Weighing the thousand ways and worries to establish an International Telemedical Information Society

Amsterdam 13 April 1999 As we move from data to information knowledge, we need models of simulation and data visualization. If we are looking at population studies for outcomes, also at the economical and financial level, the conclusion has to be that standards and high-end computing applications are urgently being required. This statement from Dr. Luis Kun formed the starting point of the third forum discussion during the ITIS-ITAB'99 April meeting in Amsterdam. There are a host of telemedical applications to start with, like Virtual Reality, Augmented Reality, prediction and diagnostic models, all of which are ways to try and push back the limits of technology. We shouldn't even think about the bandwidth that is available today, but it is good to bear in our minds the whole spectrum of possibilities. Conference co-chair Andy Marsh challenged the ITIS-ITAB audience to ponder on the structural bricks for the building of an International Telemedical Information Society.

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As we move from data to information knowledge, we need models of simulation and data visualization. If we are looking at population studies for outcomes, also at the economical and financial level, the conclusion has to be that standards and high-end computing applications are urgently being required. This statement from Dr. Luis Kun formed the starting point of the third forum discussion during the ITIS-ITAB'99 April meeting in Amsterdam. There are a host of telemedical applications to start with, like Virtual Reality, Augmented Reality, prediction and diagnostic models, all of which are ways to try and push back the limits of technology. We shouldn't even think about the bandwidth that is available today, but it is good to bear in our minds the whole spectrum of possibilities. Conference co-chair Andy Marsh challenged the ITIS-ITAB audience to ponder on the structural bricks for the building of an International Telemedical Information Society.

Dr. Luis Kun, Research Professor of Health Informatics and Information Technology CIMIC, Rutgers University, New Jersey, USA
Let's take the example of endoscopy where a camera is taking images from inside the body. The University of Tennessee is building a library with this kind of objects to help physicians understand the internal structures. Complicated issues rise when you start to perform remote consultations. If you have somebody in Amsterdam submitted to an endoscopy, and a doctor in the United States has to analyse the results, the Dutch physician is giving the actual control into the hands of the expert overseas.
Outside the medical problem, there are still other issues to cope with such as reliability, availability, and redundancy. Obviously, you cannot afford the system to go down for reasons of physical security. From a computational point of view, the movements of the camera provide information which can be very relative and has to be compared to other data.
Dr. Andy Marsh, ITIS-ITAB'99 co-chairman, Greece
Where do you see the real problems in creating a telemedical society, if we take into account the interesting spectrum of applications in the fields of telecommunications, diagnosis, and information services support? What is stopping us, as scientists, from starting something up tomorrow?
Dr. Swamy Laxminarayan, Editor-in-Chief - IEEE Transactions on Information Technology in Biomedicine, USA
One of the fundamental points is that with the technology growing so rapidly, our own position to this technology is still not quite robust. Very recently, I was talking to the technical manager of Deutsches Telekom and I was really astonished to find that bandwidth is no longer a problem, at least not in Germany, a country that seems to be loaded with bandwidth. There áre important resources indeed, if it comes to bandwidth of which a lot is now available.
Dr. Andy Marsh
You have a good point there, since I remember some three or four years ago, when I started to talk about telemedicine, the first question people used to ask me was: "what about bandwidth?" Another difficult issue was security. For the last two years however, we have grown accustomed to a lot of new services. The virtual bank is now operating through the Internet so why can't we simply use these technologies in medicine?
Dr. Lars Edenbrandt, Department of Clinical Physiology, University of Lund, Sweden
It is very important to involve the medical community in the technology because the everyday routine in the hospital is to take care of the patients. The physician's interest is to integrate telemedicine into medical decision procedures and into the daily clinical practice.
Dr. Luis Kun
The question really is focused on requirements. The information society has to deal with the quality issue but who can assure that what you need is good enough? In the United States, we have a choice of general practitioner. The patient can decide to go on the Web and select for the type of disease he has, situation A, B or C. Subsequently, the patient asks the physician what to do: take A, B or C? The doctor might be surprised because he doesn't even have the time perhaps to seek for information on the Web.
What happens now is that if the patient doesn't get an answer, he will go to somebody who can provide a solution. This situation brings new challenges. The users will fundamentally have to deal with quality and standards of care. We will have to educate the nurses because the Web holds in store a lot of nonsense. There is a lot at stake in taking the right decisions. That is why many physicians in the United States are still against telemedicine because of the insurance problems.
Dr. Andy Marsh
Let's use another example which is not related with medicine. We now give a presentation by means of slides. Not so long ago, we were writing the slides by hand and this was generally accepted. Later on, we typed them in Word and now, we compute them in PowerPoint, using sound and movies. Yet, it takes a lot more time to prepare them but still we do it because we are able to better present our case in this way.
Dr. Luis Kun
There is a reason since these technologies improve your effectiveness. At first, I was very lucky to take some marketing courses, a subject I had no idea of because my background was purely technical, but I learned it.
A picture is a thousand words, so you have to go through all this work, if you want to attract the attention. This illustrates the importance of images and this is why so many companies use PowerPoint because it makes the difference.
Dr. Swamy Laxminarayan
Very important is the fact that things are application dependent. The Internet was not concurrent before the arrival of the World Wide Web which only came into existence in 1994. After this, the Internet exploded since the people really wanted to use these technologies. From that stage, we moved step by step to create higher bandwidths, vBNS, Internet2, and so on.
Dr. Andy Marsh
Yes, but the market is forcing it and the people are demanding it.
Dr. Swamy Laxminarayan
It's the user dependency. Look at the history of supercomputers. The Monte Carlo simulation programme was already performed way back in the sixties. High Performance Computing is not new. As technology has grown up, we have identified newer applications and now, we are able to address the older applications in a far better way.
The most essential issues today however are the usability and the end-user requirements expressed by doctors and nurses. These are things which we seriously have to consider.
Dr. Andy Marsh
What would happen if tomorrow, you would discover on the Internet: "come and get your health card here"?
Dr. Tuomo Kauranne, University of Joensuu, Finland
Health care is probably the second most institutionalized human activity after the military. There are many fundamental reasons for this. If we think about how institutionalized it is: for example, the certification of doctors, the education of physicians, the funding of health care. All these are legally very carefully restricted. There is an extremely detailed technical knowledge, a very strict hierarchy of authority which deals with medical expertise, second opinions and medical science itself as a whole. Health care constitutes a huge web with a lot of interdependency technically and legally. We are facing a rigid body which will not be moved so easily. It will never change very fast. The patients and customers are put in a very sensitive condition. If you are in a vulnerable situation, you are very conservative in your choices.
If you compare this environment to the Internet, this is the exact opposite, where you have no structure whatsoever, but complete chaos, easy use and extremely undemanding customers who never complain. That in fact is the fundamental reason why things are not moving fast. We have to take this into account and find these avenues which are some kind of outlined in this workshop, and pass to the funding-related issues.
Dr. Luis Kun
In the United States, the reports of 1996 show 30% of savings for home care thanks to telemedicine. The nursing process takes also a big part in it.
Dr. Tuomo Kauranne
We have been running a home care project for elderly people. In that situation, you're not at all that sensitive. First, we introduced an Internet shop for delivering groceries to home care patients. By the end of this year, 90% of the grocery shops in Finland will have an Internet service because it is wanted by the customer.
Dr. Gudrun Zahlmann, GSF - National Research Centre for Environment and Health, Germany
We are facing a severe problem with regard to the limited life cycle of projects. At the research institutes, there is enough bandwidth available to deliver more services but all we have to deliver are nice projects and nothing more.
We are stepping into a very new field of work and delivering the technology but we continuously struggle against the short life time of projects and the restricted funding. There should be a way to bridge the gap between the actual project's period and the real life service. Therefore, industrial support is needed.
Dr. Andy Marsh
This is a topic which has come up many times because, if you see the honeycomb diagram from above, at one side you have the research centres which are responsible for the commercialization and prototyping of products. At the other side, you have the marketing and selling industry but we need an intermediate glue to a company in the middle to bring the various entities together in order to make the product.
Dr. Gudrun Zahlmann
I fear that the research community has to make money of the projects.
Dr. Yiannis Samiotakis, Atkosoft S.A., Greece
From our experience, we have found that these main issues in research are organizational. As a research industry, health care is very institutional. The great issue is economics. In the equation, something is missing because the benefit goes to the patient while the cost savings are not being integrated into the equation. Let's take the example of some patient who is referred to a doctor on his own expenses. The patient gets all the profits in the equation since telemedicine is very cost-efficient and could be driven by market forces. The problem in the equation is that the services are paid by individuals. In this way, telemedicine is going to make the equation cost-effective only for the patient, but not for the institutionalized health care. Therefore, there is no market force to support or to push forward the adoption of telemedicine.
Dr. Ewart Carson, City University of London, United Kingdom
I think we've got a number of issues here. The user requirements are absolutely essential because the technology is only going to be adopted if it can produce real benefit. We are limited by social change which causes us to face some constraints.
In the United Kingdom, the integration of Information Technology into health care has been a disaster in the past two years due to a centralized approach of the British government. It still is even now. In spite of all the good words for telemedicine which are expressed by politicians, there is no funding.
If we really want to be serious about this, we have got to enter the fora of the medical professionals. Last year, I was in a diabetes conference where there was a half day devoted to informatics engineers talking to an audience of 500 doctors and we caused them to listen to us. It's up to us to take the views, the ideas, the opportunities that we've got, into the light.
Dr. Luis Kun
We have indeed a technology here which requires teamwork from both government and industry, in co-operation with the information technology scientists and the medical community.


Leslie Versweyveld

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