Dispatches from the hi-blogs.info krew

Med-e-Tel 2009 – Friday miscellany April 3, 2009

A shorter report this morning, as I have been more actively involved in the workshop I attended, and so taking less notes. For the first part of the morning,  I attended the workshop on “Sustainable collaborations in healthcare open source software”, run by Etienne Saliez and Thomas Karopka. Etienne introduced the session, and the first draft of the website developed to discuss the issues – www.chos-wg.eu Thomas introduced a range of issues, which have also been previously discussed at a meeting in Portugal earlier this year – http://mimwiki.med.up.pt/images/a/a0/Osehc-thomas_karopka_text.pdf

A new proposed strategy is being explored, to include:
(1) FLOSS-HC inventory – What is already there?
(2) FLOSS-HC communication platform and software repository – Where to find applications and information
about FLOSS-HC
(3) FLOSS-HC use case data base – What is really needed?  These use cases and may be workflows
should describe the use cases from the health professional view point.
(4) FLOSS-HC knowledge base – Description of modules and their capabilities

The discussion focused on different needs in different parts of world, the possibility to develop regional collaborations among groups woring in free/libre and open source in health(care), and whether it might be possible to develop some kind of  certification process for FLOSS-HC products. The example of the EOS (enterprise open source) directory – http://www.eosdirectory.com/ – was introduced, and we discussed whether a similar area is needed for healthcare OS.

I then went to try and listen to another telenursing session, but the speaker had not turned up. However, I caught  good presntation from Maurice Mars (University of KwaZulu-Natal, South Africa) on his experiences of delivering a telemedicine training course in Rwanda. His summary of things to take into account when teaching in such areas echoed my own recent experience of teaching in South Africa, including not to rely on the infrastructure (Internet, electricity) always being reliably avaialable, to have materials available on CD-ROM, and to focus on ‘key lessons/issues’, rather than trying to teach too much in a short period.

Med-e-Tel 2009 – eHealth in space April 2, 2009

There are several sessions about eHealth in ‘extreme environmental conditions’, which are mainly about health and space weather; the sessions are in co-operation with the Belgian Institute for Space Aeronomy (www.aeronomie.be), part of Space Pole. They sound interesting, so I thought I would attend a few sessions. the first talk is by Norma Crosby, titled “Health issues and space weather: an introduction”. She started with an introduction to space weather and its effects, both in space and on earth, and a look to the future. Space weather touches everyone directly or indirectly; mobile phones rely on satellites, for example, and solar disturbances in space, for example, can cause problems. Space weather is about conditions on the Sun and in the solar wind and the layers of the atmosphere on earth, which can influence space-borne and ground-based technological systems – how solar activity can have unwanted effects. The Sun is the driver of local space weather; Sun has an 11 year cycle of activity, although solar flares can have influences at any time. Space weather induced effects include damage on satellites, increased radiation to airline passengers, etc.

Health issues relate to ‘space biology’ – how gravity (or lack of it) affects cells, gravity can affect development of cells, and radiation biology. Radiation sickness can be a problem for astronauts having long exposure on space missions; sometimes airlines have to change routes if are high levels of solar activity, esp. on polar routes. There will be increasing numbers of people affected with rise of space tourism. There can also be affects on earth’s magnetic field, in particular at higher latitudes. ‘Indirect indicators’ include temporal and spatial variations in epidemiological data.

Long space voyages, eg to Mars, will mean the need for telemedicine; there will be problems due to long communication delays, and also due to loss of geomagnetic shielding from solar wind problems.

Med-e-Tel 2009 – Telenursing session April 2, 2009

It’s Thursday afternoon, so it’s the Telenursing session. I am giving a talk as part of this, but am also blogging the rest of it. The first talk, on “Telehealth’s evolution and future in Canada” (Lois Scott; presentation given by Diane Castelli), started with a geographic overview of Canada, which covers a large area, but has relatively small population, with 90% concentrated in the south, within 200 miles of the border with the USA. Canada, as with many countries, has a shortage of healthcare workers in all disciplines; average age of nurses is 46. Patient safety is an increasingly important issue, and patients are playing a more active role in decisions about their healthcare. The first telehealth era, the 1940’s, was based around the use of telephone contact, most often to give advice/help in acute situations, but often with no protocols. The second era, the 1950s to 1970s, saw the emergence of social crisis lines, often staffed by lay volunteers, and with the emergence of formal protocols. The third era, the 1980s to early 90s, saw expansion of telemedicine services, with homecare monitoring, telepsychiatry, and development of web-based health information. The current (fourth) era, the mid 1990s to the present, saw the emergence of telephone triage, telecare services and support from electronic decision support systems. Currently, most of the Canadian provinces and territories are providing 24/7 telecare services for their populations; all are mostly telephone contact centre-based, for people across the spectrum from the well to those with severe illnesses. canada has found that public uptake levels have depending on marketing of services, and most opposition to services comes from health professionals, rather than from patients, while competencies and standards for telenursing need to be further defined.

Diane then gave her own talk, “The advancement of international telenursing”. She began by defining telenursing as ‘the practice of nursing over distance using telecommunications technology” (a 1997 definition from the USA). In the USA, there are examples of nurses providing telehealth for prisoners and for rural natives in remote clinics. She then discussed the ISfTeH telenursing working group.

Elenor Kaminsky, from Uppsala University, Sweden, spoke about “Detective or educator? – telenurses’ understanding of work”; this was based on work that has been published in the Journal of Advanced Nursing earlier this year. Telenursing is a first line of healthcare in Sweden, started in 2006 and using call centres with telenurses; there are 75-90 calls per working day per nurse, and provide an opportunity to influence public health. She described a qualitative study, based in phenomenography, to study variations in conceptions among the 12 telenurses interviewed in 2004-05. Five categories were work were identified [1] assess, refer and give advice to the caller; this was a form of detective work, with the nurse listening for clues; [2] support the caller, guiding them and maintaining contact; [3]  strengthening the caller, increasing their self-confidence; [4] teaching the caller, with an emphasis on what the telenurse thought the caller needed to be taught; and [5] facilitate the caller’s learning. All nurses in the study expressed category 1, while only proportions identified the other categories within their  work; category 5 was seen as a ‘highest level’, and nurses identifying this also identified all other 4 areas. This identifies different forms of work – in effect, different health services, possibly leading to variation in outcomes, depending on which nurse answers the call. The outcome space identified forms a telenursing roadmap. My talk came next.

Annica Ernesater, from Sweden, presented “Computerized decision support systems in telenursing: how is it perceived by telenurses?” She also mentioned the Swedish call centres mentioned by Elenor, and it is similar to NHS Direct in the UK; this uses a computerised decision support system (CDSS). Telenursing is seen as knowledge-intensive work, with the telenurses triaging callers’ needs and giving advice, including self-care advice. She described a study of nurses’ use of the CDSS, which showed that telenurses found the system to be supporting, inhibiting, and controlling – the system was found to simplify their work, but there could also be disagreement between the CDSS recommendations and the nurses’ previous professional experience, with the software being incomplete; this lead to frustration among the nurses. Searching the CDSS for information sometimes lead to nurses paying less attention to the callers as they searched the system for information, although it also meant more consistency in the information given to the patients. The CDSS cannot replace nurses’ knowledge and experience, and should be seen as complementary, not competitive to their own skills.

The final talk of the session, “It’s easier to talk to a woman – aspects of gender in Swedish telenursing”, was from Anna Hoglund, also at Uppsala University. 90% of the nurses staffing the Swedish call centres are female, and all are registered nurses who act as the first line of response to callers. About 50% of calls are for self-advice, while rest are for a mix of issues, including getting appointments. Most of the callers to the help line are women (60-80%). An interview-based study of Swedish telenurses in 2004-05 found 5 themes – [1] female subordination in the family, ie females in some families are not free to contact health services themselves, especially in cross-cultural encounters; [2] disrespect in dialogue with female nurses, ie from male callers who were not valuing the nurses’ experience; [3] distrust in fathers’ competence, ie mothers being better to describe the problems with children; the telenurses seemed to trust female callers more, especially in relation to child issues; [4] reluctant male callers, ie callers needing to be encouraged by their family members to call; and [5] woman-to-woman connection, ie ‘its easier to talk to a woman’, resulting from commonalities of experience. The study concludes that gender aspects in various forms in telenursing, and there is a risk of stereotyping dialogues depending on callers’ genders.

Med-e-Tel 2009 – second morning, part 1 April 2, 2009

It’s the start of day 2 here at Med-e-Tel in Luxembourg. Yesterday evening we had the civic reception at the City Hall (Hotel de Ville) in the centre of Luxembourg; some reasonable city-branded sparkling wine, but I also had some useful discussions about open source with Alvin Marcelo and Thomas Karopka. The public transport bus system here works very well, although there seems to be lots of new building and construction vehicles on the bus routes, which slows things down a lot.

The first session this morning that I am attending is from Pascal Collotte from the European Commission, talking about online cross-border initiatives in health at the European level, and from different EC programmes. His focus is on the eTEN programme, which has been about deploying trans-European e-services for all in the EU market, in particular with a focus on public e-services and supporting eEurope 2010. This ended in December 2006, although funded projects will run to 2010. eTEN projects were built on services that had been initially tested in research and development, to pilot-test initial market deployment, and identify issues. They were meant to end up with business plans for sustainable deployment in at least several countries across the EU.

The political focus and goals of eTEN projects were aimed at mobile European citizens should be able to receive medical treatment anywhere in Europe – so looks at things such as EHRs usable or accessible from across Europe at sites of healthcare. Interoperability was also a key focus, so as to avoid/prevent new digital divides. Co-operation of national healthcare systems was needed to ensure success. Nowadays, Pascal says, interoperability is more of a legal and administrative problem to be overcome, rather than a technical problem.

Among challenges the programme sought to address were aging populations within Europe, with increasing expectations and rising demand for health and social services; it has been important to reduce inequalities in access to healthcare. Increasing patient mobility in Europe, and of health professionals, has also raised issues. He talked about two projects, Netcards and TEN4health, the latter being a portal in several languages to verify individuals’ heath insurance status.

UPDATE 11:20

Ehealth in Colombia and Latin America – Colombia has only 12 hospital beds for 10,000 of the population (compared with 36 in Brazil, about 40 in Argentina), and 96% of health agencies are private (ie, only 4% public). 38.5% of population use Internet, but 57% of cities have 3G internet access, which could provide a platform for telemedicine systems. The Colombian government aims to have telemedicine in 89% of public hospital network in 2010. many patients living in rural areas do not have ready access to healthcare – but through wireless systems can receive telemedicine interaction.

Trying to listen (not very successfully – too much noise generally from the exhibition area, people chatting in the audience, etc) to a presentation about developing health information collection system in Albania – first part seems exactly the same as presenter gave yesterday under a different title, although some different material in later part of session.

My presentation for this afternoon (Tele-nursing session) is at http://www.slideshare.net/drpeter/medetel09-murray-final

Mobile health session at Med-e-Tel 2009 April 1, 2009

The afternoon has been split into four parallel sessions; I decided to try the ‘Mobile Health’ stream for the first part of the afternoon. The first talk is on mobile tele-work places for radiologists (www.radiology2.at or http://www.assteh.org), which uses home teleradiology workstations linked online via VPN networks, which show good diagnostic accuracy. The trial showed benefits in many areas, including flexible work patterns for radiologists, although lack of senior radiologists in hospital departments to report on images can be a limitation on development of systems. In a 21 month trial, 458 tests (CT, Xray, ultrasound, MRI) were used and transmitted over VPN for reporting.

The second session, on the role of telemedicine in long term care facilities in the USA, with Julie DiMartino reporting on a joint venture (Penn E-lert eICU) between Good Shepherd Rehabilitation Network, Allentown, PA and University of Pennsylvania Health System. She described development of an audiovisual link between the eICU to the  long term acute care hospital setting, so that ICU specialists could also link to deliver critical care to the linked setting. Benefits to the long-term setting included reduced need to transfer patients to the ICU setting, reductions in common post-ICU complications, and reduced costs.

The third session is on integrated mobile and stationary nursing care information exchange in Austria. The speaker set the problem of older people at home or in nursing home needing nursing care, and who interacts intermittently with hospital care; this results in a great deal of paperwork as a result of the nursing care data and documentation. There are often insufficient communication processes, due to lack of joined up processes, or information being in multiple records. A pilot project between a nursing home and a hospital about 20km away compared status quo wherein a paper care summary from the nursing home was sent to the hospital, and vice versa, as against a new system in which a server links the care home and hospital, although due to legal restrictions, the data has to be re-entered at each end of the system, even though sent electronically. The project uses an IHE-compliant system for patient care data exchange. In the future, mobile care providers will be brought into the system, although problems exist at present. The main issues to be solved at present seem to be legal, rather than technical; data acquisition is reduced, the speaker claims, although problems also exist due to the mix of IHE-compliant and non-compliant systems that exist.

Med-e-Tel 2009 – opening session, part 2 April 1, 2009

The second part of the opening morning featured a series of seven short presentations. The first speaker, Gerard Comyn, from the European Commission, spoke about European Commission policy initiatives on telemedicine, under the title ‘Telemedicine for the benefit of patients, healthcare systems and society’. He mentioned a joint initiative between his directorate and DG SANCO. he sees telemedicine as part of medicine and believes it should be part of normal medical training – he sees separating medicine and telemedicine a a trap we should not fall into. he says many people, especially doctors, are not convinced by the benefits of telemedicine – one of the objectives of the Commission will be to provide the scientific evidence for benefits. He sees potential for growth in telemedicine market of 19% per annum, from 4.7 to 11.2 billion Euro between 2007 and 2012.

Telemedicine in Europe has, so far, been mainly regional pilots, but there is no real national deployment anywhere in Europe. There are currently legal barriers (national regulations), which are the main barriers to telemedicine use, and often attitudinal barriers due to perceived lack of scientific evidence of benefit. There is not, though a single ‘telemedicine’, and different people mean different things, so there are many ‘telemedicines’ – can we have one legal environment to cover many different delivery/interaction methods? Specific services may have specific issues/problems, eg comparison of telemonitoring of patients at home, versus teleophthalmology services involving remote interpretation of health tests (the latter a ‘telecommerce’ transaction between two partners, which is different from telemonitoring). There is now a Telemedicine Communication aimed at supporting integration of services enabling patients to get benefits, and to provide a consistent approach across Europe for the benefit of the mobile patent. There are principles of trust (building confidence and acceptance of telemedicine services, through collection of good practice examples, and aimed at providing evidence from large scale pilots); developing legal clarity, encouraging national legal frameworks to support telemedicine use, as well as developing consensus among Member States; and facilitating market development, through encouraging international interoperability for functionality of telemedicine systems.

Marco Obiso, from the International Telecommunication Union (ITU), spoke on ‘Implementing eHealth in developing countries: principles and strategies’. He spoke about ITU focus in eHealth activities, and has developed a strategy to assist developing countries at national levels, including providing tools for development of eHealth strategies, promoting co-operation among stakeholders, and facilitating information exchange, sharing knowledge on best practices, etc. An ITU-WHO scoping study report has been produced, and guidelines have been developed for identifying needs, and developing local strategies. Another initiative has been the mHealth initiative, seen by many as potential ‘killer application’ in many areas, to promote co-ordinated introduction of effective mHealth in developing countries.

Michael Nerlich began his talk by discussing global inequities in health, which are killing people on a grand scale, through social injustice combined with health inequity, resulting in a toxic combination of effects. National health does not equate to national wealth. While evidence and standard guidelines for medicine are good and can save money and patients’ lives, they can takes at least 10-15 years to be implemented on a wide scale. We currently have ‘industrialisation’ of healthcare and medicine, and assembly-line type treatment, and often do not have individualised care. Currently the doctor-patient relationship is under strain; there is growing need to take account of better informed patients, through ‘pHealth’ or personalised health.

Claudia Bartz, from the International Council of Nurses (ICN), spoke on ‘Telenursing and global health’. She described ICN as a federation of 133 national nursing organisations, which aims to bring nursing together worldwide, with an ICN Code of Ethics and programmes in leader development through the ‘Global Nursing Leadership Network’. ICN Telenursing network will be launched at the ICN Congress in Durban, South Africa in JUne 2009, and several other specialist networks exist. She says that telenursing may test traditional licensure boundaries, due to many nurses currently being licensed in their own countries or areas within countries.

Yunkap Kwankam, previously with WHO and now ISfTeH Executive Director, spoke on ‘The Rockefeller Foundation eHealth Initiative for the Global South’. He spoke about the Bellagio conferences of 2008 on eHealth connections, which focused on existing collaborations and looking to develop new collaborations. Among the major challenges are capacity building to deliver telehealth programmes; there is a shortage of 4M health workers worldwide, which does not take account of shortages in ICT capabilities. Interoperable eHealth systems are needed, as well as supporting development of educational tools and programmes. Rockefeller is looking at development of networks of networks, and collaborations.

Med-e-Tel 2009 – opening session April 1, 2009

Well, I have finally arrived at Luxexpo for Med-e-Tel 2009 – some ‘interesting’ travel experiences. I am currently sat waiting for the opening session to begin but have discovered one issue (which is not confined to this event) – while wireless internet access is all well and good (and seems to be working well here), electricity is another matter. The place seems bereft of power outlets, so I may have to take notes (even, shock horror, using pen and paper if necessary) and blog later if battery life on the laptop does not hold up.

The event seems quiet at the moment, but it is still only 09:25 on the first morning, and some people may not be arriving until today. An update to follow once things start.

UPDATE (10:00 Luxembourg time) – this is the seventh Med-e-Tel. Pierre Gramenga, Managing Director of Luxexpo gave the opening welcome remarks. Participants are from 50 countries on five continents.

Mars Di Bartolomeo, Minister of Health and Social Security for Luxembourg said that main aim of Med-e-Tel is to exchange experiences in use of telemedicine. He said that Luxembourg is ‘on track’ in using ICT in healthcare, and welcomed the European Commission support for the event. He stressed the need for high quality health service built on traditional values of the country, including solidarity-based social services, and believes that new technologies can help with this.

Gerard Comyn, Acting Director of ICT Addressing Societal Challenges and Head of Unit for H1, ICT for Health, at the European Commission followed with his welcoming address. He says that EC is one of the main drivers of telemedicine implementation in Europe; there is increasing demand from citizens for best quality care. Health care expenditure in Europe is 8.5% of GDP on average, and rising. In response to current challenges, the Commission believes telemedicine is one of the solutions that can increase accessibility to healthcare, and can overcome health professional shortages, as well as involving patients more. There is also shift from hospital-based to patient-based model of care, and telemedicine can help countries achieve this. The EC has funded research and eTEN projects to help develop telemedicine and 21st century health.

Michael Nerlich, President of the International Society for Telemedicine and eHealth (ISfTeH) gave the final welcoming address.