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Updated: Sep 17, 97 |
ANNEX II: | |
This Annex provides a summary of current applications implementation and development in telematics for healthcare for those EU states where current provision is extensive, or where major developments are currently taking place.
The UK represents a significant contribution to European telematics for health implementation, accounting for 20% of current activity, across a wide spectrum of areas. The main concentrations of activity have been in basic infrastructure provision, with an emphasis on creating a national EDI-based network, and in promoting the widespread use of electronic administration and patient recording systems, primarily to support organisational reforms within the National Health Service.
These developments have been co-ordinated through the National Health Service Executive's 'National Information Management and Technology Strategy'. The IM&T strategy is intended to support the re-structuring of the national health service via the development of a 'business culture' that has been reflected, for example, in semi-privatised 'hospital trusts'; the devolution of control over purchasing to GPs acting in the role of 'fund holders' or business managers of their clinical practices, and the setting of a national policy context for health care provision within a 'performance criteria' framework. Key initiatives of these national programmes include:
As with Europe as a whole, emerging trends are moving away from closed systems based on single application areas in single sites towards open systems architectures primarily targeting networks of specialist centres across the country; inter-site networks in urban areas or regional-based initiatives to provide integrated 'telehealth' provision. In the latter case, regional initiatives have been focused on overcoming problems associated with access to care in remote and rural areas. Examples include TEAM, a set of initiatives operating in rural Wales including teletraining; decision support systems connecting GPs with specialist hospitals and medical imaging and telediagnosis applications in domains such as dermatology; DIALECTS, providing community-based surveillance and care for diabetics again in rural Wales; tele-emergency and telediagnosis for North Sea offshore platforms around the Scottish coast, and teleradiology services in Orkney and the Shetland Isles.
The main area of telematic application in France has been medical imaging, followed closely by remote diagnosis. However, telemedicine is developing around two major axes:
The French general practitioners are, like their English counterpart, in the midst of substituting paper-based patients records for electronic dossiers. Most of the French hospitals and private clinics are now computerised.
The Midi-Pyrenees Region is the leading region in France in the telematics field. It has established links with the Regional Council network (continuous training for all health professionals) in order to foster the development of the existing network. In addition, it has set up a pilot regional telemedicine healthcare network under the aegis of the French Government, the creation of a well-co-ordinated network including Midi-Pyrenees hospitals and general practitioners.
ii) Inter-regional initiatives
There are some inter-regional initiatives, for example, a network of neurosurgery using medical imaging and telediagnosis in Gironde, Dordogne, Lot et Garonne, Landes and the Pyrenees-Atlantic. Home Telecare is an established service of tele-measurement of arterial tension. This project involves ten hospitals and thirty general practitioners in Lyons, Marseilles, Paris, Dinars and Nevers. Oreip is trying to establish an electronic patient records network between hospitals and general practitioners in the Lille region. Othello is a project linking GPs, hospitals and health insurance providers for billing purposes.
iii) Regional initiatives
In the Aquitaine region, a project linking twenty-one hospitals has established a network of telediagnosis in specialist radiology. In the Nord-Pas-de-Calais, the Loginat Project has established videoconferences for perinatal subjects and another project has implemented remote consultations for neurological emergencies. If the initial phase is successful, this network will be extended to other Nord-Pas-de-Calais regional hospitals where emergencies units are available. The current goal is to extend the scope of videoconferences in order to strengthen co-operation between the various hospitals in the technical, medical and management fields.
In Paris, the "Assistance Publique des Hopitaux de Paris" is involved in the transmission of radio imaging data for neurosurgical emergencies. The Hospital Trousseau looks at the transmission of pediactric radio imaging. A protocol of telesurveillance and teleobservance at home for patients suffering from chronic respiratory failure is being studied at Paris and in the Mid-Pyrenees region.
iv) European infrastructure
France is involved in several European projects. Nord-Pas-de-Calais has set up a French/Belgian ophthalmologic network. The Midi-Pyrenees is involved in four European projects: MAC-NET - European programme (Lisbon, Madrid, Athens, Rome, Toulouse) focusing on medical aids at sea; TOX-NET (Munster, London, Milan, Brussels, Toulouse) dealing with toxicology; SAMENET: (Athens, Toulouse) dealing with emergency care in remote location; and ETELNET: activities conducted at Toulouse University Hospital in collaboration with French overseas territories, Hanover, Brussels, Barcelona, Athens, Lisbon and Andorra. In Paris, TELEMED (a RACE programme) using videoconferencing for remote diagnosis of psychiatric illness is linked with London. The RETAIN project, supported by the TEN-IBC program, focuses on teleworking sessions between radiologists in Rennes and Barcelona using ATM equipment. Based in Aquitaine PROMPT, is aiming to help GPs improve consistency in quality of patient care in France, the Netherlands and England by using intelligence electronic guidelines.
v) Smart cards
There are five smart cards being tested in France at the moment. Vitale, is a healthcard interfacing with patient health insurance company, hospital and general practitioner medical record, emergencies services, hospital administration, hospital pharmacy and laboratories. SANTAL contains the patient details and the medical history. Unlike SANTAL, VITALE will, in addition, look after the patient billing between the health insurance companies and the hospital or the GPs and the pharmacies. SANTAL is being tested in eight sites in the Saint-Nazaire region: Le Croisis, Guerand, Pontchateau, Savenay, Paimboeuf, Pornic Saint-Nazaire and La Baule. VITALE card, distributed by a health insurance for civil servants, is being tested on four sites: Boulogne-sur-mer, Charleville-Mezieres, Bayonne and Rennes/Vitre. They link GPs, pharmacies and laboratories. The "Health professional card" is to be carried by dentists, pharmacists, GPs, mid-wives, nurses, orthopaedist, and other health professionals to access electronic patient records. It has a built-in security code. This card is compatible with all the GPs, hospitals, health insurance providers and pharmacists systems. This card is being tested in four sites chosen by the Groupement d'Interet Public.
The fifth smart card is a part of a European project for the implementation of an interoperable emergency dataset on a smart card. One of the five pilot sites involved in CARDLINK is Saint-Nazaire, which is managed by the SANTAL Association, the prime contractor of the consortium. The others are Dublin, Milan, Rome and Valencia.
Much of the activity in the Netherlands has been concentrated in infrastructure schemes involving EDI, and primarily run through government programmes. These have targeted three main types of stakeholder:
One major initiative, promoted by the Ministry for Welfare, Health and Culture is the 'Transparent' programme, directed at:
However, as with other states, the real level of implementation of EDI is extremely low, estimated at between 0.5 - 1% of current information traffic flow within the healthcare sector. The main applications areas using EDI for the interchange of data include: referral/discharge letters between GPs and hospitals; despatching test results from laboratories to GPs; digital exchange of X-rays between hospital departments.
Outside the national policy framework, applications development is largely being conducted in small-scale pilot projects involving universities and medical schools, mainly funded through EC R&D Programmes. There is little evidence of emerging new partnerships between private and public sector organisations in healthcare telematics, an isolated example being HISCOM, a collaborative partnership between the Dutch government, medical schools and RAET, a computer system manufacturer, to develop mainly Hospital Management Systems.
ii) Hospitals
With regard to it policies the following observations can be made:
Most general practitioners are using a general practitioners information system (HIS); with the implementation of a HIS, in the view of GPs, the desired degree of automatisation has been accomplished. The HISs are mainly used for financial administration purposes. Although most of the GPs have a modem, it is hardly being used for external communication and exchange of information. Most GPs use the modem if they want to contact the provider of the HIS in situations in which technical problems occur. Only a minority of GPs use the modem to send messages to a hospital or pharmacy. The EDI with especially secondary care is considered as one of the most interesting and relevant opportunities with regard to future developments in telematics applications.
Only a minority of the GPs are using it technology for information and education purposes. The direct use of it technology in function of medical practice is rarely existing. Although almost all of the GPs have the equipment at their exposal to develop and implement electronic medical records. In practice less than one third is using this module within their HIS and in the cases that EPRs are being used it is for internal purposes and not for EDI; diversity in hard- and software is one of the main problems in relation to the implementation of EDI on a practical, non-experimental basis.
iv) Pharmacies
The degree of automatisation within pharmacies is nearly 100%. Almost every pharmacist uses a modem linked for the communication with suppliers and whole sale. In only few cases there exists information exchange with GPs, banks or insurance companies.
Basically it has to be stated that there is no national strategy behind the introduction of information and telecommunication systems in the German health care system. Both in the private practice and in hospitals only such technology is applied which on one hand side makes the health care system more effective for the users and on the other hand is cost-effective for them, too. Since, in addition, patient related clinical data exchange in Germany is restricted by law, there is no common strategy concerning data communication. On the other hand a lot of certain elements are already established in particular concerning the data flow between the Regional and National Sick Funds Physicians Association (KV, KZV, KBV, KZBV) and the insurance companies. It may be possible of course that regulations concerning for instance documentation or reimbursement procedures will stimulate certain information technologies. Another problem arises from the separation between the hospital domain and the private practice. Therefore there is no general coordination between both groups of health care providers concerning the introduction of information and telecommunication techniques.
ii) Outpatient care (private practice)
At the present time around 70-80% of general practitioners and office-based specialists (in former West Germany) use computers in their practices, mainly for reimbursement purposes. Use of a programme licensed by the Regional Sick Funds Physicians Association programme is a condition for reimbursement. At present about 55% of doctors in ambulatory care routinely send their reimbursement data on diskette to their Association but the intention is to replace this with an EDI (electronic data interchange) system.
The Federal Sick Funds Physicians Association has made some software available, including a drug information system on diskettes which is updated monthly. Doctors wishing to become affiliated members of their Regional Sick Funds Physicians Association are required to use standard administrative and medical data formats. These have therefore been incorporated by software manufacturers into their products. This facilitates the exchange of information and also makes it relatively easy for a doctor to change his system.
Therefore, today's overall goal is to establish first a telematic infrastructure in this domain. This is supported by local associations and in particular by the federal bodies of private physicians (KV, KZV, KBV, KZBV). All software offered for physicians use, which is available on the German market, has to be validated and licensed. On the other hand the software companies receive recommendations for specific innovations concerning, for instance, diagnosis coding systems, drug documentation systems of the patients medical record from the KBV or the KZBV, respectively.
Some other service offered by the KBV are certain data banks with different purpose. Since the infrastructure is not sufficiently developed, information is offered usually on computer disks. For example there is a data bank on pharmaceutical products, which is updated every 3 month available form the KBV. The data banks also include closed documentation's on all the private practices and case related physician services. Today a nation-wide ISDN network between the federal body (KBV), local associations (KV) of the private physicians and the practices for sharing general information is thinkable if all practitioners are technically able to participate in data exchange.
Another step forward was taken with the decision to choose EDIFACT for the medical information exchange at least between insurance companies and the local associations of private physicians. First efforts had already been taken to adapt EDIFACT to the specific needs of health care information exchange.
There are some topical developments based on new federal regulations stimulating the application of telematics in the German health care system. First of all an insurance card including a basic set of administrative data (name, address, insurance number) has been defined and the corresponding infrastructure (reader, printer) is introduced in Germany by law. Due to data protection today this data set can not be extended. In addition the KBV is offering a patient administration system free of charge referring to the basic data set on the chip card. Hence it is attractive for the physician to introduce the necessary hardware and for their useful software which contributes to a more effective data administration for every physician or dentist. Secondly starting from 1994 the ICD-diagnosis code has to be applied to every patient for documentation. This coding system will be implemented into the forthcoming software (supported by the KBV what again makes the introduction of telematic infrastructure more attractive. Thirdly the data exchange between the private practice the accounting units of the KV and the insurance companies will be based on new regulations. All data which have to be documented for describing the service profile for each patient are now exactly defined. In addition the data have to be provided in machine readable style. Hence, a first step forward concerning a universal interface for medical data communication is taken. Today's standard would be to exchange data by a computer disk or tape. Of course, if infrastructure will be developed, it would be useful to establish an ISDN network.
iii) Hospitals
The application of information techniques in the hospitals was initiated a couple of decades ago. Since that time the market of hospital hard- and software increased tremendously. Today computer systems and in-house networks are available in almost every hospital even in the smaller ones. Many of them are running an own mainframe. The areas of application are mostly restricted to administration, i.e. the documentation of general patients data for instance for reimbursement and the management of the hospital. As far as medical applications are concerned, there are only selected island solutions in particular in the area of laboratory services, image processing, acute care and in the decision making process for diagnosis and treatment. Describing the state of the art one can at least state that the informatic infrastructure concerning hospital administration is fairly well developed. Of course, this is only a first step in the process in introducing telematics.
In order to coordinate the application of informatics in German hospitals the German government, the federal states and local institutions have mutually been active in the development of common software products since the beginning of the seventies. In 1984, 67.7% of the hospitals applied this "public" software systems. Of course, also the industry as well as the hospital themselves are very active in the development of new software products.
Much progress in this area arises from activities of university hospitals run by the federal states. Quite often they have separate departments for medical informatics which spend much efforts in the development and validation of new telematic systems, which then is demonstrated as a pilot within university hospitals. On the other hand a diffusion depends on the specific decisions of every hospital which are largely restricted by their budget.
In parallel to the domain of the private practice, federal regulations stimulate the application of telematics in hospitals. Mainly this is due to the documentation rules defining the information flow between the hospitals and the health insurance companies. Here, the German social law gives the general framework, implemented by the representatives of regional health insurance companies and hospitals (LKG) on the level of the federal states. In particular the data which have to be provided and the way how they have to be provided are defined on the federal level. Every clinical case has to be documented by a clinical basis profile containing, for instance the reason for admission, the diagnosis and the treatment. Here, the ICD-diagnosis coding system and the ICPM-coding system for treatment has to be applied. Concerning inpatient care, the nursing efforts have to be documented for every department on a daily basis. Starting from 1995 all data have to be submitted in machine readable style. This again supports the diffusion of new generations of hospital administration systems.
iv) Communication between private practice and hospitals
Since the hospitals are not administered in a centralised way (even not on the level of the federal states) it is very difficult to introduce unique solutions for the communication between the private outpatient practice and the hospital. Therefore the "user" have to go a "bottom-up" approach to establish in a first step on a voluntary basis islands of communication networks. A few of such local networks are already present in Germany.
v) Insurance Cards
Following a recent change in the law, all legally insured German citizens (more than 90% of the population) have been issued with a chipcard containing details of their Insurance cover. 100,000 medical and dental practices and 50,000 hospitals have been equipped with card readers and printers. At present, use of the card is restricted to administrative data, and storage of medical data is prohibited, though it seems likely that this situation will evolve over time.
By making available administrative information and details of insurance coverage in a standard format, the introduction of the chipcards will simplify accounting procedures whilst establishing a nation-wide information and communication network. It will also encourage doctors to use a computer system more generally within the practice.
vi) Outlook
In Germany the foreseeable developments concerning telematics in health care are:
A specific problem in Germany is, that according to new federal regulations the overall budget for providing health care has been limited. Hence, it becomes difficult to pay for informatic or even telematic infrastructure. This might only be stimulated if a cost-benefit arising from informatics and telecommunication is demonstrated.
The general policy indication is to reduce and rationalise the national healthcare expenditure whilst maintaining the quality of service provided. The situation is shifting from research driven to implementation/user driven to take advantage of the potentialities offered by telematics applied to healthcare and to foster private investment. To reach this objective the policy and healthcare authorities, the telecommunications operators as well as all the actors directly and indirectly connected to the issue have to be involved, being the infrastructural and value-added support insufficient. The latter issue requires an extensive organisational re-engineering of the healthcare services to integrate them with information and communications technologies, also aiming at the development and training of the human resources.
In Italy there is awareness of the obstacles to the implementation of the healthcare telematics plan which relate to the necessary sources of investment, to the lack of financial resources to fund the running costs of telemedicine systems, which have to be taken from the overall healthcare expenditure. Moreover, it should be considered that practitioners not always considers telematic systems applied to healthcare as the highest priority, the potentialities of telematics being still inexperienced by most operators.
To face these problems, a financial strategy to join public and private support is required. A clear understanding of the peculiar characteristics of the healthcare sector must be achieved by all the actors involved, who must be aware of the risk to develop without clear policy guidelines.
In fact, what has already happened, is that the market is already crowded with applications offering non-standard operational solutions thus restraining globalisation and interoperability.
It is regarded as a concrete possibility to attract the Italian industry towards this field adopting interoperability solutions developed at European level and adhering to the European Standards and guidelines.
From the citizens' point of view, it is judged important that the healthcare telematic services constitute no risk for data confidentiality and that the systems and technologies are secure and reliable, in order to guarantee the continuity of the systems and therefore the access to vital data.
i) Telemedicine issues
One of the primary issues of the Italian healthcare policy is the establishment of a telematic network for primary care, assigning the general practitioner the role of periferic orientation and filter of the whole healthcare system. The basic function assigned is of preventive information of the patient, of orientation and guidance of the decisions related to health. Furthermore the general practitioner is assigned a role of interface between the patient and the whole system, managing all the healthcare systems services to be delivered to the patient.
This interface will not only reflect the specific patient's needs and personal preferences, but also take into account constraints such as budget limitations, social and economic opportunities and the global management constraints. The global management of the system will be particularly critical in the case of financial involvement of governmental bodies.
The Italian healthcare authorities expect that this policy will lead to a more cost-efficient management of the system, reducing the access to the secondary care levels.
Another strategic issue in Italy is represented by healthcare emergency: therefore telemedicine for emergency, with reference to the territorial coverage, creating the 118' system. 118' is an emergency phone number part of an integrated telecommunications system based on a wide area network interconnecting the phone service with a radio network for emergency interventions.
Smart cards are another means to support to the entire healthcare system and its integration, also being a tool to access the healthcare telematic network at the same time assuring data security and confidentiality.
Eventually, it is necessary to mention the National Telemedicine Research Plan, covering the extension of telematic services to healthcare, funded by the Ministry of University and of Scientific and Technological Research.
These cover three basic areas:
1) The healthcare management area with:
| Theme 1 | Integrated Information Systems for Healthcare Site Management |
| Theme 2 | Training Systems for the general practitioners and of the citizens |
2) The medical area with:
| Theme 3 | Systems for capturing and processing of digital X-ray images and for the set-up of diagnostic consultancy systems |
| Theme 4 | Systems for capturing, processing and integrating of bio-medical images for high-level diagnostics |
| Theme 5 | A telematic system for the management of a cardiology department |
| Theme 6 | Remote monitoring of high-risk heart-disease patients and pace-maker bearers |
| Theme 7 | Remote monitoring of dialysis treatments and monitoring of the new-born |
3) The social area with:
| Theme 8 | Systems for disabled communications |
These projects are currently ongoing and will produce results within the next 1 or 1.5 years.
ii) General considerations on the co-ordination between Italian policies and actions and current actions promoted by the EU
In order to harmonise the national policies and actions with those developed at European level, the expectations from the present telemedicine activities are:
Health Information Systems are becoming increasingly integrated into the strategy of health care organisations at all levels. Strategy is oriented at the creation of an integrated information system, including administrative, clinical and social-demographic data. Telematics for healthcare is now attracting interest throughout the health service.
Background
The Spanish public health system, Sistema Nacional de Salud', is formed by the Health services of the State Administrations and the Health Services of the Autonomous Communities (the Regional Governments).
At the State level, general co-ordination of health policy, international affairs and the regulation of pharmaceutical products are dealt with. All other health activities are organised by the regional activities, apart from public health functions which are assigned to local authorities. To date, health competencies have been transferred to the Autonomous Communities of Andalucia, Catalonia, Basque Country, Valencia, Galicia, Navarra and Canary Islands. The National Institute of Health (INSALUD) manages healthcare services in the rest of the country.
The Spanish National Health System is based on the principles of university, equity, solidarity and public funding. Its objectives are to provide integral care including health promotion and preventive care. The concept of health services includes also the right to information, the right to privacy and the guarantee of quality.
Public health services cover 99% of the population, about 40 million citizens. In addition, a variety of private services are offered by international companies to independent professionals. There are 40 insurance companies operating in Spain, serving about 5.5 million people (14.2% of the population). As with other European Member States, the Spanish health system faces the need to satisfy a growing demand and increasing requests for quality versus limited budgets.
Strategy in the public system has been concerned with controlling the health expenditure. Main actions have been oriented to the definition of service provision, the separation of the roles of insurance, administration and provision of the services, as well as the promotion of new organisational structures.
ii) Scenarios and trends
Telemedicine in Spain presents a rapidly evolving scenario. The increasing decentralisation of healthcare competencies and the transfer of power to the Regions have resulted in proliferation of policy forming structures and decision making bodies. Information and Communications Technology strategy development in healthcare is strongly variable depending on technical literacy and different attitudes towards innovation of the organisations.
iii) Strategic factors
Some strategic factors are particularly relevant to assess the main trends characterising telemedicine in Spain:
The potential of telematic technologies in solving health problems is increasingly recognised by health organisations in Spain. Some current strategic actions are:
v) Main barriers to ICT implementation
In spite of the effort and activities supporting the widespread adoption of healthcare telematics in the Spanish health system, there are a series of barriers inhibiting development. These include administrative constraints due to legal provisions, resistance from healthcare professionals and budget constraints.
vi) Major trends
Recently, suppliers have adopted a new approach oriented towards problem solving and user needs satisfaction, rather than product orientation.
On the user side the main benefits would belong to the following areas:
In 1994, the Ministry of Health issued a strategic health Informatics plan, incorporating the implementation of Hospital Information Systems but also including several other initiatives:
The first phase involved information systems being installed in fifteen (15) major hospitals covering mainly administrative applications, while medical/nursing applications are under development.
Portugal is currently reorganising its IT management and planning arrangements at national level, following the change of Government at the October 1995 elections.
The Institute of Informatics and Financial Management of the Ministry of Health has responsibilities for nation-wide management of technical resources. Its activities cover the legal responsibilities, such as to:
In the telematics field, an operational plan was launched in order to create a private network for the Health ministry. This plan had the responsibility for assisting in financing telematics projects. Also, in the field of telemedicine, major efforts are being directed towards networking between hospitals and health centres in the Central Region of Portugal, with the aim of providing the necessary conditions for the widespread use of electronic data. The most recent project in this area - Health information Network of the Central Region (RISC) - is a project whose main goal is to provide each institution with tools for remote access of images and at the same time provide administrative and clinical information management.
The RISC project comprises three essential components which are improvements on clinical and administrative procedures, use of telemedicine for remote patient observation by the doctor and, finally, integration of other subsidiary services such as laboratories, pharmacies, health centres, social services.
The three-phase project started in May 1995. The first phase involves 2 central hospitals, 2 district hospitals, and 4 health centres. The second will introduce a distributed database with clinical and administrative data, and in the third phase regional health information network will be implemented. This will be based on an open systems structure will allow future development of telematic services in the health area and at the regional level for all the institutions which are partners in the pilot project. It is intended to progressively add new functions, and add a further two central hospitals, 3 district hospitals, and 6 health centres.
The project aims to lay the foundation of vertical telemedicine applications, contributing to gaining experience in this field, an important future use of the information highway.
The plan of activities for 1996 includes two major goals: the first related to IGIF's activities as the Health Ministry Information Service coordinator which will:
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