What obstacles might prevent the establishment of a Telemedical Information Society (TIS)?

Mr. Vladimir Cerny, Institute of Physics, Bratislava, Slovakia

There is one aspect we should not lose sight of, namely the people's psychology. Currently, we are dealing with a sort of overspecialisation in medicine. If we are going to computerise even more and provide everybody with smart cards, people will ask themselves eventually where the healing part of the doctor's job has gone to. They are searching for alternative kinds of approaches, where they still enjoy the experience of being properly treated as human beings. People should feel that medical treatment is performed for their benefit.
From the doctor's point of view, it is important that the practitioner realises himself that his work is preventive, and not purely a matter of filling in yet another form for the sake of statistics. If a patient suffers from abdominal pain, for instance, the physician has to think and act in two different ways. First, he has to worry about and ease down the patient, and second, he has to enter his scientific findings into the database stream. It is not always obvious to separate those two totally different manners of proceeding.

Dr. Andy Marsh

This is indeed a very good point. What would you accept as a patient, if you had a medical problem? Would you go to a doctor, who appears as a television screen to discuss with, or would you prefer a doctor who is just a speaker, or a virtual doctor? To which point do we, as users of the system, and not as developers, tolerate this level of technology? Do we, as patients, actually want to be treated via a computerised interface?

Professor Jean-François Moreau

What does a patient, belonging to the consumer oriented society, expect? There are two possibilities: either we try to stimulate or to slow down the consumption. At present, the consumers are not ready for telemedicine because they don't know what it really is. Those accelerating the process, are both the industry, looking for new markets, and some physicians, understanding that it constitutes a possibility to improve patient care in some situations.
The telemedicine boosters are North Canada, Scandinavia, and countries consisting of islands. The political point of view balances on the question whether telemedicine will save money or whether the cost of medicine will increase. Everybody is waiting to get into the race. There are plenty of institutions, insurance and software companies which are trying to conquer a market share for their products. The politicians are still blocking the telemedical development because of its cost and typical political issues, such as confidentiality and security legislation, which are not solved yet.
We absolutely have to avoid the emergence of a black market in telemedical applications. This is not difficult to imagine. You just have to put a boat two hundred miles away from the coast in order to be safe to do whatever you want. There is a great demand for telemedicine. The satellite dishes, for example, are currently booming in the developing countries. When you have these satellites like Astra with fifty four channels, which are constantly in competition with other satellite channels, fighting for new customers, the risk for black market practises is growing. The problem is being seriously discussed now at the level of several official institutions, such as the American Medical Association, and various commissions in Europe. We'll find a solution.
As far as the cost is concerned, there are plenty of different social systems in Europe. Will it be possible to find a sound solution before we face a total deregulation of telecommunication systems' prices. In a few years, we will already have some telemedical applications in our houses. If we have telemedication, we are able to find out the cost more easily than with the promotion of teleconsultation. In fact, we should teach both the medical institutions and the population how to use the tool to open the market. Only then, less negative experiments will reach the ears of the politicians.

Dr. Lars Edenbrandt, University Hospital Lund, Sweden

The patient expects the physician always to take the right decisions, but it is very difficult for a practitioner to be an expert in all kinds of different areas. Telemedicine can help the physician to extend his expertise. Looking from the administrator's side, if you can show that you can save money by assisting the physician in his general practise, you can prove the cost-effectiveness of telemedicine.

Dr. Andy Marsh

Do you think the doctor's job is to provide health care or should he aim at seeing as much patients as possible in order to have earned more money at the end of the day? In the UK, there exist some schemes, measuring the GP's income by the number of patients who come to visit him. He can be tempted to promote telemedicine because it offers him an opportunity to get his results faster.

Professor Jean-François Moreau

One should study how many doctors make a diagnosis by means of teleconsultation. In contrast with what many people think, telemedicine does not save time. Doctors have to be on place to study the files. The number of doctors, having time to study the files, will not be larger than now. They may even have a visual dispatch to perform medical activities at each period of time during the day or the night. It doesn't mean that you will have the best professor of surgery available seven days a week. This problem is seriously being discussed in the United States. In some states, they already work with telemedicine but one doesn't know which doctor one will get. The identification of the physician is a problem which is not solved as easily as people think.

Dr. Massimo Luciolli, European Commission, EC

You have to improve the quality of the job. For instance, if a patient arrives at the hospital during the night shift, the telemedicine system can be used to have the radiologist consult the X-rays from his home. So, there is no need for him to come to the hospital whereas the patient is receiving a better service. Another example constitutes the fact of medical images being studied in one city while the patient is staying in another one and simply doesn't have to travel. In this way, telemedicine forms an opportunity to improve the quality of service.

Professor Jean-François Moreau

There is no doubt that emergency constitutes the first application of telemedicine, in situations where the distances are large. If you have a snowstorm, and even an ambulance cannot reach the patient, a telemedicine service obviously is able to offer the solution. Just the same,if there is a task force which cannot respond according to request. Still, we have to accept the concept of the physician as an interlocutor, able to interpret the data. The more data are located on place, the faster the doctor can perform his diagnosis. If the data are not precise enough, telemedicine will just be a loss of time since the data were incorrect from the beginning.

Professor George Papadopoulos, University of Cyprus

There are two sorts of telemedical environments, the one from doctor to doctor where the patient still is in contact with a human doctor, and the other one creating two telemedical sites where the doctor is brought to home electronically.
If you take into account the experiences in a project of telebanking, for instance, it was noticed that at least 50% of the customers did rather not use the machine but preferred to go inside and queue in front of the counter in order to be helped by a human person. The fear of technology and the aspect of human contact are two important psychological factors, you have to deal with when teleservices are being introduced.
In Cyprus, people are used to go to their own family doctor. Perhaps, in other European regions, they only want the best available doctors, but in some countries, this is simply not acceptable in the spirit of tradition. Again, this is a matter of psychology. How are we going to deal with the introduction of the telemedical concept in these countries?

Mr. Mariusz Duplaga, Head of Computer Section, Jagiellonian University, Krakow, Poland

Telemedicine obviously appears to be for special areas, and often not for general medical practices. General medicine can only be substituted with a computerised system, if the distance requires remote consultation, it seems. However, general practitioners can also benefit from these new tools and services to offer an improved patient care but it is up to him or her to decide whether he or she will introduce these innovative techniques. Perhaps, we should focus more on this possible type of solution, in order to optimise the role of the general practitioner who, after all, is able to deal with the majority of the patients' problems.

Dr. Andy Marsh, showing the picture of a cyber-doctor:

Would people like to be treated by this technologically sophisticated general practitioner?

Mr. Mariusz Duplaga

Patients need interaction with a human being, computerised or not, but this is a caricature of the past time, I'm afraid.

Professor Jean-François Moreau

If we have a look at the devices, provided by the industry, we dispose of home videoconferencing systems, which are constantly being improved. By means of satellite networks and cable linkage, they should be implemented within the homes of the patients. Through a camera-connection, you could discuss face to face with the physician. This would change the behaviour of telemedical procedures.
Most of the people think that there are plenty of doctors in the reference centre. This is not true, so a general practitioner might ask for an emergency responsible at a moment, when he is responsible for thirty five files. This situation, of course, is not affordable. We have to train people at schools or at universities to use the services at a reasonable cost.
The politicians are not realistic because they slow down the system without providing the possibility to officialise any of the services. They should take into consideration that a wild form of telemedicine suddenly can emerge without any control whatsoever, but in fact, they hate telemedicine. Unfortunately, too many mistakes have been made by the first promoters of telemedicine, at the beginning. We have to reform our approach, showing that we have to focus on some applications, make them work and try to persuade the politicians.

Dr. Andy Marsh

In the United States, the Congress has just accepted to make funds available to reimburse telemedicine. The funding has been forced from the bottomup because people are starting to use telemedicine actively.

Dr. Tuomo Kauranne, University of Joensuu, Finland

We have been considering the telemedical field from a rather professional perspective, either technical or medical. In our country, we have small regions where professionals from different disciplines meet regularly. Their aim is to care for people. The cost is not at all seen in the human care but rather in logistics and information processes. Doctors use their time badly at filling in too many forms and papers while the patients are waiting in hospitals. Here, we should be able to reduce the costs and yet improve the service.
We try to keep people away from institutions, clinics and hospitals after treatment. When they are old, they prefer to live at home, rather than to stay in hospital, and they would, if only they were certain to be safe and to obtain good care and attention. We now try to put together teams of caretakers and nurses for certain areas, for certain villages, who can build up a personal relationship with the patient. The teams have a responsibility to agree on who is visiting who, where and when. They have to communicate with mobile communications.
The idea is to make more specialised resources effectively available for these people who always still are needing care. If necessary, immediate booking can be reserved in a hospital, since the team disposes of on-line information about the availability of specialists and services. The patient never really has to interact directly with a cyber-doctor. It is the caretaker, having some professional training, who takes care of the contacts. The patient is fully covered by a variety of specialities which are at his disposal without the usual inconveniences.
Information technology should aim at a better use of everybody's time. Instead of focusing on the obstacles, it is better to promote this idea of care delivery, performed by responsible teams. We shouldn't focus on highly technical, specialised care in the first place, which has only an impact on a very small population. There has to be a combining approach between the business and the care process. The fundamental gainers have to be the patients. In the end, the patient has to receive better care for paying less.

Mr. Mariusz Duplaga

There was no change when the doctor performed auscultation with his ear or using a stethoscope. It is merely a tool, and the physician should use the tool for the improvement of the services.

Mr. Adam Koprowski, Head of Computer Department, John Paul II Medical Centre, Krakow, Poland

The computer has become a common tool. In the future, medicine will be based on the computer system. There is no other way. We will have to discover a method which transforms the telemedical application into a human approach.

Dr. Andy Marsh

Referring to the original idea of the twenty building blocks, these areas are coming up and up again in the discussions we have. Is there something grossly missing out in the spectrum that we are looking at? Is there one building block standing out, forming the central problem? If so, what is it? Is it the communication, or the marketing and promotion, or rather the standards? Do we have to build everything at the same time, or concentrate on one building block?

Professor George Papadopoulos

I don't see the word "evaluation". I think it should be above "usage". This is where the psychological factor is situated.

Dr. Andy Marsh

Perhaps, we should put "evaluation" instead of "marketing and promotion", or maybe combine "marketing and promotion" and introduce "evaluation" after standardisation.

Professor Jean-François Moreau

There are two things which are very important in medicine, namely evaluation and accreditation. Accreditation has become a routine in North America as well as in the United Kingdom. In France, we have already started this process of accreditation. In the years to come, it will move to other parts of Europe as well.

Mr. Vladimir Cerny

One thing is missing in this construction of the twenty building blocks, and this is the thermodynamical limit of systems like that. I have never heard of a system which is anticipating to something that complex and that large. If you have a situation like that, it could easily end up in a chaos. The blocks are not robust enough to face all kinds of problems, if the system becomes too large. Somehow, I don't see a technology which is faceted enough to handle this distributed, relational datasystem with no central database.
The technology should be something in between a complete, integral, relational database and a complete mess, like the AltaVista search of data. One should find a technology which can handle these large scale problems.

Dr. Andy Marsh

What I am looking for, is the comparison with a transportation device. We all agree on the fact that a car should have four wheels and an engine. Is there any way we can do this with telemedicine? First, we should identify the core and then choose no matter what shell to build around it. Just like a car can come in many shapes, is there any possibility for realising this in the field of telemedicine, once of course, the core has been defined?

Professor Emil Jovanov, Institute "Mihajlo Pupin", F.R. Yugoslavia

If you try AltaVista search for telemedicine products, you only find a very low number of hits. Few companies obviously make devices for home care. I have a feeling that some nuclei are growing around different themes, such as visualisation, image processing, hardware, and so on. It is very important that we promote telemedicine as a tool towards both the patient and the doctor. As a patient, I was impressed even by an old fashioned book, describing exactly what you can do if you have certain symptoms. This kind of approach, namely the presentation, promotion, and active development of the various possible telemedical tools to the benefit of patient and doctor, could find its way.

Dr. Lars Edenbrandt

For ordinary people, the use of Web browsers is very important. Within ten years from now, it will be very common to view news and data on the Internet in private life. The development of new platforms for doctors will follow as well. Netscape will form an excellent tool to view the data.

Professor Zhang Yuan Ting, Chinese University of Hong Kong

It is difficult to give an answer on future developments. In any case, the communication channels have to be further developed and we should go on investing in computer telecommunication.

Dr. Andy Marsh

It is very constructive to try and continue the discussion as well as diverse the different domains, which is the most difficult. To this purpose, we should begin to create a kind of working group with a representative background. Participants have to be investors in their own mind and should be quite flexible as well. If you want to promote something like telemedicine, you have to dispose of cross disciplines and balances in order to cover the variety of ideas. We have seen the seeds of such a kind of working group around here.

Professor Jean-François Moreau

If you want to have something well established, you have to set a deadline. If you have a project for the next year, it must be prepared for the year coming. If it is only in five years, the situation is totally different.

Dr. Andy Marsh

I think we'll have to finish here. We should now begin to make some promotion steps forward during future conferences, in order to actively promote the Telemedical Information Society.
Once again, I'd like to thank everybody who has contributed to the success of our discussion forums.

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Leslie Versweyveld