G8 Global Healthcare Applications SubProject 4 "International Concerted Action on Collaboration in T

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G-8 Global Healthcare Applications Sub-Project 4
"International Concerted Action on Collaboration
in Telemedicine"

• André Lacroix, M.D.
• Canadian representative and Project Chair
• Telemedicine Unit, Research Centre, Hôtel-Dieu,
  Centre Hospitalier, Université de Montréal (CHUM)

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Global Information Society

• G-8 Governments wish to share more efficiently
  their expertises in selected areas including
  healthcare
• Healthcare ranks very highly as a priority for
  individual citizens of all countries
• Global telecommunications networks could
  contribute significantly towards
  achievement of a healthier world

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G-8 Global Healthcare Applications Sub-Projects

• SP-1 Towards a Global Public Health Network
• SP-2 Improving Prevention, Early Detection,
  Diagnosis and Treatment of Cancer
• SP-3 Improving Prevention, Early Detection,
  Diagnosis and Treatment of Major
  Cardio- vascular diseases
• SP-4 International Concerted Action on
  Collaboration in Telemedicine 
• SP-5 Enabling Mechanisms for a Global
  Healthcare Network

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G-8 Global Healthcare Applications SP-4
National Representatives

• Canada André LACROIX (Chair)
• France Louis LARENG
• Germany Dittmar PADEKEN / M. NERLICH
• Italy Marcello BRACALE
• Japan Yoshikazu OKADA / Yoich OGUSHI
• Russia Oleg I. ORLOV
• U.K. James Mc GEE / Richard WOOTTON
• USA Jay H. SANDERS
• Australia S PREROST / I McDONALD

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Objectives of G-8 GHAP Sub-Project 4 in
Telemedicine

• Enhance the collaboration between G-8 countries
  to resolve key issues which retard the
  application of the Global Society in Healthcare
  via telemedicine and health telematics
• Initiate the establishement of an international
  multipoint network between
  Telemedicine Units in academic
  centers in G-8 countries

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G-8 SP4 FORUMS in Telemedicine

• FORUMS bringing together
• Health care authorities
• Key decision makers
• Telemedicine experts and users
• From G-8, EU-non G-8, and other countries
• Meetings organized and chaired by
  the national representative of the host
  G-8 country with the help of the
  steering committee

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G-8 SP4 FORUMS on Telemedicine

• Each meeting focuses on one theme
  identified as a key issue
• Interoperability in Telemedicine and Telehealth
• Impacts of Telemedicine on health care
  management
• Evaluation of cost-effectiveness of telemedicine
• Clinical and technical standards in telemedicine
• Medico-legal aspects of national and
  international telemedicine

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G-8 SP4 FORUM on Interoperability in Telemedicine
and TelehealthMontréal, May 28-30 1998

• Host A. Lacroix
• Participants
• 91 canadians
• 33 from 10 other countries
• 39 presentations in plenary sessions
• Working group sessions
• technical aspects
• organisational aspects
• human factors
• Report published by CANARIE

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Interoperability in Telemedicine Measures that
enable secure, accurate and reliable sharing of
health information and services between
healthcare providers and citizens at any distance
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Interoperability in
Telemedicine  On the surface, such issues
appear to be technical in nature, but in reality
the effectiveness of a technical regime is a
product of organisational structures.
Furthermore, both the technical solutions and the
organisational responses are highly influenced by
a multitude of human factors. In fact, many of
the issues in strengthening international
co-ordination and cooperation in telehealth
and telemedicine are tied to resolving legal and
professional matters.
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Recommendations on standards, network
reliability, security and applications

• Strongly recommend that telehealth applications
  and networks should adopt as many standards as
  possible
• The basic standard for telehealth systems should
  follow recommendations of ISO working groups
• Technical Quality of Service should define
  parameters of performance at a level that remain
  understandable to the clinical user
• Telehealth systems should receive bandwidth on
  demand, as apprropriate for the application

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Recommendations on standards, network
reliability, security and applications

• Existing telehealth infrastructures need to be
  compatible and interoperable with digital dialup
  and/or TCP/IP protocols they should adopt
  evolving new technologies which are performant
  and least expensive
• Encryption should be used in providing the
  highest possible security to data contained and
  transmitted through telehealth systems
• There is a need to develop a process model for
  each healthcare/ medical discipline with
  technical needs defined in terms of Quality of
  Service, security and application
  interoperability.

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Organizational barriers to integrated services

• Tension in the healthcare system resulting from
  changes
• Credentialing of healthcare workers in
  telemedicine
• Pressure of cost containment in a period of
  restructuring
• Finding appropriate formulae for reimbursement
• Political will to make hard decisions and action
• Lack of concerted efforts to effect changes
  within national and intra-regional contexts
• Technology-induced pressures on means to ensure
  privacy, confidentiality and security of the
  systems .

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Human factors in interoperability

• Human factors in communication are not well
  understood
• Language barriers
• Cultural differences
• Networks of confidence
• Ethical/legal/social issues
• Lack of utilisation by healthcare practitioners

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Actions to improve human factors

• Usability-design and useable systems
• Training and education
• Incentives to learn and use telemedicine systems
• Sufficient means to evaluate key systems
• Champions representing all levels of the
  healthcare system that can benefit from the use
  of telemedicine
• Adequate access to technical expertise
  among the user community.

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FORUM on Impact of Telemedicine on Health Care
Management, Regensburg, Germany, November 21-23
1998

• Host M. Nerliech
• Participants
• 280 participants
• 69 from 16 countries other than Germany
• Presentations
• 83 oral presentations
• 20 poster presentations
• Joint participation of G8 GHAP sub-project 5 in
  plenary and working group sessions
• Proceedings published by IOS Press, Amsterdam

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Impact of Telemedicine on Health Care Management
Working group session

• Many presentations illustrated positive impacts
  of telemedicine on healthcare management
  however
• Few evaluations of telemedicine have been
  conclusive because of difficulties in measuring
  outcomes should there be standard protocols by
  which outcomes measurements can be done?
• It has not been possible to compare telemedicine
  against traditional forms of delivering health
  care because often there are no comparative
  processes or outcomes
  against which we can measure
  telemedicine.
• Emphasis placed on access to care.

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FORUM on Evaluation and cost-effectiveness of
telemedicine, Melbourne, Australia, February
19-20 1999

• Hosts Ian Heath, Sandra Prerost and Ian
  McDonald
• Participants
• 54 participants
• 22 Australians, 32 from 10 countries
• Presentations
• 21 oral presentations
• Working group sessions
• Joint meeting with European Comission Telematics
  Applications Program Teleplans

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FORUM on Evaluation and cost-effectiveness of
telemedicine

• The key questions addressed at the conference
  were
• Where are we now in terms of telemedicine
  evaluation and in particular to assess what are
  the projects that appear to be cost effective,
  focussing on
• What is transferable and replicable to other
  telemedicine applications and
• What are the underlying principles for
  telemedicine evaluation
• What kinds of evaluation should be done
• Why evaluate ?

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FORUM on Evaluation and cost-effectiveness of
telemedicine

• Evaluation is complex, difficult but not
  impossible
• Evaluation takes place in a dynamic and complex
  system. Traditional cost efficiency and
  effectiveness analysis for evaluation is not
  always workable
• Rapid advances of IT make evaluations vulnerable
  to obsolescence as key hardware and software
  change
• Telehealth is not a single, homogenous technology
  but diverse
• Evaluators in a particular site may have
  difficulty using evaluation methodologies from
  other groups

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FORUM on Evaluation and cost-effectiveness of
telemedicine

• The criteria of evaluation should be able to
• Demonstrate that a telemedicine application was
  superior to other instruments to achieve the same
  goal
• Demonstrate appropriateness of the application to
  the objective and the health service environment
• Describe systemic interactions with other
  instruments, programs, policies and government
  frameworks
• Enable measurment of efficacy that is a cost
  effective way to achieve objectives
• Applicability and flexibility to incorporate
  effects or change

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FORUM on Clinical and Technical Quality and
Standards of Telemedicine  Washington, USA,
April 29-30 1999

• Hosts Drs Jay Sanders and Michael Ackerman
  Friends National Library of Medicine
• Participants
• 340 HII99 120 participants G8 FORUM
• 9 countries
• Presentations
• National and international standards
  telhealth/informatics
• Working group session
• Jointly with HII99 Improving Health in a Digital
  World, April 26-28 1999

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FORUM on Clinical and Technical Quality and
Standards of Telemedicine  Washington, USA,
April 29-30 1999

• World Health Organization
• U.S.National Library of Medicine
• U.S.Department of Defense
• American College of Radiology
• Canadian Institute of Health Information
• NASA
• Food and Drug Administration (FDA), USA
• Institute of Medicine, US National Academy
  Science
• International Medical Informatics Association
• US Department of Health and Human Services
• Medical Records Institute
• G8 countries academic centers

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FORUM on Clinical and Technical Quality and
Standards of Telemedicine 

• Technical Standards for Telemedicine and
  Telematics
• It was apparent from this session that standards
  are not yet established for telehealth.
• Different specialties and fields have different
  needs and that many defacto standards will
  arise as telemedicine systems are implemented.
• Technical standards to unite technologies are
  necessary. Standardized image formats and
  compression, interoperable software and hardware
  as well as capture device technology and
  transmission technology will allow globality in
  telemedical care.

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FORUM on Clinical and Technical Quality and
Standards of Telemedicine 

• Technical Standards for Telemedicine and
  Telematics
• Health practitioners need to determine what is
  needed to perform clinical services and provide
  an accurate diagnosis for patients, and/or
  provide adequate home and remote monitoring for
  patients.
• Standards are nonetheless only applicable if
  they are used in practice.
• Joint work between industry and medical
  specialties is the way of the future in insuring
  interoperability and interconnectivity
  standards..

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FORUM on Clinical and Technical Quality and
Standards of Telemedicine 

• Clinical Standards forTelemedicine/Telematics
• Clinical standards for telemedicine do not
  currently exist, and there is no obvious path to
  develop them.
• Professional bodies (Colleges of medicine,
  nursing, etc.) have a lead role to play in
  establishing the clinical requirements but it is
  not clear how to merge the technology standards
  discussions with the clinical standards
  discussions.
• All standards or guidelines that evolve must be
  evidence based and must be supported through
  rigorous evaluation programs for existing
  telemedicine services.

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FORUM on Clinical and Technical Quality and
Standards of Telemedicine 

• Integration of Telemedicine and Health Care
  Informatics
• There are a number of organizations, government
  and other, who are making progress on the broader
  issues related to standard for the application of
  information technology in health.
• This effort, and those of others developing more
  specific telemedicine standards, must be
  considered and coordinated to create
  a global approach to standards

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FORUM on Medico-legal aspects of national and
international applications   London, UK, November
28-29 1999

• Hosts Prof James McGee and Richard Wootton
• Participants
• 102 participants G8 FORUM 180 Telemed 99
• 11 countries
• Presentations
• 25 plenary speakers
• Working group sessions
• Jointly with Telemed 99 and The Royal Society of
  Medicine, November 30 and December 1 1999

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G8 FORUM on Medico-legal aspects   Consensus
Session on Security, Privacy and
Confidentiality

• Develop country wide public key infrastructures
• Creation and maintenace of certification
  authorities ?
• Implementation of any system will be superior to
  current relative lack of protection
• Primary issue of consent
• Differences between public and private health
  systems
• Technical solutions to privacy exist but will
  require policy directions and funding to implement

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G8 FORUM on Medico-legal aspects   Medicolegal
issues

• A common theme was the current legal uncertainty
  surrounding telemedicine and the need for
  policy/guidelines/law to reduce this uncertainty
• Key issues have been identified, but there was
  little agreement on the best policy solutions
• Different jurisdictions have been deciding the
  policy issues differently
• The lack of harmonization across jurisdictions
  (e.g., re licensure) could be a significant
  impediment to global telemedicine.

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G8 FORUM on Medico-legal aspects  
RECOMMENDATIONS

• As infrastructures for the use of PKI evolved,
  governments must ensure that there is an
  appropriate legal framework for its use in the
  healthcare sector and that dialogue takes place
  at an international level to ensure
  interoperability of its use between various
  countries
• Patients must give fully informed consent for the
  use of their personal medical information for
  healthcare, evaluation or research, even if data
  is anonymous its use for commercial purposes
  should be restricted to informed and ethically
  approved uses. Professional and patients
  organizations should work together to promote
  better understanding of privacy and
  confidentiality

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G8 FORUM on Medico-legal aspects  
RECOMMENDATIONS

• An international group of national
  representatives must develop ethical and
  medico-legal guidelines for the practice of
  telemedicine formal work conducted by various
  groups such as the Einbeck group should be
  considered as a starting model
• The major barrier of healthcare professionals
  licensing should be resolved by deciding that the
  telemedicine activity is occurring at the site of
  the consultant the patient should
  agree that he will follow the
  legal rules at the site of the consultant,
  as is done currently when the patient
  travels physically to that
  site.

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G-8 IMPACT Project(International Multipoint
Project of Advanced Communication in Telemedicine)

• Develop an International backbone network between
  Telehealth Units in G-8 countries and Australia
• Develop the technical protocols and agreements
  with academic and industrial partners
• Test the feasability of multipoint meetings
  using diversified telehealth equipments
• Initiate the project with selected pilot
  sites in each country
• Eventual goal link the national networks
  within an international backbone

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G-8 IMPACT ProjectObjectives of meetings

• Test-bed for G8-SP-4 FORUM recommendations
• Telelearning programs in diversified fields
• Joint multidisciplinary and multimodality staff
  meetings of experts in various fields of clinical
  medicine and healthcare
• Availability of teleconsultation in complex cases
  or during large scale public health emergency
• Simultaneous interactive retransmission of
  prestigious state of the art lectures
• Facilitate International collaborative researh
  studies in various biomedical fields

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CA
CA
JN
JN
G-8 network
USA
EU network
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Progress on IMPACT project

• February 1999 Japan-Canada network
• Tokai University, Japan - Memorial University,
  NF-CHUM / Montreal University, Canada
• Funding of Tokai Univ by Japan Ministry of Health
• Telelearning in medical schools and joint staff
  sessions
• February 1999 USA, France, Germany, Canada
• Yale Univ/MCV, EITS-CHU Strasbourg, Regensburg
  Univ, CHUM, Univ de Montréal, Oxford
• Joint staff meetings in
• endocrine and digestive surgery
• breast cancer
• orthopedics and trauma surgery

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The future of G8 SP-4 after December 1999

• The umbrella of G8 GHAP was very useful to
  attract interested participants to this project
• Despite the absence of committed national
  funding, the G8 GHAP label was very helpful to
  attract funding from public or private sectors to
  realize the FORUMS and the IMPACT projects of
  GHAP SP-4
• The most industrialized nations bare the
  responsibility to develop and test the
  technologies which have a potential to improve
  global health care including for emerging
  countries.

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The future of G8 SP-4 after December 1999

• Active participation of experts from all G8
  countries including Russia, Australia and other
  countries
• The fields of telemedicine and health telematics
  are emerging and complex their full integration
  in healthcare delivery will require years of
  concerted efforts
• Conclusions and interim recommendations have
  emerged from our working group sessions and
  will be presented at the Berlin GHAP
  summary meeting in May 4-5 2000 and
  on our Web site http// www.g7sp4.org

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GHAP G-8 SP-4 recommendations

• The GHAP sub-project 4 participants wish to
  pursue their common efforts in international
  collaboration
• Additional FORUMS are required to come to
  recommendations on the evaluation and
  implementation of medical, ethical, legal, and
  technical aspects of telemedicine services-
  including aspects of crossborder services.
• G8 and other participating countries should
  provide sufficient funding to their national
  representatives, experts and expert centers to
  pursue their work and disseminate their
  conclusions and recommendations

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GHAP G-8 SP-4 recommendations

• The G8 SP-4 working group should collaborate with
  other international healthcare organizations such
  as the World Health Organization to facilitate
  the integration of health telematics to
  healthcare strategies worldwide
• The G8 GHAP SP-4 should report annually
  on its progress and activities to its
  national health authorities and to
  citizens through its Web site.

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G-7 Global Healthcare Applications sub-project
4 "International Concerted Action on
Collaboration in Telemedicine"

• The dedicated participation of a large number of
  national experts is greatly appreciated

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Bienvenue à ISfT/CST/Health 2000

• Montréal, Canada, October 2-5, 2000
• www.isft2000.com