in remote and rural regions. The main centres are in France (Midi-Pyrenees; the Toulouse region; Nord Pays de Calais and Acquitaine); Wales; Scotland (Orkney and the North Sea oil fields); Italy (Emilio-Romagna and the Southern Islands) and Scandinavia (Oulou and Etala, Finland).
2. Teleradiology and telepathology - focusing on the storage and dissemination of medical images, and localised mainly in Scandinavia, for example, Gallivare in Sweden and Tromso, Norway.
3. EDI, hospital information systems and electronic patient dossiers - these tend to be in the form of large-scale infrastructure networks, providing messaging systems, integrated regional administration networks for hospitals and 'smart card' systems. They are mainly concentrated in northern Europe, and particularly in the Netherlands (Westland, Scheiland, Delftland, Rotterdam and Maastricht); France (Dordogne, Gironde, Marseilles, Lyon and Paris) and in Denmark.

iii) Types of applications: sectoral distribution

In relation to technical configurations, Figures 4 to 6 show the range of communications infrastructure, communications media and tools identified by the Audit.

The Figures show:

• Two main types of infrastructure can be identified: 'closed networks', involving either stand-alone PC-based systems with menu-driven operations, or closed networks on central file servers, and 'open networks' linking remote sites primarily through ISDN.
• Videoconferencing systems are well-represented in applications implementation. These tend to be used primarily in telediagnosis, and in teletraining for clinicians. Communications by electronic bulletin board and e-mail is also well-represented. There is a significant level of systems integration, involving mixes of different communications devices.
• The audit suggests a high concentration of technical investment in distributed databases, represented in over 50% of applications surveyed. Databases are used across a wide spread of applications areas, but primarily in administration storage and retrieval systems, and, medical imaging. Multimedia systems are still in the embryonic stage, accounting for less than 20% of systems used, whilst the low level of knowledge-based systems in use is a reflection of the waning interest in expert systems in the light of a growth trend towards open systems architectures and the Internet.

The user groups addressed by the range of service provision identified includes both direct end users and intermediate users (Figure 7). Hospitals account for 37% of the total users audited, where the main demand is for integrated administration systems and electronic patient records. GPs account for around 20% of the users, largely in the form of patient records and telediagnosis services integrating primary and secondary care. Patients themselves account for a smaller proportion of users - 14% - and in this case the market segmentation is primarily in the form of applications developed to provide home support for 'at risk' groups (for example telesurveillance of elderly people). Insurance companies are a minority - but growing - user group, with an interest mainly in smart cards to store medical and health insurance data.

Telematics applications are represented across a wide spectrum of health care domains, as illustrated in Table 3.

Table 3: Healthcare Domains	%
General Information Systems (billing; insurance; patient data; appointments; medical protocols and standards; health promotion info)	39
General MRI, X-rays	7
Clinical consultations	7
General Practitioner medicine	7
Psychiatric	6
A&E	4
General pathology	4
Maternity, paediatric	4
Cardiac	4
Neurosurgery	3
Pharmacology	2
Diabetes	2
Cancers	2
Dermatology	2
Home care	1
Marine A&E	1
Genetics; toxicology; respiratory; neontology; asthma; enecephalic; surgery; cranial surgery; geriatric; ulcers; dieticians; anaesthetists; rheumatology; gastroenterology	< 1

The Table shows:

• By far the most dominant health care domain penetrated by telematics applications is in the area of general information systems, accounting for just under 40% of applications audited. These systems cover a wide range of tasks and functionalities, including patient data storage; billing and insurance tasks; appointments management; information and health promotion services for patients; on-line specialist databases for clinicians; protocols and standardisation management.
• The generic nature of telematics for health is counter-pointed by a number of domain specialisms, though at a much lower level of concentration. The main ones include radiology; clinical diagnosis; general practice; psychiatry; pathology; accident and emergency care; paediatric medicine and cardiac medicine.

As discussed above, the applications audit involved a mapping of the implementation of telematics applications for healthcare using a classification framework based on indicative generic 'applications environments'. These indicative typologies denote configurations of technological artefacts within a particular institutional setting and providing services for specific user groups. Drawing on the results of the state of the art review carried out in Deliverable 1, TELMED adopted a classification based on the following:

• EDI - denoting infrastructure networks to facilitate message transfer and data transactions through electronic means
• HIS (hospital information systems) - denoting systems to facilitate the intra or inter-site storage, retrieval and dissemination of information
• EPR (electronic patient records) - systems to integrate patient information from different sources within a single distributable database, including 'smart cards'
• Decision Support Systems - denoting applications to facilitate decision-making by allowing, interactively or otherwise, dialogue between a decision-maker and a remote expert (typically between GPs and specialist clinicians)
• Teletraining - the utilisation of distance teaching and training within the medical domain
• Telediagnosis - the utilisation of telematics systems to carry out medical consultations remotely, for example using videoconferencing between a specialist medical centre and a minor injuries unit
• Tele-emergency - telematic systems to co-ordinate and operationalise emergency service interventions (for example navigation systems to assist ambulance services in locating emergencies in remote areas)
• Community health services - the provision of a range of integrated services using telematics to promote and monitor community health. Examples include monitoring of epidemiological trends in a particular area; the provision of public information for citizens; the installation of electronic surveillance systems for the elderly
• Medical Imaging - the storage, retrieval and dissemination of medical images, for example CAT scans, X-rays, magnetic resonance images. This set of applications is typically linked to:
  
  • Teleradiology - the use of telecommunications and informatics to transmit and receive X-ray images for the purposes of diagnosis, and
    
  • Telepathology - the use of telecommunications and informatics across a range of pathology services, for example the results of laboratory analysis

Figure 8 shows the distribution of applications identified by the audit across these categories.

The Figure shows:

• A broad spread of applications environments is represented within Europe, with no dominant concentration in a particular type
• However, implementation has been most marked in the EDI, medical imaging (PACS), telediagnosis, community health and electronic patient record sectors, with each accounting for broadly 15% of the total applications identified
• The sectors currently under-represented are in teletraining and tele-emergency services

It should be emphasised that the broad sectoral categories discussed above do not represent mutually exclusive telematics scenarios for healthcare. Commonly, a particular application or intervention will embody a range of generic products and services, for example utilising EDI infrastructure networks and medical imaging applications to provide telediagnosis services for users. We discuss the pattern of different combinations in more detail in the next section of this report. An alternative classification model, however, is to consider the 'setting' or 'scenario of use' in which products and services are delivered. Setting or scenario denotes both a spatial context, which refers to the geographical area covered by the application, but also an organisational boundedness within which different actors interact. The spread of scenarios of use identified by the audit is shown in Table 4.

Table 4: Scenarios of Use: Classification
Scenario	Description	Example
Single site	Applications environment facilitates interaction between user groups in one spatial and organisational setting	HIS system linking different departments in one hospital
Single provider	Environment involves a single provider but within an open network	Single GP practice providing telesurveillance to distributed user group
Inter-site	Local network of sites	PACS system linking several hospitals in an area
Local network	Local network of dispersed providers	EPR linking networks of local GP practices
Regional Network	Integrated multi-service care provision within a region	Regional community health care system
National network	National/transnational system	UK EDI programme for the NHS
Single user	Services for single individual users	Remote support for diabetics patients at home
Network users	Networks of recipients of service provision	Electronic bulletin boards for NGOs/ patient networks

Figure 9 shows the distribution of scenarios of use identified by the Audit. The Figure shows:

• Regional healthcare scenarios account for the bulk of implementation of telematics applications, with just under 30% of the total identified
• The other two main concentrations of application implementation involve single site scenarios and large scale national projects (each around 25%)
• Scenarios that are relatively under-developed are open networks of primary care practitioners, home-based user-controlled scenarios and systems for user networks like self-help or patient groups. This reflects the continuing dominance of traditionally hierarchical professional practice structures within the medical domain, and the slow pace of devolution of care and control from specialist to primary care and self-management regimes

iv) Who is involved? Partnership arrangements identified

The Figure shows:

• A broad spread of academic departments, government and health authorities, hospitals and individual clinicians or their organisations, telecoms providers and social services is represented
• However, the largest sector involvement in telematics provision originates from hospitals, representing some 34% of the total participants identified
• PTTs, hardware and software manufacturers and other commercial organisations are also relatively well-represented, accounting for just under 15% of the total participants

The audit identified five main types of partnership clusters, illustrated schematically in Figure 12. These were:

• National Infrastructure projects, led primarily by PTTs usually in partnership with government institutions (such as the Ministry for Health)
• Regional partnerships, typically led by regional government institutions or regional health authorities and co-ordinating service providers
• Hospital-based partnerships, where interventions are managed by single or networked hospitals, with the participation of health authorities and PTTs
• R&D partnerships: reflecting a typical EU Programme structure, and involving medical schools, hospitals, commercial organisations, PTTs

Figure 12: Partnership Clusters

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