The integration of information technologies within telemedicine has to benefit the patient

Amsterdam 12 April 1999 The growing role of Information Technology implementation within the evolution towards a fully integrated electronic health care record. Cross-border collaborations and multidisciplinarity as necessary means to generate the required form of patient file integration. The influence of national policies on the technical developments in telemedicine and the critical question of liability. The emergence of novel services and the need for standardization. All these issues were tackled in a vivid and lively discussion during the first forum session at the ITIS-ITAB'99 Conference last April in Amsterdam. Co-Chairman Dr. Andy Marsh specifically concentrated the participants' focus on the matter of how to harmoniously integrate the great variety of emerging technologies into the everyday medical practice.

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The growing role of Information Technology implementation within the evolution towards a fully integrated electronic health care record. Cross-border collaborations and multidisciplinarity as necessary means to generate the required form of patient file integration. The influence of national policies on the technical developments in telemedicine and the critical question of liability. The emergence of novel services and the need for standardization. All these issues were tackled in a vivid and lively discussion during the first forum session at the ITIS-ITAB'99 Conference last April in Amsterdam. Co-Chairman Dr. Andy Marsh specifically concentrated the participants' focus on the matter of how to harmoniously integrate the great variety of emerging technologies into the everyday medical practice.

Dr. Gudrun Zahlmann, GSF - National Research Centre for Environment and Health, Germany
Which are the strategies that are deployed in the United States for keeping Information Technology applications at the forefront within the engineering community?
Dr. Swamy Laxminarayan, Editor-in-Chief - IEEE Transactions on Information Technology in Biomedicine, USA
When we look at the past, the Engineering in Medicine and Biology Society has always maintained the leadership role in disseminating the innovations in Information Technology. The EMBS influences organizations, such as the National Institute of Health and the National Science Foundation by writing position statements and by giving advice to the national science councils about the issues that occur, as to help them channel their decisions and funding into taking advantage of these technologies.
Dr. Andy Marsh, ITIS-ITAB'99 co-chairman, Greece
What do we expect a doctor to be like to accept the new technologies and have access to them?
Dr. Mary Moore, Dean of Library and Information Resources at the State University of Arkansas, USA
The answer is always that it depends. It depends on what you are trying to sell and on who your target market is. In the very small field that I've studied, with a specific interest and a specific application, it took me many years to regard telemedicine as a whole because there were too many variables and too many distinct applications.
Dr. Andy Marsh
Is there an area we should target first, for example cardiology or urology?
Dr. Mary Moore
We have already seen that medical experts target themselves, like for instance radiologists. If we are to communicate with these individuals, we have to gather information about the new techniques they are interested in as a professional.
Dr. Swamy Laxminarayan
The technology scope has become very broad. Yet, the applications for certain disciplines are starting to get focused and narrowed.
Dr. Luis Kun, Research Professor of Health Informatics and Information Technology CIMIC, Rutgers University, New Jersey, USA
There is a different perspective, which is related to telemedicine. One of the big issues, both in Europe and in the United States, consists in finding a rank for the ethics of computer. Funding may go to the application level or to the structural level. The applications themselves allow to cross the border of nations and to be shared internationally. Rather than focusing on urology, cardiology, or radiology, we have to make sure that the Internet highway is properly connected to services that guarantee the required privacy of health care records and security. We also have to provide tele-consultation facilities to enable real time communication between a physician performing a surgery in Amsterdam and a specialist in New York, offering advice for instance.
Dr. Mary Moore
The limitation is that United States grant funding still doesn't support this kind of services and keeps putting it off.
Dr. Gudrun Zahlmann
Telemedicine projects are always assessed on an economical base, so you must have big numbers to state your point. Still, I believe cross-border initiatives are not always the right solution. As a general practitioner, you also have to work on the local level.
Dr. Luis Kun
Suppose I were a nephrologist and I had twenty transplant patients. The largest database in the world for transplants is located at the University of Heidelberg, a project started in the early eighties. The cost-effectiveness with the availability of 2000 transplants in the same age group, which I don't dispose of in my own country, is substantial. If my standards of collecting information were different, I would not realize this. This is the direction in which we are moving. It doesn't really matter where the database is, as long as it exists, as long as we can access the information.
Dr. Swamy Laxminarayan
The National Science Foundation has selected three major disciplines to which the funding will go in the next years. In the right order, these are Information Technology, Biotechnology, and Nanotechnology. Should we not be working together in order to generate cross-collaborations?
Dr. Andy Marsh
What worries me when talking about cross-borders in Europe, is that we also have to address issues relating to cross-cultural and cross-language difficulties. Do you have the same experience in the United States with the Hispanic and the non-Hispanic areas? Perhaps in Europe, telemedicine would work better for travellers. If, for instance, I go to Germany, I would really like to communicate with a native English speaking doctor. However, I am not sure if a Greek doctor would ring up an Italian physician to ask his opinion on a Spanish patient. This would raise too many problems.
Dr. Mary Moore
We provide services to South America, as long as the consultations are in English.
Dr. Luis Kun
We have a very different policy. In the United States, it's all a matter of licenses and liability. You have people today in New York, who retire and go to live in Florida. They can no longer consult their own physician since this doctor simply is not licensed to perform consultations in Florida. In fact, we should be able to consult our medical records wherever we are, in Europe or in the United States, as long as the privacy of the files can be secured. This is the direction we should be heading to.
The concept of putting medical records in a Web page holds aspects of both some incredible goodness and some incredible badness. In the United States, you have a population that moves from city to city with a medical record that is scattered among different localities. Also the health care environment is distributed between general practitioners and various medical specialists. The Web allows you to collect all this medical data in one page. However, if you want to perform a population study to compare factors relating to food, environment or medical effectiveness, different physicians would be using their own standards of collecting information.
Dr. Andy Marsh
You can use the Web environment to locate the data that can be stored in a particular source. You're not changing the source.
Dr. Luis Kun
If I have a mammography of a forty-five year-old woman and I want to to study the image by comparing the data of 2000 women with the same age, you can not store the information on a local server.
Dr. Andy Marsh
This is indeed one of the biggest problems in data management: how are you to store all this data?
After a designated period of time the hospital doesn't want the data anymore. It's only being kept for legal reasons. The data is stripped and separated from personal patient information and collected in resources at a regional or national level. At this moment, you can start with population studies.
Dr. Tuomo Kauranne, University of Joensuu, Finland
We are talking about two different issues, namely access to individual patient information on the one hand, and the management of data on the other. The latter forms the business-to-business end of medical services between professionals, for which the matter of standardization is relevant. For the individual patient on the contrary, access is important.
Dr. Luis Kun
Who in Europe or in your country has the responsibility for the health care record, the general practitioner or the hospital leaders? In the United States, the responsibility usually resides with the hospital management. If you are a researcher and you want to study the directories of patients who don't care about the physician's name, you might not have those records available. I recommend the hospital as the place where the patient files are stored.
Dr. Andy Marsh
There is a distinction between the record and the medical image. You cannot continue to store the medical images in the hospital, they have to be outsourced somewhere.
Dr. Luis Kun
The computer-based medical record indeed consists of various types of data. You may have a point there for declining the hospital as a repository for the images but the record itself has to contain all the parameters for the data which might come from different sources. That is the environment in the United States.
Dr. Gudrun Zahlmann
In Germany, this is not allowed for reasons of authorization as well as of patient privacy protection. It is not really a matter of technology but more a problem of policy.
Dr. Luis Kun
I think it ís a technical issue because the registration of images requires the collaboration of different experts, such as for example Magnetic Resonance Imaging, Computed Tomography, and Nuclear Imaging centres of specialization. You have today operators allowing to combine diverse types of modalities to obtain data, which is not available separately by itself, and to receive information which did not exist before. The integration of different modalities is for the benefit of the patients. Of course, there might be some political issues which don't allow this thing to happen but the final outcome should be the integrated record.
Dr. Andy Marsh
Perhaps, this integration should constitute a customized service since you can have one doctor who believes in MRI and CT, and another one who prefers the X-ray/MRI comparison. They both have to be able to combine the images in order to see for themselves. I agree that the data have to be added to the electronic patient record but maybe, there should be another medical record as well.
Dr. Gudrun Zahlmann
By combining different imaging modalities at the level of international services, it is possible to find some new information which is not available in your country. Therefore, it is crucial that decision makers enable this kind of services, so they can be taken to the next technical level for storage of the data.
Dr. Luis Kun
In the pharmaceutical sector, one has currently started to integrate laboratory data with signal processing. This is true integrated technology because you can see the influence of the pharmaceutical data on the laboratory results.
Dr. Andy Marsh
There is a distinction however between the provided services and the data.
Dr. Tuomo Kauranne
Specialized services are bound to emerge as well as gateway-services. For example, services with specific knowledge, such as brain segmentation to which you can query images in the right format to have them computed and get the result back. You will also have an impact on this service, by the way. As for the application of standards, new gateway-services will be generated to convert data from one format to another, for instance.
Dr. Luis Kun
In this model, there are two steps missing. When you go from data to services, you move from data to information and from information to the creation of models. You can only perform this transformation by applying integration. The other missing link refers to the standards. If you do not collect the data in a certain format, you won't be able to use them properly.
Dr. Tuomo Kauranne
Yes, but surely we do not want the slowness of the standardization process to delay the emergency of the integrated health care record. The development of both processes can actually be worked on in parallel.


Leslie Versweyveld

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