5. TELEMEDICINE IN OTHER COUNTRIES

General

The selection includes

Australia
Canada
China
Japan
Latin America

Australia and Canada are both participating in G7 activities. The experience of both countries on telemedicine is well known. Geographical distances have been a key element driving telecommunication applications to aid health care provision to distant sites in their wast territories.

Japan is an industrial power and one of the main player in the competence for information technologies and telecommunication markets. Japanese devices are widely used as components in Telemedicine systems. However telemedicine experience is rather unknown probably due to a lack of english published information.

Finally China an Latin America are good sources of knowledge on international Telemedicine initiatives.

5.1. AUSTRALIA

5.1.1. Introduction

As in other countries, the geographic characteristics have played and important role in the development of  telemedicine and telecare applications in  Australia. The cummulated experience is quite important. There are approximately 150 telemedicine sites in Australia. These sites provide a range of services, with most developments occurring in clinical consultation and remote counselling services. The use of videoconferencing facilities is thus central to many telemedicine facilities.

Although some stand alone projects are based in urban centres, many of the telemedicine sites are located in rural areas of Australia, with links to other rural cites and central urban sites. Clinical consultations, diagnosis and remote counselling services are primarily rural based, with professional development and administrative services distributed more evenly across urban and regional centres.

The key supporters of telemedicine development in Australia come from: federal, state and local governments; universities; hospitals; and private organisations.

The term "telehealth" has quickly grown in  popularity, and it used in official documents.

5.1.2. History

The past  years has seen a steady growth in the number of Telehealth projects in Australia. There are now some 230 interactive video based projects.

5.1.3. Current situation

5.1.3.1. On-going projects and achievement

 5.1.3.1.1. Presentation of major projects

The Renal Dialysis Telemedicine Project was established in 1994 at the Renal Unit of the Queen Elizabeth Hospital in South Australia. It was designed to improve the health services for renal dialysis patients located in regional South Australia. Four satellite dialysis sites, at Woodville, Wayville, North Adelaide and Port Augusta (300 kilometres away), have been provided with telemedicine facilities to evaluate its use in enhancing the delivery of renal health care and professional development. Each site is connected by ISDN to the Queen Elizabeth Hospital in Adelaide and supplied with videoconferencing technology, including a portable desktop unit, which can be moved from patient to patient.

The network is used by various clinical staff including doctors, nurses, pharmacists, dieticians and others, to communicate with patients and each other. The network is also used for instructions, tutoring and administration. The Queen Elizabeth Hospital is also conducting trials in remote imaging techniques.

The Metropolitan and Country Healthcare Network is 'the first multi-site, 'many-to-many' broadband telemedicine program in Australia.' This network links three urban hospitals, St Vincent's Hospital, The Royal Victorian Eye and Ear Hospital(REEH) (http://iris.medoph.unimelb.edu.au/library/homepage/rveeh/rveeh.htm) and The Royal Children's Hospital (RCH) via a broadband ATM connection, and the Goulburn Valley Base Hospital via an ISDN link.

The network will be used for concurrent projects, established in the first phase of the program which runs throughout 1996 and 1997. They are:

• The Remote Pre-Admissions project will reduce patients' travelling time, by allowing local doctors to perform pre and postadmission examinations and by utilising a videoconferencing link at the local hospital, for an interview with the surgeon.
• The Slit Lamp Imagery Project allows local doctors to magnify opthalmic imagery using the slit lamp and send it via the videoconferencing link to specialists at the RVEEH hospital for diagnosis.
• The Children's Burns Project will allow rural patients to visit their local hospital and utilise the videoconferencing network for remote assessments and supervised physiotherapy via a paediatric physiotherapist located in the RCH. Burns patients require regular physiotherapy and in the past, country patients have had to travel to the city twice a week for such care.
• The Neurosciences Projects enables medical registrars at local hospitals to take a CT Image series and transmit them via the videoconferencing network to a city-based neurologist or radiologist for diagnosis. This is then relayed back to the medical registrar, establishing what treatment is required and if further investigation is needed.
• Similarly the Radiology Project allows registrars to transmit CT, ultrasound and x-ray images from the hospitals for assessment by radiologists in the city.
• The Cochlear Implant Project will facilitate the transmission of image data (from CT or MRI Scanner) of patients who will be undergoing cochlear implant surgery. The patient is required to be anaesthetised during the scanning and this occurs at the RCH. The images are required for surgical planning and are sent via the network to surgical staff at RVEEH.
• The ICU/Case Management/Education project will also be established to increase staff access to professional development courses and peer group discussions on case management issues. An Adult Psychiatry project is also being developed in conjunction with the Mental Health Research Institute.

In 1995, the Telemedicine Unit was established. This operates as part of mainstream mental health services in South Australia and forms part of the Rural and Remote Country Health Division of SAHC. It aims to promote mental health services in rural and regional South Australia.There are 16 telepsychiatry centres in regional and rural South Australia and videoconferencing links in Darwin, to provide supervision to psychiatric trainees making it one of the largest networks of its kind in the world. A 24 hour, seven days a week telephone support service is also available. Videoconferencing services are primarily used for psychiatric assessments, consultations and for liaison between family members, health care practitioners and patients.

The Health Department of Western Australia (http://www.publichealth.gov.au) is implementing the Northwest Mental Health Service Telepsychiatry Network for remote psychiatric service. This network will link seven sites in Broome, the Kimberley and Pilbara regions to Graylands Hospital in Perth and will utilise videoconferencing networks. The service will initially be provided by ISDN and then by a satellite network.

Remote counselling is also available via Internet chat lines and bulletin board services. Individuals can contact people for advice, to discuss problems and issues of concerns over the Internet. These operate in a manner similar to telephone crisis centres such as Lifeline and the Women's Information Referral Exchange.

The Health Communications Network (HCN) (http://www.hcn.net.au)
While HCN's focus is on the provision of access to medical information databases via the Internet, it has also established a number of telemedicine trial projects. They are,

- Teleradiology Pilot
The pilot comprises a link between a hospital in Wagga Wagga, New South Wales and St Vincent's hospital in Sydney. It involves the transmission of diagnostic images (X-rays, CT scans and the like) for patient management and diagnostic advice Established in 1991, the system was evaluated in 1993 with the finding that HCN should provide funding assistance. This assistance has seen the network extended from Wagga to smaller rural hospitals in the region, and from St Vincent's to the Prince of Wales Children's Hospital (http://www.powh.edu.au). The project is considered a success given that it is enabling remote medical practitioners to access specialist advice and to reduce the cost of transport and treatment of patients.

- Athsma Management Pilot
A network involving Campbelltown Hospital, in Sydney's south western suburbs, and 15 local general practitioners, paediatric specialists and athsma patients. The project enables patient records and consultation information to be transferred between practitioners and the hospital (with patients' informed consent) and returned when patients are discharged.

- Anaesthetic Incident Monitoring Study Pilot
Under this pilot, ten hospitals and private anaesthetists in five states are linked to the Australian Patient Safety Foundation (http://goblin.mad.adelaide.edu.au/~apsf/apsf.phtml) in Adelaide. The electronic reporting and feedback facility allows participants to anonymously send incident reports to the Foundation. The perceived benefits of the pilot are in the areas of increased patient safety through more timely addressing of potential problem

The Royal Brisbane Hospital (http://www.medicine.uq.edu.au/rbh/default.htm) in Queensland has established the Telemedicine Application for Remote Distributed Interactive Systems (TARDIS) . This project commences in 1997 with a trial linking two rural hospitals in Queensland (Nambour and Maryborough) with clinicians working in Intensive Care Units (ICUs) at the Royal Brisbane Hospital. An ATM network will enable clinicians at Royal Brisbane hospital to consult with doctors, and monitor and diagnose patients in rural and remote locations. It is anticipated that this will reduce the number of patient transfers required and reduce costs. If successful, the network will be expanded.

Some leading private organisations in the field of telemedicine include Telemedicine Australia (http://www.health-sa.net.au/db/6.html) (see The Queen Elizabeth Hospital), the Australian Computing and Communications Institute (http://www.acci.com.au) (see the Metropolitan and Country Healthcare Network (http://www.mchn.net.au/launch.html)) and Macquarie Health Corporation Ltd.

The Common Ground Bulletin Board Service (BBS)
(http://www.dircsa.org.au/cgpam.html) was launched in 1993 to address the communication needs of people with severe disabilities. The BBS provides access to newsgroups dealing with areas of interest to people with disabilities, electronic versions of relevant government policies and information resources, as well as a multi-line 'chat' facility which provides an avenue for discussing problems and raising issues of concern.

In 1995, it was estimated that Common Ground serviced 800 users, and received 150 calls to its help desk daily. The BBS can now be accessed via the Disability Information and Resource Centre's Web site.

5.1.3.1.2. Type of TM services or applications

Educational services provided by telehealth networks in Australia include professional development, via continuing medical education of practising clinicians; the training of medical and health care students; and support for staff utilising telemedicine services

5.1.3.1.3. Medical Speciality actually involved in TM

In addition to psiquiatry and  urology, other specialities involved in telemedicine are: radiology; cardiology; dermatology; emergency/triage; intensive care/emergency; mental health; nephrology; obstetricy-gynaecology; ophthalmology; pediatrics; speech pathology.

5.1.3.1.4. Most common applications found in the TM activities

Although some stand alone projects are based in urban centres, many of the telemedicine sites are located in rural areas of Australia, with links to other rural cites and central urban sites. Clinical consultations, diagnosis and remote counselling services are primarily rural based, with professional development and administrative services distributed more evenly across urban and regional centres.

Telehealth networks are a means of providing access to health services to rural residents through the delivery of remote medical services and applications. In general, these networks are capable of transferring text, voice and image data, with noticeable differences in the speed of transfer and quality of data arising through network variations. The main services provided through these networks are:
 

• clinical consultation;
• clinical diagnosis, including image transfer;
• remote counselling;
• public health information;
• administrative activities; and
• professional development activities.

5.1.3.1.5. Type of communication networks currently in use

5.1.3.1.6. Type of medical devices actually found in existing applications of TM

5.1.3.1.7. What is the place for the Internet and for Web based technology in the TM

The Health Communications Network (HCN) (http://www.hcn.net.au)  is an Australian company which provides health-related information via the Internet to the medical professions, and to the general public. The company also offers Web page design and Internet service provision.

The West Australian State Government (http://www.sage.wt.com.au/~tcnwa/telecent.html) is piloting through its telecentre network a pre-consultation, preventative health care program, in conjunction with the Electronic Community Health Organisation (ECHO). An initial pilot service, supported by West Australian Health (http://www.publichealth.gov.au), has been running for evaluation

The South Australian Health Commission (http://www.health-sa.net.au) has established a Health Online Unit (http://www.health-sa.net.au/db/6.html) which has the potential to deliver professional development for practitioners, education and training for health students (including medical and nursing students) and community access to medical and heath-related information. This service is still in demonstration phase.

The Gasbone-Anaesthetic Online Education programme (http://gasbone.herston.uq.edu.au:8080/mirror/vat/vatissue.htm) provides a network for exchanging materials and resources between staff at the Royal Brisbane and Townsville General hospitals (http://www.medicine.uq.edu.au/rbh/default.htm). The network is used for the remote delivery of lectures, tutorials, a bulletin board 'chat line' and other resources for medical students and anaesthetists. Lectures and tutorials are directed through the Internet and videoconferencing facilities. Administrative support material, including discussion groups, library resources and course handouts is made available via the World Wide Web (WWW) and bulletin boards.

CMENet is a Queensland consortium established to improve access to continuing  medical education for regional, rural and remote rural health care providers via the use of distance education technologies, particularly the Internet. CMENet exploits the Internet as the integrating factor in the delivery of relevant medical educational programs and resources. The CMENet website (http://www.cme.net.au) was developed to improve access by rural and remote  practitioners to a broad range of educational programs and resources

5.1.3.1.8. If projects are HCT telematics projects or related to them in any way

  5.1.3.1.9. Involvement of research organisations

The Centre for Medical Informatics, Monash University (http://www.monash.edu.au/informatics/default.htm), has been involved in various telemedicine projects including the Primary Health Orientated Computer Users' System (PHOCUS) and the Project for Rural Health Communications and Information Technology (PHRCIT). It is also a consultant for the General Practice Branch of the Commonwealth Department of Health and Family Services (http://www.health.gov.au) which is examining the use of PCs and IT&T by GPs in Australia.

The James Cook University (http://www.cs.jcu.edu.au) of Northern Queensland has developed a software program, UniMed, which is currently deployed in numerous general practices in Queensland.

St Vincent's Hospital (http://www.svhm.org.au) is trialling telemedicine applications through the Melbourne Metropolitan and Country Hospital Network as are The Royal Children's Hospital, The Royal Eye and Ear Hospital and the Goulburn Valley Base Hospital in Shepparton.

5.1.3.1.11. International activities in TM

• health computer software;
• teleradiology;
• health education via video-conferencing by universities and teaching hospitals;
• standards;
• telepsychiatry; and
• telerenal medicine.

5.1.3.1.11. TM Professional organisation in the country

The Health Informatics Society Australia website www.hisa.org.au
The General Practice Computing Group (GPCG)
Australian Medical Association (AMA).
The Royal College of Nursing Australia (RCNA)
Royal Australian College of General Practitioners (RACGP)

5.1.3.1.12. National (or federal) policy concerning the development of TM

One of the key strategic elements is to “Ensure that affordable access to quality telecommunications services is available for the health sector and consumers in rural and remote Australia”

Concerning Government's vision for Australia in which all Australians  have improved access to health, education and government services. Three specific  health strategies include:
 

1. Using online technologies as an enabler to redesign information management practices in the health sector. Information technology offers unparalleled opportunities to knit together the communications and information sources of the many players in the health field, and to generate efficiencies in information management.
2. Expanding the use of online technologies to deliver better health services. There is already a substantial body of work in progress, involving all levels of government. In the long term, the government envisages an Australia where consumers and providers of healthcare,     wherever they are located, have online access to clinical advice, specialist referrals, diagnostic tests, results and other telehealth services.
3. The expansion of markets for Australian online health services.

 Other important reference is the report of The House of Representatives Standing Committee on Family and Community Affairs entitled “ HEALTH ON LINE . REPORT INTO HEALTH INFORMATION MANAGEMENT AND TELEMEDICINE” published on October 1997.

• the costs and benefits of deploying advanced telemedicine services to rural and remote Australia;
• issues which may arise including privacy and security issues;
• the development of standards for medical information; and
• the possibility of Australia becoming a leader in the area of telemedicine.

The Victorian Government is involved in various initiatives and has established the Public Hospital Information, Information Technology and Telecommunications Strategy which aims to provide integrated telemedicine networks in rural and metropolitan hospitals in Victoria.

5.1.3.1.13. Total investment in Telemedicine

5.1.3.1.14. Regulations affecting the development of TM

 5.1.3.1.14.1. Legal and regulatory aspects including privacy and security

 5.1.3.1.14.2. Others

5.1.4.1.15. How TM development is related to other Healthcare telematics programmes

5.1.4.1.16. Is TM related to other  sector applications than healthcare

5.1.4.1.17. Business approaches and Sector industry

Estimates of the growth of the telemedicine industry in Australia, based on consultations for the DIST study, are:

• 1997 $24m
• 1998 $36m
• 1999 $54m.

     Emerging markets in telemedicine in Australia include:
 

• call centres
• telemedicine to the home
• telemedicine to aged care facilities
• correctional services telemedicine
• Aboriginal telemedicine
• Defence forces telemedicine
• ambulance telemedicine
• emergency, outback telemedicine
• combining digital communications at the GP’s desktop
• telehealth information on the Web
• export of telemedicine services to Asia.

To enhance awareness of Australian health industry capability, Austrade has arranged participation in a number of major international trade promotions in which a number of health information technology companies have been represented.

5.1.3.1.18. TM activities self-sustainability and economical issues

Experience can be drawn from radiology and pathology companies who have used teleradiology and telepathology techniques for a number of years. In fact, teleradiology is the largest single application of telemedicine in Australia, with an estimated 150 sites around the country. Interestingly, many of these companies use telemedicine not just to save time and expenses in transporting films and samples, but to provide a superior service to their clientele.
 

5.1.4. Factors of Success in Implementing Telemedicine

5.1.4.1. Incentives to the diffusion of TM

• Increased access to appropriate health services for both providers and patients in regional and remote areas;
• Reduced time away from work and homes for health consumers living in regional and rural Australia;
• more efficient health service delivery through reduced delays and costs relating to patient transfers;
• more efficient and effective diagnosis and treatment through rapid access to diagnostic test results and online advice for providers;
• improved communication between health care providers across health care settings;
• improved professional support and decreased professional isolation for rural and remote practitioners;
• potential cost-savings through supporting home based care rather than institutional care;
• increased online support, education and training of health care professionals; and
• a valuable vehicle to export Australian health care expertise

5.1.4.2. Most important barriers to adoption of TM

• lack of national coordination,
• remuneration, of mactitiones
• liability issues
• standards,
• evaluation,
• ethics;
• technological infrastructure;
• project management.

5.1.4.3. What is actually done or planned to overcome them

• privacy, security and legal issues that concern the electronic transfer of health information;
• the development of national standards with international compatibility for health information management and information technology;
• infrastructure issues required to progress online activities in health;
• training and support for health workers and consumers; and
• research and development.

The Government’s Public Key Authority (GPKA) Gatekeeper project outlines the requirements for a security infrastructure. The Health Insurance Commission (HIC) is the health sector representative on the GPKA. The HIC has initiated the Public Key Infrastructure Project . Concerning Certificate Authority, Registration Certificate issue will commence in the second quarter of 2000, limited to particular business applications.

One of the remarkeable planned actions is to establish a national Clearing House for pilot projects. The evaluation methodology being developed by the Australian New Zealand Telehealth Committee may
provide a model for this.

A comparable service, using satellite technology is envisaged for those areas not able to obtain ISDN services. The government’s Regional Telecommunications Infrastructure Fund (Networking the Nation) is also aimed at improving infrastructure arrangements in rural Australia.

In 1996, the Australian Health Ministers’Advisory Council (AHMAC) endorsed the establishment of the National Telehealth Committee, now known as the Australian New Zealand (ANZ) Telehealth Committee. The ANZ Telehealth Committee (a committee of  some states) are aiming to use resources from the National Health Development Fund for  extension of telecommunications infrastructure.

The ANZTC’s website (www.telehealth.org.au) countains, the database of current telehealth projects, programs and services across Australasia;

5.1.4.4. What are the most pressing needs

5.2. CANADA

5.2.1. Introduction

Today the term telehealth is used more frequently than telemedicine. Telehealth is defined as  the use of advanced telecommunications and information technologies to exchange health information and provide health care services across geographic, temporal, social and cultural barriers (based on Reid 1996).

Further there is growing interest in the emerging tele-homecare sector. New initiatives have been undertaken and a number of Canadian companies focussing on tele-homecare services and products have emerged in the last few years.

5.2.2. History

Small-scale experiments and trials such as these continued for almost 40 years, involving a small group of pioneers and researchers supported by equally small government subsidies and R&D grants.

Recent pilot projects have been developed as consequence of the strong national policy to use information technologies and telecommunication to support health care objectives.

5.2.3. Current situation

5.2.3.1. On-going projects and achievement

 5.2.3.1.1. Presentation of major projects

• Remote Teleconsultations and Continuing Medical Education

Hospital for Sick Children Telehealth Program , Toronto, Ontario, Canada            http://www.sickkids.on.ca.

As part of its mission to be a "Hospital Without Walls", The Hospital for Sick Children, a tertiary care academic health science center, uses ISDN technology to videoconference to distant and remote sites for patient and physician-to-physician consultations, and training for a variety of medically related disciplines. Tele-education sessions (Rounds) in a variety of Paediatric Specialities are conducted nationally and internationally throughout the year. The hospital Telehealth Program is currently establishing a Home.  Telemonitoring Program.

International activities includes operations in Argentina, Canada, Dubai , India , Israel, Japan , and  United States.

- Nova Scotia Rural Physician Network
During 1996, the Nova Scotia Department of Health conducted a 12-month pilot project, connecting Halifax to 4 rural sites. PC-based videoconferencing was used for CME, and for consultations in radiology and dermatology. As a measure of the project’s success, the next provincial budget will provide funding to most of the hospitals in Nova Scotia to be equipped with these tools.

- Child Telepsychiatry Project
The Child Telepsychiatry Project addressed the lack of child psychiatrists in rural regions of Newfoundland. 23 patients were involved in the randomized control study, which compared telehealth interviews with face-to-face interviews.
 

- Rural-Urban Telehealth in Alberta
Alberta We//net. Edmonton, Alberta, Canada  http://www.albertawellnet.org
To provide improved access to healthcare especially in remote communities; to provide improved communications and educational opportunities for healthcare providers; to improve the efficiency of delivery of specialized healthcare. Alberta Wellnet acts as a facilitator to allow the 17 regional health authorities and two provincial boards to engage in telehealth. Applications are: cardiology, emergency/triage,  internal medicine,  mental health,  radiology,  rehabilitation, and  rheumatology
Health care providers at one rural site in Alberta consulted specialists and subspecialists at a tertiary care centre for a period of ten months, via the use of a 24-hour real-time telehealth system.

- Quebec Inter-regional Telemedicine Network
Phase 1 of this pilot project began in September 1996 using a videoconferencing system over ISDN to conduct biweekly CME and multidisciplinary staff meetings. Phase 2 began in March 1997, adding teleconsultations as an application.

The University of Ottawa Heart Institute has recently initiated a project to use satellite ATM technology to transmit diagnostic information from remote areas, so that a third specialist can carry out comprehensive consultations. The aim is to show that telehealth is a viable alternative for delivering health care in Canada, to improve access to health services in Ontario, and to increase the efficiency of service delivery. The project will produce remote satellite consultation workstations, remote consultation software, in addition to evaluation studies on cost and educational aspects.

- TeleInViVo
TeleInViVo is an application for “collaborative volume visualization”, enabling communication of multimedia data between a remote site and a base station. This application was tested by the US Army in Bosnia, using a 38-kg package in the field which allowed image transmission and videoconferencing, for remote diagnosis. TeleInViVo allows non-trained persons to scan patients in a remote location with an ultrasonic scanner, thus affording critical emergency medical information previously unavailable. This will provide emergency medical personnel with life saving information anywhere on earth.

• Emergency Situations

• - Prehospital Emergency Service

The Prehospital Emergency Service project in Quebec is engaging networking technologies throughout the critical time period from a 911 call through to arrival at the hospital. The goal is to provide superior initial care to reduce the mortality of critical patients. At the same time, the system aims to effectively use the knowledge of remotely located medical control, while enhancing the efficiency of system resources.

The project aims to establish an emergency dispatch centre that links ambulances, directing them to the most appropriate care facility. It will also create a telehealth link from the ambulance to the hospital, with live data transmissions on blood pressure, heart rhythm, EKG and pulse oxymetry; the dispatch centre will also be able to facilitate screening for specific problems, like cerebrovascular accidents and acute myocardial infarction.

- Emergency Medicine in Alberta
Foothills General Provincial Hospital in Alberta has also addressed emergency applications of telehealth. This pilot project assessed the scope for emergency medicine, identifying situations where it is effective and determining whether it is cost-efficient. In 26% of the cases, a transfer of the patient to a major centre would have been avoided had telehealth been available. The most successful areas of applicability being trauma, C-spine fractures and drug overdoses. Both video and X-Ray transmission were important components of an effective remote consultation system.

• New Tools for Health Care Practitioners

- College of Family Physicians of Canada
The College of Family Physicians of Canada is actively investigating the opportunities and challenges of implementing IT into family practice. The CFPC’s Clinical Practice Management Network (CPMN) has been designed to address the needs of family physicians, by providing them with powerful information management tools to allow family physicians to participate proactively in health care restructuring. The CPMN is seeking to: build a computerized patient record; validate and disseminate computerized and evidence-based clinical practice guidelines and other forms of CME; collect family medicine data for different kinds of primary care research; and, establish a national network of family physicians for information and communications purposes.

The CFPC is also designing a Clinical Management System (CMS), an integrated suite of applications to support physicians in streamlining administrative and clerical activities in their practices, such as billing, referrals and scheduling. The CMS provides a “summary sheet”, a quick snapshot of the patient to identify clinical events that need attention, and to plan callbacks to optimise patient care for those at risk. It also has a drug information and advisor function, and acts as a decision-support tool.

- HEALNet Primary Care Network Project
HEALNet is a network of physicians from seven participating regional networks across Canada, with an initial focus on evidence-based prevention in primary care.

• Connections and Integration

• - HealthLink

HealthLink connects 20 health institutions in Ontario, including seven hospitals and a number of home care sites. Initially, the project took a clinical focus, looking at clinical data exchange for perinatology (now fully on-line), and oncology. Key application areas for physicians include: electronic storage of clinician’s notes in charts; access to radiology images and reports; links to laboratory results and drugs administered; and patient demographics.

- Integration in New Brunswick
New Brunswick has made IT readiness a priority, reflected in its deployment of a digital network across the province, and in an aggressive development plan for a broadband ATM network by 2 carriers in the province. Since 1993, 12 hospitals have been linked into a 36-room multipoint videoconference network, used for administrative meetings, education courses and clinical consultations. Because hospitals own the videoconference units, they are able to generate additional revenue by renting them out.

Also, hospitals, health centres and a growing number of physician's offices are linked into the “Wellness Network”, a private and secure health care network. The province has been successful as a test bed environment for leading edge telehealth initiatives, including direct radiography and client server hospital information systems. Teleradiology linkages are present in half of all regional Hospital Corporations and the province has implemented a province-wide telephone triage system.

- Clinical Testing Networking
EQuAlity is a new external quality assurance system that will network clinical laboratories across Canada and facilitate the standardization of their testing systems. Currently, clinical laboratories in Western Canada are monitored on a regular basis by this program as a part of their licensing requirements.

The current system is moving to the Internet so laboratories can link directly to EQuAlity and move towards standardization.

- Networking in the Home Care Context
The SISMAD system, designed by Artefact Informatique, will provide operational support for home care in more than 160 sites in Quebec. SISMAD optimizes clerical and administrative work to enhance the logistical efficiency of home care. Five modules
provide powerful support tools for home care personnel: user registration and orientation; biopsychosocial evaluation; the intervention plan; scheduling and planning; and, follow-up health services.

One of the main advantages of the system is to allow the personnel to remotely access and update, with a Personal Digital Assistant, clinical information (vital signs, medication, progress report, etc.), as well as operational/administrative information (schedules, expense reports, etc.). This helps to make the right information available at the right time to each person involved in a specific case of home care services. A Community Health Information Network for the Next Century IntelliCHIN is a vision for the next generation Community Health Information Network. It is based on a self-funded, shareable Electronic Patient Record (EPR), a comprehensive health information resource, and on-line professional services. The Medi-Net

• Leveraging Telecommunications Expertise

- NBTel in New Brunswick is conducting a trial of direct radiography in association with the Atlantic Health Sciences Association and Sterling Diagnostic Imaging. This technology displays x-rays, MRI scans and other information on computer screens rather than film

- BC TEL is currently upgrading its existing HIS patient care applications at the Vancouver General Hospital. The resulting local network will host multiple institutions and could soon be rolled out to other hospitals, regional health boards and the Ministry of Health.

- In Saskatchewan, SaskTel is conducting a Mobile Diagnostic Equipment project to test the effectiveness of an emergency response unit for remote communities. This project uses satellite-based Global Positioning Systems to dispatch ambulances. Through radio communications, it transmits diagnostic
information to the nearest hospital at the same time.

- In Alberta, TELUS has played a strong role in the development of the Alberta Integrated Health Information Network (AIHIN). The vision is to successfully assist individuals in achieving health and independence through an integrated network that provides timely, accurate and confidential information. To date, the AIHIN has undertaken a health information proof of concept trial. The current phase is a full-scale practitioner trial to test the feasibility and access of the AIHIN on a province-wide basis. As of last June, some 200 practitioners from the majority of the 17 health regions in Alberta were participating in this trial.

-In Quebec, Bell Canada is partnering with smaller companies for 18-month experimental project looking at distance education for health. For some time now, Montreal’s teaching hospital, H^tel-Dieu, has been organizing semiweekly consultations and seminars in cooperation with regional hospitals in Trois-RiviPres, Joliette and Rouyn-Noranda. The current phase is using ISDN technology to conduct real-time international consultations, enabling quick exchange of test results, radiographs, CAT scans, and other medical images.

It is a research project that will evaluate the implementation of telehealth applications in five First Nation communities across Canada. Up to a maximum of three telehealth applications will be chosen by each community according to the needs of the community identified in the community need assessment process.

The Minister of Health announced the approval of the National First Nations Telehealth Research Project on September 3, 1998, and it will end on September 30, 2000.

The First Nations and Inuit Health Programs Directorate of Health Canada’s Medical Services Branch (MSB) in Ottawa will manage the project with the assistance of MSB regional personnel in those five participating regions. The five participating communities are:

Anahim Lake - British Columbia
Berens River - Manitoba
Fort Chipewyan - Alberta
La Romaine - Quebec
Southend – Saskatchewan

5.2.3.1.2. Type of TM services or applications

5.2.3.1.3. Medical Speciality actually involved in TM

Cardiology, emergency/triage, internal medicine, mental health, radiology,  rehabilitation,
 rheumatology

1. Most common applications found in the TM activities
2. Type of communication networks currently in use
3. Type of medical devices actually found in existing applications of TM

5.2.3.1.4. What is the place for the Internet and for Web based technology in the TM

The Canadian Women’s Health Network (CWHN) is a Partner in Health Canada's Centre of Excellence in Women's Health Research Program, aiming to improve the health status  of and services to Canadian women. Part of the CWHN’s mandate is to empower women through user-friendly access to information on women’s health, diagnostic and preventative. The CWHN is expanding its web site to include an on-line database of  groups, organizations, researchers and health information, particularly that concern health determinants and promotion. The site will include links to other relevant sites, selections from their newsletter, information for members, and an “alert” area that will highlight new  information and activities.

In  British Columbia there is a project Using the World Wide Web to Deliver a Cardiac Rehabilitation Program to Patients at Home.

5.2.3.1.5. If projects are HCT telematics projects or related to them in any way

5.2.3.1.6. Involvement of research organisations

- Canadian Nurses Association
- The Nursing Knowledge Network
- Canadian Infectious Disease Society

Newfoundland
- Canadian Mental Health Association
- A Provincial Health Information System for Newfoundland  and Labrador
- Newfoundland Cancer Treatment and Research Foundation
- Provincial Systemic Therapy Program

Prince Edward Island
- West Prince Health Authority
- West Prince Telehospice

Nova Scotia
- Queen Elizabeth II Hospital: Nova Scotia Breast Screening Program
- A Nova Scotia Linkage
- Dalhousie University Internet Facilitated Decision Making for Prostate Cancer

New Brunswick
- The Canadian Deaf/Blind Rubella Association
- Deaf/Blind Rubella Project
- New Brunswick Easter Seal March of Dimes
- Prescription and Assessment of Technical Aids Using Internet Video

Quebec
- McGill University.
- Royal Victoria Hospital
- Montreal General Hospital Research Institute
- Canadian Major Trauma Information Program

Ontario
- Ontario Public Health Association
- Ontario Food Security and Nutrition Network
- University of Ottawa Heart Institute Research Corporation
- Markham Stouffville Hospital
- North Shore Tribal Council
- Web Nosh Kun
- St. Elizabeth Health Care Centre
- VHA Training and Educational Centre
- University of Toronto
- Cancer Care Ontario
- University of Guelph
- The Hospital for Sick Children

Manitoba
- University of Manitoba
- Saskatchewan
- Saskatoon District Health Tele-Health Network

Alberta
- Calgary Regional Health Authority
- University of Alberta
- Keeweetinok Lakes Regional Health Authority
- Alberta Vocational College

 British Columbia
- Malaspina University-College
- Wrinch Memorial Doctors Clinic
- St. Paul’s Hospital
- University of British Columbia
- British Columbia Centre for Disease Control Society

 5.2.3.1.7. International activities in TM

Hospital for Sick Children Telehealth Programme based in Toronto, (Ontario, Canada). (http://www.sickkids.on.ca) operates with Argentina and with CHENNAI, India . A PC-based videoconference link connects specialized  doctors at Toronto's Hospital for Sick Children, and the Sri Ramachandra Medical College in Porur, Chennai, India.

5.2.3.1.8. TM Professional organisation in the country

5.2.3.1.9. National (or federal) policy concerning the development of TM

Most federal strategy  has resulted of a series of studies around CANARIE. A central feature of  the development of such a national strategy is the creation of a Canadian Health Iway. The vision was stated as “ The Canadian Health Iway will be a virtual “information centre” that is created and used by communities and individuals across Canada.  It will be open and accessible, yet assure sufficient confidentiality and privacy to assist decision-making by health professionals and patients; support research and training; facilitate management of the health system; and respond to the health information needs of the public.  The Network will be an agent of change for the health system and contribute to improving the health of Canadians.  It will also foster the development of globally competitive Canadian technologies and services.”

In 1996, the Government of Canada's Science and Technology Strategy proposed a National Health Information Network to improve health service delivery and access to medical expertise for remote communities. Health Canada's Science &Technology Action Plan set out five strategic objectives, including to mobilize Science & Technology information and information technology and telecommunications. Also in 1996, the Government of Canada's Information Highway Action Plan announced a national strategy for an integrated national health information network, to be undertaken by the Minister of Health in cooperation with provincial and territorial governments, other federal departments, the private sector and professional bodies.

To some extent, provincial governments are already taking steps in implementing health information and telehealth systems in their own jurisdictions. The first two from New Brunswick and Ontario New Brunswick is increasingly using networking technologies to enhance the efficiency and effectiveness of managing and delivering services, and has identified telehealth as one of five key investment and trade sector priorities. A provincial Telemedicine Coordinating Committee has been created, and a Hospital Corporation Information Technology Forum is currently developing a strategic information and ICT plan. Success indicators are based on demonstrating that telehealth improves health outcomes, increases access to health services, results in service delivery at the same or less cost, generates a high level of patient and provider satisfaction, and facilitates administrative management of the system.

The Ontario Smart System is guided by a vision of providing "the right information to the right person at the right time to meet the care delivery, deployment, management and social objectives of the provincial health care program. Coordinating the system is a Program Management Office (PMO), which includes as partners the Ontario Health Providers Alliance, the Information Technology Alliance of Canada, and the Ontario Ministry of Health. Over the next ten months, the PMO will be developing a governance structure for the Smart System, a high level architecture, and initial standards to be followed by vendors developing products for the system. Key areas of investigation include: computerizing the office of the physician; creating a universal drug health network; supporting the networking of laboratory activities; creating an electronic patient record; and, encouraging the use of remote consultations.

Via a contract with SmartHealth, the Manitoba Health Information Network is under development and will link authorized health care professionals at defined points of access to health information. Draft privacy legislation concerning health information was introduced in the Spring of 1997. Manitoba also has a Drug Program Information Network and a Home Care Project.

The Saskatchewan Health Information Network is based around a province-wide health information network linking the various districts and their health care facilities.

The recently established Newfoundland & Labrador Centre for Health Information (NLCHI) will create an integrated and comprehensive information technology system  for health and social services. Coordinating health information and databases will assist government, health providers, consumers and special interest groups in making more informed decisions about health and health care.

PEI's Island Health Information System connects over 1000 users at 40 sites where health care delivery and administration occur. In the acute care facilities, applications have been implemented in: admission/discharge/transfer; institutional pharmacy; medical records; and, clinical scheduling. The next phase will expand the network to include physicians and pharmacists.

The Home Care Nova Scotia program, based on the Manitoba program, will allow remote communications between home care coordinators and a central server in Halifax, linking to the provincial health card master file and demographic, diagnostic and socioeconomic information about the patient.

Quebec will be holding a Request for Proposals for the implementation of a health and telecommunications network, and is reviewing the uses, economics and health outcomes of “smart cards” that contain elements of patient medical files.

British Columbia’s Healthnet/BC is a province-wide technology infrastructure, based on Internet standards, allowing stakeholders to provide a variety of health services, including PharmaNet and an Organ Donor Registry.

Alberta is taking on a province-wide health information management and technology initiative and has established a Senior Reference Committee and Technical Co-ordinating Group. An industry alliance has also been created and the Health Information Protection Act is undergoing public scrutiny and consultation. The Telehealth Working Committee is currently generating a strategic and business plan.

5.2.3.1.10. Total investment in Telemedicine

The Health Transition Fund (HTF) was announced in the 1997 Federal Budget Speech as part of the federal government's initial response to the final report of the National Forum on Health which recommended a multi-year "Transition Fund" to support innovations leading to a more integrated health system.

The HTF provides $150 million over the next three years (1998-1999/2000-2001). Of this $120 million will fund projects sponsored by the provinces and territories. The remaining $30 million is for funding national initiatives. Health Canada's Medical Services Branch (MSB) submitted a National Telehealth Research proposal on behalf of First Nation & Inuit communities to the HTF and received $2 million for the project.

The main objective of the Health Transition Fund, through which this project is funded, is to provide evidence that will help determine which approaches for continued reform and improvement of the health system actually work and are feasible for implementation. An important means of obtaining this evidence is through pilot and evaluation projects. Because telehealth has rarely been rigorously evaluated, its effectiveness in improving access and quality of care and in a cost-effective manner has yet to be demonstrated.

5.2.3.1.11. Regulations affecting the development of TM

Privacy, confidentiality and security are among the most pressing concerns of Canadian citizens. These issues are of special importance in the field of health, where protecting personal information related to health status, ensuring traditional doctor-patient confidentiality in telehealth sessions, and safeguarding the networks that connect the parts of the health system have to be given special priority.
Some provincial governments, such as Quebec, Manitoba and Alberta, have passed or are tabling legislation in this area, and others are sure to follow. Federal legislation is also present .

Canadians have become much more aware of privacy and confidentiality issues in recent
years. Privacy is considered a human right in Canada, as evidenced by both the Canadian Charter of Rights and Freedoms and the Quebec Charter.

Privacy protection in Canada is a shared jurisdiction between federal and provincial governments. The challenge is that the laws, regulations, policies and voluntary measures applicable to privacy in the context of the health info-structure are a patchwork.
Federally, the Privacy Act covers the protection of personal information in the public sector. Significant variations now exist in provincial and territorial laws, regulations and guidelines for privacy and the protection of personal health information in the public sector. Quebec is the only province that has comprehensive personal information protection for both public and private sectors. The federal government also brought forward in
October 1998 legislation (Bill C-54, the Personal Information and Electronic Documents Act) that would apply to those parts of the private sector under federal jurisdiction for the next three
years. Three provinces have introduced or passed new legislation intended to protect personal
health information. However, compatible approaches are not always taken.

Lessons can also be learned from Canada’s Aboriginal people. With agreement of the Medical Services Branch of Health Canada, in many cases either band councils or individuals themselves control the data.

The Canadian Standards Association (CSA) Model Code for the Protection of Personal Information, is a Canadian voluntary code developed in response to the need for a harmonized approach to data protection, was an excellent starting point. The Code is based on internationally recognized data protection principles, namely the Organization for Economic Co-operation and Development Guidelines on the Protection of Privacy and Transborder Flows of Personal Data, to which Canada subscribed to in 1984.
 

Other
Ethical, Legal and Social Issues (ELSIs)
A variety of issues surrounding the relationship between physician and patient also need resolution. Networks raise issues of medical responsibility, such as ensuring that the treating physician remains responsible for the patient, and, similarly, that consultants are liable for their opinions. Traditional concerns also remain, such as informed consent to ensure that the patient understands the procedure being recommended, and that proper, signed consent is obtained. Reimbursement and licensing issues across jurisdictional boundaries, and granting of full privileges at the remote hospital, are of concern to those involved in remote consultation. Even name changes, as the result of marriage or divorce, can pose difficulties with medical records if they are not addressed from the outset in the design of the system. The Centre for Bioethics at the Clinical Research Institute of Montreal is studying the range of ELSIs encountered by telehealth initiatives. They note that project managers are generally not equipped to deal with ELSI issues, and so they are developing management guides for them. The Centre is also developing a  telehealth ELSIs Observatory, to keep telehealth researchers, project designers and managers in touch with related  technological and social developments, and to keep the ELSIs guides up to date.
 

5.2.3.1.12. How TM development is related to other Healthcare telematics programmes

5.2.3.1.13. Is TM related to other  sector applications than healthcare

5.2.3.1.14.     Business approaches and Sector industry

The Canadian industry is fragmented, with both very large and very small companies, though not much in-between.

Many companies exist in the area of clinical and computerized patient record software, so there appears to be little room for newcomers in this area. However, there are a relatively small number of Canadian companies in telemedicine markets. There is also a demonstrated need for “turnkey” solutions, but there are very few companies capable of providing such services.

Business models describing economic incentives for telemedicine services are absent
 

5.2.3.1.15. TM activities self-sustainability and economical issues

5.2.4. Factors of Success in Implementing Telemedicine

5.2.4.1. Incentives to the diffusion of TM

5.2.4.2. Most important barriers to adoption of TM

5.2.4.3. What is actually done or planned to overcome them

The Centre for Bioethics at the Clinical Research Institute of Montreal is studying the range of ELSIs that telehealth initiatives can expect to encounter, and therefore address beforehand to the greatest extent possible. These include:
- Conflicts between professions and specialties, such as conflicts between doctors and nurses, physicians and pharmacists, and radiologists and nuclear medicine specialists;
- Conflicts between institutions in the health care system, such as incompatible objective between requirements for researchers and those for administrators;
- Social and scientific controversies;
- Inter-regional and inter-institutional differences that require standards to be implemented;
- Appropriate use of information once collected, and incentives for those overworked people who collect information; and, participation in and the openness of the network development process.

The Canadian Institute for Health Information is active in standards issues related to telehealth. CIHI has a collaborative approach based on work with other standards organizations and with the key stakeholders in the field, including the Provincial Health Ministries. Six Working Groups were established in Spring 1997 to address the variety of standards issues in the field:

- Health Information Model -- includes the development of a data model and the elements required for an electronic patient record;
- Terminology, Classification and Nomenclatures -- development of health management indicators using standards for classifying data;
- Security, Privacy and Quality -- standards for health information security, privacy and information integrity;
- Information Exchange Protocols -- standards for information exchange, applications and communications protocols;
- Advanced Health Technologies -- standards for advanced technologies such as videoconferencing, document scanning, diagnostic imaging and patient cards;
- Health Identification Systems -- standards for linking provincial health information systems and formation of national health identification cross-reference facility.

There is some overlap between these categories. Where possible, CIHI recognises de facto standards.

5.2.4.4. What are the most pressing needs

5.3. CHINA

5.3.1. Introduction

5.3.2. History

The deployment of the China Golden Health Medical Network (CGHN), the national network for health, is a major effort for medical IT.

5.3.3. Current situation

5.3.3.1. On-going projects and achievement

5.3.3.1.1. Presentation of major projects

- The China Golden Health Medical Network (CGHN) planned by the State Council, led and supervised by the Ministry of Health, and sponsored and run by China Golden Health Medical Network Co. Ltd.. It started in 1996. 30 hospitals and more than 3000 medical experts have joined the CGHN.

- Clinical Gait Analysis at Hong Kong Polytechnic University Case presentations are made with digital video and 3D biomechanical findings. A tele diagnosis system uses e-mail.

- The Chinese Medicine International Telemedicine Center. Established in October 1997, the Center is located at the Chinese Medicine Research Institute. Its main function is to provide traditional Chinese medical consultation for Chinese and non Chinese patients worldwide, linking partners by ISDN, Internet and others.

- The Dalian Telemedicine Center. It was founded in July 1996. It uses videoconferencing and Internet. The system connect Peking Sino-Japanese Frienship Hospital and two local remote sites, Changhai and Zhuanghe Hospitals. The DTC is strongly connected with the European Institute in Strasbourg, France.

 5.3.3.1.2. Type of TM services or applications

Several major teleconferences involving two or more sites have been carried out with partners in Beijing, Guangzhou, as well as overseas colleagues in Australia, the UK and Western Europe, Canada, and the USA. These have been both consultative and educational in nature.

5.3.3.1.3. Medical Speciality actually involved in TM

5.3.3.1.4. Most common applications found in the TM activities

5.3.3.1.5. Type of communication networks currently in use

Depending on technical requirements and resource availability, ATM service and satellite transmission are being tested.

The CGHN operates primarily over VSAT and the DDN (the national public data communication network)

5.3.3.1.6. Type of medical devices actually found in existing applications of TM

5.3.3.1.7. What is the place for the Internet and for Web based technology in the TM

5.3.3.1.8. If projects are HCT telematics projects or related to them in any way

5.3.3.1.9. Involvement of research organisations

5.3.3.1.10. International activities in TM

Partners Telemedicine, and the University of Southern California (USC) Advanced Biotelecommunications.

Other example of international cooperation is the project on Clinical Gait Analysis at Hong Kong Polytechnic University with Australia, and Austria.

5.3.3.1.11.   TM Professional organisation in the country

1. National (or federal) policy concerning the development of TM

The Ministry of Health has issued a number of directives under such titles as

“Comments and Suggestions about the construction of the Golden Health Network”

“Prospects for the Construction of the Golden Health Network”

“ A Notification about Preparing to Develop Specialized Satellite Networks for Administration in the National Health System”

2. Total investment in Telemedicine

There is no data on investimets for Telemedicine in China. Neverthelen the total amounts are not segnificativily relevant.

3. Regulations affecting the development of TM in China

There is no any data in the literature about regulatory issues.

4. How TM development is related to other Healthcare telematics programmes

The development of TM in China depends on the deployment of telecommunications infrastructures.

5. Is TM related to other sector applications than healthcare

Presumably, telecom infrastructures are deployed for general usage.

6. Business approaches and Sector industry

There is no knouledge about concerning telemedicien any business approach. No notice exist about any local sector industrial development

7. TM activities self-sustainability and economical issues

Economical issues must be analysed in the particular context of China. Presumably economic factors play a definitive role but in a different way than in free-market countries.

5.3.4. Factors of Success in Implementing Telemedicine

5.3.4.1. Incentives to the diffusion of TM

5.3.4.2. Most important barriers to adoption of TM

- Lack of infrastructures
- Economic barriers
- Cultural environment
- Other health care priorities are first

5.3.4.3. What is actually done or planned to overcome them

 International cooperation may favour also potential projects on telemedicine.
 

5.3.4.4. What are the most pressing needs

- To provide basic telecommunication infrastructures
- To implement health care information systems

5.4. JAPAN

5.4.1. Introduction

Second, by saying "from a remote site," Japan definition do not specify whether communication sites must be medical facilities. Usually, the word telemedicine implies that both transmitting and receiving sites are medical facilities. Patients receiving such care at home are also included in the definition of telemedicine.

Third, by using the expression "medical care and health supporting practices," it do not limit telemedicine to medical care only. They predict that the application of image-transmission will be extended to home-based care for the elderly. In the growing aged society, home health care will be a big issue. The users of telemedicine will not be limited to physicians, but may include dentists, nurses, medical technicians, pharmacists and other medical care professionals.

Telemedicine can be used in four circumstances: (1) between medical facilities and doctors, (2) between medical facilities and health facilities without doctors, (3) between medical facilities and individual homes, and (4) between co-medicals and individual homes. In general, the definition of telemedicine encompasses (1) and (2), while (3) and (4) are referred to as tele-care or telehealth.

5.4.2. History

In 1972, the Nippon Telegraph and Telephone Public Corporation experimented with transmitting x-ray images from Aomori Teishin Hospital to Kanto Teishin Hospital. The purpose of the experiment was for doctors in Tokyo to look at transmitted x-rays, make diagnoses, and talk with patients in Aomori - all through television. The most advanced technology at that time included the TV relay circuit, telephone circuit, and data transmission circuit. Although the technology was excellent, maintenance of the high band zone proved difficult and for that reason, the experiment was not developed further.

In 1974, there were two additional teleconferencing experiments. First, Nagasaki University implemented CCTV. In the Okinawa prefecture, a comprehensive medical information system for remote areas used still image transmission. This was seen as a great accomplishment because the difficulty of transmitting analog x-ray pictures through telephone lines had been well established. The project in Okinawa helped advance both the acceptance and expansion of telemedicine.

Experiments using "New Media" were conducted in the pilot project of a communications satellite called CS-2. This experiment was aimed at medical support in the time of disasters, and was the result of collaboration between Tokai University and the Radio Research Center at the Ministry of Postal Service and Telecommunications. An experiment in Mitaka used the digital communication network (INS64) to explore medical care for patients at home by transmitting images using a videophone. At the Suwa Chuo Hospital in Nagano, a medical support system for patients at home, based on a commercial CATV network, was used for several years. Although there have been many other telemedical experiments, few remain today. As occurred elsewhere, none of the various programs started in the 70’s survived the decade

In spite of promissing expectatives rised few years ago when the number of active programs jumped from 49 in 1995, to 98 in 1996 and to 148 in 1997, only 7 new programs have been identified in 1998 indicating that the expected boom has failed to materialized.

5.4.3. Current situation

5.4.3.1.  On-going projects and achievement

5.4.3.1.1. Presentation of major projects

Dr. Isao Nakajima of Tokai Medical School has partnered with Hitachi to develop a satellite-mediated ambulance data transmission system. Due to the particular orbit of the satellite used and an innovative dish tracking system developed by Dr. Nakajima, data transmission from a moving ambulance remains largely uninterrupted, even in highly built-up areas.

Dr. Keiko Nakamura of Tokyo Medical and Dental University investigate provider acceptance of telecare: 13 medical and ancillary staff at a local municipality center used ISDN videoconferencing equipment from Fujitsu to care for a total of 45 homebound patients Secom’s world-leading Hospi-net teleradiology service shows continued growth. In the absence of reimbursement, the service now provides 6,000 CT and MR readings per month from 125 spokes.

5.4.3.1.2. Type of TM services or applications found

5.4.3.1.3. Medical Speciality actually involved in TM

5.4.3.1.4. Most common applications found in the TM activities

(1) Examination data

    (a) Radiology pictures: chest, abdomen, digestive tract, head, bone, blood vessels
    (b) CT images: head, chest, abdomen, pelvis
    (c) MRI images: head, chest, abdomen, pelvis, bones, cartilage
    (d) Ophthalmology pictures
    (e) Pathology pictures: cells, tissues
    (f) Electrocardiogram
    (g) Electromyogram

(2) Immediate patient data

    (a) Ultrasound
    (b) Phonocardiogram
    (c) Endoscopic examination
    (d) Fluroscopy
 

 5.4.3.1.5. Type of communication networks currently in use

 5.4.3.1.6. Type of medical devices actually found in existing applications of TM

 5.4.3.1.7. The place for the Internet and for Web based technology in the TM development

 5.4.3.1.8. HCT telematics projects

 5.4.3.1.9. Involvement of research organisations

 5.4.3.1.10. International activities in TM

- Hospital for Sick Children Teleheath Programme in Toronto (Canada) operates in Japan.

- 5th Japan-Scandinavian Symposium Progress in Radiology 1996. Stockholm June 16-18, 1996

- The 3rd International Conference on the Medical Aspects of Telemedicine, held from May 30 - June 1, 1997 in Kobe, Japan.
 

 5.4.3.1.11. TM Professional organisation

  5.4.3.1.11.1. Telemedicine Societies

  5.4.3.1.11.2. Publications

  5.4.3.1.11.3. Scientific or medical organisations addressing Telemedicine

  5.4.3.1.11.4. Key national meetings

  5.4.3.1.12. Policies concerning the development of TM

 Koseisho’s financial support is largely limited to incidental funding of expert advisory groups. It is currently funding 5 telecare projects, but these are uncoordinated and the ministry has no clear idea of the results it seeks to obtain.

 Prof. Patrick Barron of Tokyo Medical College notes that this absence of government support means that Japan is missing an important opportunity to provide leadership in Asia-Pacific countries. Dr. Mizushima currently obtains much of his support from other ministries, such as those of Posts and Telecommunications and International Trade and Industry. He states that while most hospitals will be linked to networks within the next several years, senior physicians show little interest in telemedicine and that widespread implementation must await generational change.

 5.4.3.1.13. Investments

 5.4.3.1.14. Regulations affecting the development of TM

  5.4.3.1.14.1. Legal and regulatory aspects including privacy and security

In Japan, physicians must be in the presence of a patient to practice formal medical care. However, telemedicine refer to situations where this is not the case. This creates legal problems. On the other hand, current insurance policy covers phone consultation with a physician after an initial visit. Thus, in these situations, medical care without the presence of a doctor has already been included in the medical system. It may be possible to extend that medical care to encompass telemedicine in the future.

With new technology, there are medical situations that fall somewhere between traditional face-to-face meetings and telephone consultations. These situations have not been defined or clarified.

Everyone has a right to privacy and access to images should be limited to the appropriate personnel. It is critical to discuss and agree upon access rights before commencing image transmission.

The form of telemedicine between a medical facility and a home has not been legally clarified yet. Medical law defines diagnosis only in the form of a face-to-face encounter, but does not directly prohibit any other forms of diagnosis. The legal boundaries should be clarified by the Ministry of Health and Welfare. Practitioners must assume the same responsibilities for diagnosis via telemedicine as for normal medical care.

 5.4.3.1.14.2. Regulation of medical devices applied to TM

 5.4.3.1.14.3. Others

 5.4.3.1.15. How TM development is related to other Healthcare telematics program?

5.4.3.1.16. Relationships to other program part of information society (other sector applications than healthcare)

5.4.3.1.17.  Business approaches and Sector industry

5.4.3.1.18. TM activities self-sustainability and economical issues

5.4.4. Factors of success in implementing telemedicine in Japan

5.4.4.1. What are the incentives to the diffusion of TM

Some situations where telemedicine will be useful are: (1) when a patient does not have easy access to a hospital, (2) when a physician has limited access to a patient, and (3) when emergency care is needed.
 

5.4.4.2. The most important barriers to adoption of TM

Other reason why telemedicine has not spread is because telemedicine has not been reimbursed under current insurance coverage. In Japan, most medical care is covered; nothing can expand without insurance coverage. Some, if not all, of telemedicine must be covered by insurance immediately.

Transmission fees in Japan are higher than those in other countries. For telemedicine to become economically feasible, a policy to reduce or waive the cost of medical transmission is necessary.

The payment system at public medical facilities should be better organized to accommodate smooth payment between medical facilities. In the future, more patients will be seen/treated/diagnosed at more than one medical facility, in part due to telemedicine. The current, rigid system makes it virtually impossible to make and receive payments on many cases. The current system is hampering the growth of telemedicine.

The medical community is also responsible for the slow spread of telemedicine in Japan Although telemedicine has been legal and has been shown to be medically beneficial, physicians were reluctant to try new diagnostic methods, preferring to stay with their old ones.

There are no legal restrictions on telemedical consultation between medical facilities. However, there is no consensus in the medical community on how telemedicine should be applied under various situations. Beyond that, the wide use of telemedicine is impossible because telemedicine is not reimbursed under the present insurance system.

There are no legal problems in making a diagnosis based on transmitted radiology images. However, there is no consensus in the medical community on what guidelines should be followed regarding these images. First, there is the question of whether or not diagnosis can be made based solely on CRT. Secondly, there is the question of what image quality is appropriate.

By law, CRT images must be stored on film; the length of storage depends on the particular insurance system and laws associated with it. This issue prevents CRT diagnosis from becoming widespread. If this technical issue is solved, CRT diagnosis should be encouraged.

5.4.4.3. What is actually done or planned to overcome them?

5.4.4.4. What are the most pressing needs?

Some reorganization in medical facilities will be necessary for telemedicine to root itself as a legitimate form of medicine. Until now, telemedicine has been supported and practiced by physicians on an informal basis.

Wide band transmission must be ensured for telemedicine to become popular. Image quality is very important for medical applications. Creating and completing an infrastructure for wide band transmission will be very important for that reason.

There are some complicated questions about standards in telemedicine technology which need to be clarified. For example, what colors in the color CRT band should be available, what should be the frame rate per second, and what should be the transmitting bandwidth are all questions which should be  specified in general standards. Nonetheless, participating physicians must assume responsibility for their consultations even if there are standards.

ITU recommendations do not regular the quality of still images. ITU only regulates the transfer protocol; displaying images is a human interface issue. The standardization of still image quality may be on MEDIS's agenda because high-resolution images (high definition) will be required for medical consultation and diagnosis. The standardization of still image quality is left for future inquiry.

Standardization at the function and human interface level is not sufficient. It is difficult for industry to lead the efforts in human interface / user's handling because this is the domain where each firm can express its own uniqueness. However, today, the basic TV conferencing system cannot be used in telemedicine. Many functions specifically adapted to telemedicine are needed. Most of these functions are on the functional or human interface level. To make good standards for these functions, users must provide feedback and the specifications will be achieved with a collaboration of users and the industry.

5.5. LATIN AMERICA

5.5.1. Introduction

Telemedicine in many (but by no means all) Latin American countries is hobbled by monopolistic, overcontrolled telecommunications markets and by poor quality telephone lines. However the growth of information technology in that region has been consistently higher than the other parts of the world for over a decade. This has been motivated, at least in part, by the continuing deregularisation and privatisation of telephone companies that begun by Chile in 1989, and followed since by Argentina, Mexico, Venezuela, Peru, Bolivia, Colombia, Ecuador, El Salvador, Guatemala, Honduras, Panama, and Puerto Rico. More rcently, in 1998 Brazil, Colombia, Nicaragua, Honduras, and Paraguay  begin the privatisation process.

Some countries, notably Argentina, Brazil, Chile, Costa Rica, Mexico, Panama, Uruguay, and Venezuela have taken the biggest strides in modernising their telecommunications infrastructure.

For the next several years it appears that telemedicine activity in Latin America will be centered in Argentina, Costa Rica, Mexico, Uruguay, and probably Brazil. Several programs in these countries are now reaching activity levels rivaling those in North America.

The wide variety of demographics, economic conditions, medical needs, telecommunications infrastructures, and political systems makes Latin America a fertile testbed for experimenting with alternative telemedicine technologies and delivery strategies. By large, Latin America represents the more important area of international telemedicine activities from organisations rooted in USA and Canada.

5.5.2. History

The first transmision of laparoscopic surgery in vivo by the Internet was produced from Buenos Aires in 1996.

The current development is quite high, mostly supported by international programmes.

5.5.3. Current situation

5.5.3.1. On-going projects and achievement

• Visual Forum (Buenos Aires) doing about 15 international interactive teleconsultations and 20 hours of education programming per month;
• Costa Rica’s Telemedicine Project, doing about 15 interactive teleconsultations and a few hours of education per month;
• Mexico’s ISSSTE Telehealth Project linking 7 states and doing about 60 interactive consultations/ month; and
• Montevideo’s National Institute of Cardiac Surgery, which is transmitting about 600 store-and-forward images each month for clinical and educational purposes.

5.5.3.2. Presentation of major projects

One of the major objectives of the project is the implementation of facilities to improve the quality of , and access to, health care, especially in rural areas. This Tele-medical network consists of a central communication node, three reference hospitals (principal nodes) and telemedical stations in peripheral points (10 rural hospitals at this time), such as regional hospitals, Antarctic settlements (remote notes). The equipment in each node is accessible to the rural medical centre. The central hospitals are connected to the network 24 hrs/day and the remote nodes login by standard telephone lines with modems. With this scheme, a set of telemedical events can be developed, including teleassistance and tele-education. This program has been running since 1998.

The ARGONAUTA project was started in October1997 in the frame of the INCO-DC* program of the EC. The countries involved in the project are Argentina, Chile, Germany and Italy.
 

- Visual Forum (Argentina)
The International Telemedicine Center in Buenos Aires began in 1995 to provide interactive video-mediated teleconsultations with selected medical centers in the U.S. These include the Yale U. School of Medicine, the M.D. Anderson Cancer Center, the New England Medical Center, Mass General Hospital, Vermont University and Johns Hopkins.

Depending on the patient’s medical problem, the medical staff of the International Telemedicine Center selects the most appropriate consulting center and physician in the U.S. There the patient’s medical history and medical images, compiled with the help of the local physician, are sent by email attachments via the Internet or by using ISDN links. A videoconference is then arranged, and as necessary translators and technicians are brought on board to overcome language and technical problems. Consultations are videotaped for the local physician to review.

Since theprogram’s inception there have been more than 400 consultations from a variety of specialities.

The breakdown of medical specialties accessed by the Visual Forum telemedicine project:

40% - Oncology
25% - Cardiology
10% - Dermatology
10% - Neurology
5% - Orthopedics
3% - Rheumatology
2% - Ophthalmology
5% - Other

The system is also used by Argentinean HMOs to provide a second opinion and to determine whether certain expensive procedures are in fact medically necessary.

Visual Forum organizes videoconference courses, seminars, and international forums. Most are done under the auspices of medical associations and hospitals, though pharmaceutical firms have sponsored some. An example was a course on new technologies in dental implantations between Tufts University and Buenos Aires, sponsored by the Odontological Society of Argentina.

In December, 1996 Visual Forum presented its concept of a National Telemedicine Network to the Minister of Health and the Secretary of Communications, in response to a decree by the latter that there be an umbrella organization–including the Chairs of the faculties of medicine of Argentine university medical schools–to integrate telecommunications technologies for medical purposes. The proposal was accepted and the Network has been funded by a $1 million (US$) investment from the Argentinean telephone company TELECOM. The first stage of this project is underway, connecting the provinces of Buenos Aires, Córdoba, Misiones and Salta. During the pilot phase access to this technology is being provided free of charge. In each of these provinces two technology configurations are being deployed:

a) The principal public hospital is being outfitted with a telemedicine station for medical teleconsultations. Through a special waiver, ISDN lines are being used within the country.

b) Teaching auditoriums are being equipped with distance learning teleconferencing equipment. Multipoint bridging enables up to eight sites to be linked simultaneously. These can all link internationally as well.
 

Telemedicine project of Catholic University of Chili (jbadia@puc.cl)

 Te project is perfomed by a Consortium formed by

a) the Catholic University of Chili through the Faculties of Medicine and Engineering, and the Service of Computing, Informatics and Communications.

b) the Ministry of Health, through the Health Care Service of the Area Sur-Oriente of Santiago.

c) private companies: CTC (Compañía de Telecomunicaciones de Chile), Coasin (NewBridge Networks Corp.), Kodak, Tandem Chile (Fore Systems Inc.).

 The system uses fiber optic ATM links connecting reference hospital and secondary hospital 20 milles to support teleradiology and telepathology applications.

Telemedicine and Education University of Sao Paulo
Faculty of Medicine, Discipline of Telemedicine, Av. Dr. Arnaldo 455, Sao Paulo, SP, Brazil http://www.saudetotal.com/gyorgy.htm  telemedicine education.

ELCANO: Electronics Publications and virtual Library
Funded by EC- INCO Programme. The objective is to develop a  Virtual Library of unusual cases. "ELCANO" makes use of top informative techniques like the HTML format or the Internet World Wide Web, to present clinic information with a high scientific value to a growing forum of exchange medical knowledge. Consortium is formed by organisations from Mexico (Secretaría de Salud CENIDS), Spain (IMIM), Canada, and Argentina.

The Brazilian Virtual Hospital Project: Professional and Patient Education on the WWW
(http://www.hospvirt.org.br/)
Leaded by the center for Biomedical Informatics of the State University of Campinas, in the state of São Paulo, Brazil, was founded in March 1996, following the model set forth by the University of Iowa's Virtual Hospital (http://www.vh.org/). The BVH is a rich on-line metaphor for providing information to end-users (students, health care professionals and patients) via the WWW paradigm.

The INFOVIDA Project – The Implementation of a Health Information Service in the state of  Pernambuco - Brasil (http://www.na-rc.rnp.br/infovida)
Infovida is a health information server on the World Wide Web that aims to characterize health in the state of Pernambuco. It intends to make available via the Internet those health-attending services available in the state, whether they be in hospitals, clinics, laboratories, or health centers, and includes services offered by autonomous professionals. It will also make available information about: institutions, courses, projects, libraries, magazines, and journals related to health; health organizations and how they interact with the society; where to find health products, whether medicines, or medical-hospital accessories and equipment; those on line services available (teleconsultations, telediagnosis, discussion lists); public utility services and social security and health care, and other information. It also intends to validate the use of telemedicine in the state, publicizing and promoting the use of the Internet as a support instrument for information and rendering of health services.

It is a project of the Department of Bioinformatics of  the Keizo Asami Imunopathology Laboratory (LIKA) at the Federal University of Pernambuco (UFPE) with the participation of National Research Network (RNP) and the Secretary of Health of the state of Pernambuco, financed by the Support Foundation for Science and Technology (FACEPE).
 

5.5.3.3. Type of TM services or applications found

5.5.3.4. Medical Speciality actually involved in TM

5.5.3.5. Most common applications found in the TM activities

5.5.3.6. Type of communication networks currently in use

In Argentina, due to federal regulations, ISDN lines may be used to communicate to the outside world, but it is illegal to use them inside the country until 1999 when the telecommunications market will be opened up. This has hampered development of telemedicine within the country, although there have been waivers allowing telemedicine and tele-education networks to begin operating.

The use of the Internet – Intranet  is a growing trend for several aplications.

5.5.3.7. Type of medical devices actually found in existing applications of TM

5.5.3.8. The place for the Internet and for Web based technology

 It is expected that major developments of telemedicine in Latin America would be based on the Internet.

5.5.3.9. HCT telematics projects

5.5.3.10. Involvement of research organisations

• Cátedra de Diagnóstico por Imágenes.Facultad de Medicina. UCES
• Investigaciones Médicas. Centro de Diagnóstico Sanatorio Otamendi del Profesor Doctor Gonzalez Toledo The Brazilian Virtual Hospital Project: Professional and Patient Education on the WWW

was founded in March 1996, following the model set forth by the University of Iowa's Virtual Hospital (http://www.vh.org/). The BVH (http://www.hospvirt.org.br/) is a rich on-line metaphor for providing information to end-users (students, health care professionals and patients) via the WWW paradigm.

5.5.3.11. International activities in TM

Brazil
- Allegheny General Hospital Telemedicine Program
- Partners Telemedicine (http://telemedicine.partners.org);

Mexico is client of several telemedicine providers such as
- Cedars-Sinai Medical Center (http://www.csmc.edu)
- Partners Telemedicine (http://telemedicine.partners.org);
- South Texas Telemedicine,
- WorldCare /WorldCareUK. (http://www.worldcaretech.com)

Cuba
- Indiana University Ophthalmology Program from parent programme ORBIS operates from 1998.

Argentina
- Fletcher-Allen Health Care Telemedicine Programme (Vermont, New York). (http://www.vtmednet.org).
- Hospital for Sick Children Telehealth Programme based in Toronto, (Ontario, Canada). (http://www.sickkids.on.ca)
- Mount Sinai Hospital in New York
- Cooperation in Education and Training programme. ISCIII. Spain.(http://api.isciii.es)
- ARGONAUTA program (Austral On-line Network for Medical Auditing and Tele-assistance). http://www.tm.conae.gov.ar . Cordoba Argentina. EC funded.
- ELCANO Europe-Latin America cooperation on medical case studies using Internet. Coordinated by IMIM-Barcelona, include partners from Argentina and Mexico. EC funded.
-  Programme of teleconsultations with the Child Centre in Moscu (1998).
- Telesurgery from Singapore (1999)
- Georgia Statewide Academic and Medical System

Chile
- University of North Carolina Telemedicine (http://med.unc.edu)

Peru
- Health communications (Satel-life) Advisory functions to support basic teleservices for primary care settings.GBT. Spain.
 

Other relevant activities

•  ACIETH (Association of Latin American Telephonic Operators) is very active in dissemination and awareness creation. It organises an annual conference on Telemedicine and produces materials such as videos and documents. Telefónica. Spain.
•  ITU/BDT organised the Second World Telemedicine Symposium for Developing Countries, in Buenos Aires, Argentina, from 7 to 11 June 1999.

5.5.3.12.TM Professional organisation

5.5.3.12.1.Telemedicine Societies

5.5.3.12.2. Publications

5.5.3.12.3. Scientific or medical organisations addressing Telemedicine

5.5.3.12.4. Key national meetings

5.5.3.13. Policies concerning the development of TM

5.5.3.14. Investments

5.5.3.15. Regulations affecting the development of TM

5.5.3.15.1. Legal and regulatory aspects including privacy and security

5.5.3.15.2. Regulation of medical devices applied to TM

5.5.3.15.3. Others

5.5.3.16. How TM development is related to other Healthcare telematics program?

5.5.3.17. Relationships to other program part of information society (other sector applications than healthcare)

5.5.3.18. Business approaches and Sector industry

5.5.3.19. TM activities self-sustainability and economical issues

5.5.4.  Factors of success in implementing telemedicine in Latin America

5.5.4.1. What are the incentives to the diffusion of TM

Telemedicine is a suitable mean for providing continuos education in academic center connected with highly reputed centres accross the world.

5.5.4.2. The most important barriers to adoption of TM in LA

 5.5.4.3. What is actually done or planned to overcome them?

5.5.4.4. What are  the most pressing needs?

• Education and training
• Lack of resources, Investments
• Evidence of cost-effectiveness in routine use
• Reimbursement issues
• Licensure, legal issues
• Better collaboration between different actors