Dutch telemedicine policy summarised in eight propositions at Healthcare ICT 2001

Rotterdam 17 October 2001The implementation of telemedicine is rather a matter of organisational issues than of technical obstacles. Cost reduction over the years has slowed down the development of ICT in health care within The Netherlands but now new ICT investments should be prior to benefit. Two overall conclusions following the debate in the telemedicine session at the recent Healthcare ICT Congress in Rotterdam. The forum leaders were Dr. de Vries and Dr. Vierhout, both of Twente University, and Mr. Balm, Director Medical Technologies at Siemens Netherlands NV.

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Participants of the parallel telemedicine session at the Healthcare ICT Conference were invited to share their views on 8 challenging theses relating to the introduction of telemedicine in the Dutch health care sector. The first one introduced by Dr. de Vries, adressed the problem whether telemedical innovations should be focused on volume before quality. Debaters from the industry as well as from clinical environments agreed that an organisational framework is needed to introduce relatively simple telemedicine applications. These so-called low hanging fruits can be produced in high volumes to prove to the medical market place that telemedicine is really functioning. As such, patient home monitoring offers the ideal area to launch low-end technologies and yet to deliver remote care transcending the hospital walls.

Even if recession continues, clinical understaffing will be a continuous issue; therefore, telemedicine has to replace personnel with capital goods according to Dr. de Vries in his second thesis. The forum acknowledged the fact but was not altogether pessimistic about it. As occurred in industry with the introduction of IT, Mr. Balm expected both a shift and renewal in professional functions because all medical processes will be integrated. The health care sector will have to offer new challenges for a different kind of employment. Dr. Vierhout suggested that medical education can play a crucial role in bringing ICT and telemedicine to the attention of future health care providers, in basic as well as in highly specialised training. "Give people the right tools and the specific software guidelines, and doctors will gain more confidence in new technologies", several attendants confirmed.

Telemedicine involves addressing the total process, not just optimising parts of medical processes, stated the third proposition. Everyone consented to the fact that partial optimisations are only useful when they fit into an overall plan. First, you need to organise the work flow and then apply the necessary changes among the workers in the field. One of the attendants referred to the situation in the United Kingdom where the National Health Service (NHS) has created call centres for patients to speed up the identification of medical problems. In The Netherlands, patient diagnosis still is a slow process. However, Dr. Vierhout stressed that patient care should be clearly distinguished from consumer care: the patient has a need to physically SEE the doctor, just because he is in a far weaker position than the healthy average consumer.

The fourth definition claims that telemedicine is hardly practicable without an efficient Electronic Patient Record (EPR) whereas the EPR cannot be effective if suitable telemedicine applications have not been implemented. The creation of a national EPR constitutes a delicate topic in The Netherlands. Several people in the audience complained that medical professionals have not sufficiently been involved in the EPR discussion between the government and the industry. More than the patient privacy problem, the lack of industrial standards is blocking the introduction of an EPR. Vendors refuse to give priority to integration, compliance, and compatibility. Instead of being guided by technological visions, the EPR has to emerge from within the health care process. For the rest, EPR and telemedicine are not necessarily interdependent. A lot of telemedicine is able to function without EPR availability whereas telemedicine is by no means a conditio sine qua non for the introduction of an EPR.

"Is Medical Technology Assessment (MTA) a real condition for successful telemedicine implementation?" asked Dr. de Vries. It seems so, according to Mr. Balm and Dr. Vierhout. In order to get novel applications introduced to and accepted by the health care market place, you need assessment as an added value for the medical professional. Yet, the question is raised whether MTA does not limit creativity since the number of projects will be necessarily reduced. Mr. Balm does not fear that imagination in telemedicine development will shrink because of the need for assessment. Not all problems have to be solved at once. It is likely that some solutions will never make it to the market but the learning process is never lost.

Another sensitive theme was addressed in the sixth thesis where Dr. de Vries made a plea for a greater engagement of the health care professionals, and in particular the scientific societies, regarding the development of telemedicine applications. The health care profession is undergoing a lot of changes lately. The forum suggested that the arrival of telemedicine could mean a serious threat to both physicians and scientific societies. However, the medical societies have a vital role to play in the process of telemedicine acceptance by their doctor members who have a great trust in this kind of scientific institutions. In fact, they are ideally placed to highlight the financial and juridical aspects of telemedicine, as well as to make an inventory of the implementation offer and need in the health care and disease management market.

As already slightly put forward in the second proposition, Dr. de Vries stressed that telemedicine, research and education within the health care sector have to be adjusted to one another. The curricula of doctors and nurses should provide telemedicine courses, according to the session participants and everyone agreed that a shattered offer of educational programmes split and spread over different universities should be avoided by all means. Dr. Vierhout defended the concept of a centralised training institute for telemedicine where skills can be learnt and practised in the areas of medically related virtual reality and simulation of surgical interventions to teach trainees the ropes of complex procedures.

The last statement presented trauma care in regionalised centres as a test bed for telemedicine development. At present, there are ten regional trauma care centres in The Netherlands with a clear distribution of speciality functions among the different hospitals, according to Dr. Vierhout, who is working in the Twente trauma clinic. There is a logical link between telemedicine and trauma care. The use of a trauma helicopter guarantees that the patient is transported to a specialised hospital within the golden hour after the accident or trauma has taken place. The idea is to set up an on-line connection with the medical experts for direct and remote intervention before the patient has arrived at the hospital.

The telemedicine forum leaders and session participants concluded that all these new approaches in health care relating to ICT and telemedicine have to closely fit together as a puzzle. This can only be achieved by setting up a homogeneous organisation in order to co-ordinate the various initiatives. To this purpose, it will be necessary to shift from a money-saving paradigm to a patient-friendly universe where one is willing to spend more capital in promising technologies and projects which are rooted within the health care process itself, steered and supported by the medical professionals who are the end-users of these pioneering technologies.


Leslie Versweyveld

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