AIM PROJECT A2011 F E S T FRAMEWORK FOR EUROPEAN TELEMEDICINE SERVICES DELIVERABLE No: 14 Planned submission: December 1992 Actual submission : December 1992 TITLE A SURVEY OF TELEMEDICINE SERVICES TODAY Nature: T Type : P Version: 1 FEST CONSORTIUM: Bertin & Cie, Dansk Sygehus Institut, Database Informatica, SIP, Telemed Foundation Italy, National Research Council, Detecon, Sistemas Expertos, Deutsches Herzzentrum, Technische Univ. Berlin, INESC, Philips Medical Systems, Hospital Vall D'Hebron, Univ. of Athens, 01 Pliroforiki, Univ. of Dublin, Heriot Watt Univ., Univ. of Edinburgh, Lothian Health Board, Univ. Polit. Madrid, Techn. Research Center of Finland, Dutch National Council for Public Health. Deliverable: 14 2011/UOA/MPL/DR/UNR/014/b1 TITLE: A Survey of Telemedicine Services Today Prepared by: Workpackage 8: Recommentation of Standards and Specification of Telemedicine Services and AIM Applications Activity 8.1: Review of Existing Telemedicine Services, Applications and Related Standards Workpackage Leader: Dimitrios SOTIRIOU, Medical Physics Laboratory, University of Athens Mikras Assias 75, GOUDI 115 27 Athens, Greece tel.: ++(301) 77.93.273/ 77.88.199 fax : ++)301) 77.93.273 Authors: Dimitrios SOTIRIOU, University of Athens George PANOS, University of Athens Contributing partners: Dr Ken BODDY, University of Edinburgh, Edinburgh Dr Andres BUJOSA, Systemas Expertos, Madrid Dr Angelos MAVRIDIS, Detecon, Berlin Mr Constantinos METAXAS, 01 Pliroforiki SA, Athens Dr Lorentana SALVI, SIP, Rome Dr Jean-Luc WEBER, Bertin SA, Aix-en-Provance Subject: A Report on the actual situation of Telemedicine Services and Applications in Europe and other countries Date: December 1992 Abstract: The results of a Survey on Telemedicine Services and Applications in Europe, EFTA countries, the USA and Canada is presented. In addition to the findings, an analysis of the results is attempted. Keywords: Survey, Telemedicine, Services, Applications, 1992 This work is not subject to copyright Table of Contents page 1. Introduction 4 2. The Questionnaire 4-5 3. The Survey Procedure 6-7 4. The E-mail Pre-survey 7 5. Results of the Survey: The Findings 8 5.0 Results of Introduction of Telemedicine Sevices 8 5.1 Services Offered 8-10 5.2 Infrastructure 10-11 5.3 Policies and Strategies 11-12 5.4 Evaluation 12-13 5.5 Personnel 13 5.6 Training 13-14 5.7 Research 14 5.8 Economic Aspects 15 5.9 International Co-operation 15-16 6. Bibliographic Survey 16-17 7. Analysis of the Survey Results 17 8. The Particular Cases of Greece, Italy and MDIS 22-32 9. Future Work 32 10. Tables 33-34 I. Survey of Telemedicine Services and Applications Questionnaire Distribution List 33 II. Survey of Telemedicine Services offered 34 11. Maps 35-36 I. National Health HCC MPL Telemedicine Services 35 II. The ENCEPHALOS private diagnostic Telemedicine Network 36 12. Annexes 37-46 I. The Questionnaire 37 II. The e-mail pre-survey 38 III. List of Telemedicine Services and application by medical speciality as reported in bibliography 39-40 IV. List of Telemedicine Providers Questionnaire Respondents & Address Archive 41-44 13. References 45-46 SUMMARY OF THE FINDINGS 1. Many applications/services have been introduced and a substantial number of applications in various medical fields are planned or are under design and are mainly concerned with improved health services but cover also specific medical needs. 2. The majority of respondents are of the opinion that through Telemedicine patient treatment and timeliness of patient care are improved, patient displacement and multiple examinations are reduced and cost-effectiveness and efficiency can be improved. 3. The majority of establishments involved in Telemedicine services/applications are University Hospitals or Medical Schools while the type of Telemedicine services available are primarily public sponsored and oriented and cover emergencies and routine cases. The Telemedicine communication is mainly between physicians. Only half of the providers include strategies for remote patient or home monitoring applications. 4. Telemedicine services are user driven and initiated and are implemented due to an effective collaboration between academic, research, industrial and health establishments. No significant involvement of social security schemes and professional associations are reported. 5. No need for reorganising health care services at any level nor the introduction of new hierarchical structures is reported by most providers, at least at the initial system set up. On the other hand no feedback mechanisms are adequately incorporated or designed by the majority of providers to assist in Telemedicine implementation. 6. The main promoting factors are reportedly: - improvement of health services - availability of advanced technology and support - financial support for those involved 7. Some evaluation activities appear to be incorporated in many Telemedicine services strategies but few are involved with the assessment/monitoring of these services, autoevaluation activities and suitable evaluation tools development. 8. Needs in personnel are rather easily covered when required but trained personnel is scarce and there are no postgraduate studies in Telemedicine. 9. Participation in establishing standards (medical and/or technical) ranges from 40%-60% among respondents. 10. After the installation of Telemedicine network systems, research is reported to be more active in technological rather than medical aspects, at least initially. 11. EEC R&D policies appear to have substantially helped in the introduction and implementation of Telemedicine services in Europe. 1. INTRODUCTION The provision of Health Care is a dynamic process in which both the care of the individual patient and the techniques by which it is undertaken are under continuous review. Telemedicine represents an innovation in care which is likely to have substantial effects upon the delivery, quality and costs of Care. In order to identify the possibility for improvement of care, using Telemedicine, there is a need for systematic appraisal of the acceptability of the changes and costs it generates. These assessments must include the perceptions of those receiving care, the clinicians providing, the agencies funding it and the industries providing the systems, equipement and technical environments by which to support it. Thus the overall objective is to develop and implement means for the continuous evaluation of the effects of Telemedicine upon quality of clinical care and the costs of its provision. The assessment of Health Care through the utilisation of Telemedicine will imperatively involve at least at the initial stage questionnaire and interview survey of recipients, providers of care and bodies or organisations planning to install Telemedicine Services, in Europe and in a number of other selected countries. This will result in the charting of existing Telemedicine systems and applications as well as of the intentions and planning of parties to install and provide such services. This (assessment) process (by questionnaire and interview survey) must be continuous, respective and comparative hence resulting in the establishment of a continuously updated network of telemedicine involved parties such as industry and health care providers, facilitating prompt communication and feedback for collaboration and co- ordination towards the implementation of a consistent and coherent European Telemedicine Health Care approach. It is anticipated that Telemedicine applications, products and standards will emerge as well as information by which medical care can be improved in Europe. 2. THE QUESTIONNAIRE For clarity of the presentation it is worth describing first the definition of Telemedicine Services used in the FEST project. Although Telemedicine Applications and Services can be very closely related terms for reasons of better understanding, a distinctive clarification of the terminology can lead to more specific communication and more efficient planning, investigation, R&D, validation and integration of systems. In utilising the functional definition of Telemedicine, a clear distinction between (telemedicine) applications and (telemedicine) services can be made by specifying that a Telemedicine system that has been validated and integrated (Project FEST/ Technical Annex) can thence be considered as a Telemedicine Service. The functional definition of Telemedicine, used by FEST (see also the Technical Annex of FEST): "The investigating, monitoring and management of patients and the education of patients and staff using systems which allow ready access to expert advice and patient information no matter where the patient or relevant information is located" Any Telemedicine system that has either not been completely validated and integrated nor does it meet the functional definition of Telemedicine, can be considered as a Telemedicine application. The compilation of the questionnaire was based on our extensive experience and involvement in Telemedicine and its first draft was presented to the consortium partners during the Technical Week in March 1992, in Rome. The revised draft was submitted to partners for review; comments or ideas have been appropriately incorporated, thus reaching an integrated format. The philosophy in designing this Questionnaire was to provide, by its content, an overview of the ingredients that are essential and contribute decisively in the realisation of a Telemedicine service. For matters of functionality it was divided in ten sections, out of which the first was used in order to facilitate responces from people that were involved in Telemedicine, but not necessarily in a position to provide the detailed requested information. The following nine sections correspond to topics which aim to provide upon completion, detailed information pertaining to the finer aspects encountered in the design, implementation and operation of the service. We are of the opinion that this information is directly relevant and can contribute significantly in the formulation and development of the Framework model. 3. THE SURVEY PROCEDURE The Questionnaire in its final proposed form was decided upon at the Tampere Project Meeting on June 3, 1992 after extensive consultation among the consortium partners. Its final form consisted of 24 pages and in the period between June and the end of August 1992, two hundred and forty eight (248) Questionnaires were dispatched to prospective Telemedicine involved parties under the European domain assigned to be surveyed by The University of Athens/Greece, also to involved parties in EFTA countries, the USA and Canada. No switable address list for Japan and Australia could be compiled on time. These countries will be surveyed with the revised Questionnaire in 1993. Work share for the completion of similar work had also been undertaken by members of the consortium, namely SIP/ Italy, Sistemas Expertos/Spain, University of Edinburgh/ U.K. and DETECON/Germany who also participate in Workpackage 8. These parties undertook the responsibility to survey their own countries with the same Questionnaire. Bertin & Cie/ France had undertaken on a voluntary basis, to carry out this survey for France. Reminders in the form of letter communications had been dispatched to all parties and contacts via telephone and fax messages had been made repeatedly, in a selective manner, to urge and remind receivers to respond to the Questionnaire. We are still in the process of establishing contacts with Telemedicine involved parties and carry on with reminders for the return of Questionnaire responses. Due to late receipts of filled in Questionnaires the deadline for responses has been extended in order to accommodate for late responders but also to give a chance for response to parties that had been identified late in our search to contact telemedicine involved establishments. The responsibility in carrying our repeat surveys on Telemedicine services, with a revised questionnaire content, has already been undertaken by us in order to provide an updated picture of the Telemedicine services and applications offered. This policy is dictated by the rapid changes that are taking place in the field of Telemedicine and enhanced by the already received information pertaining to projects, services and applications that are in preparation (see also Chapter 8). Out of 43 responses received by the end of November 1992, the 26 were positive responses with completed questionnaires and the 14 were negative responses ie. information that the respective institutions have no Telemedicine activities. Table I summarises the distribution of the Questionnaire to the various countries and the responses received. 3.1 ESTABLISHMENTS INVOLVED The majority of establishments involved in Telemedicine services/applications are Universities (8/26=30.7%) and in particular University Hospitals or Medical Schools, followed by State Hospitals (7/26=26.9%). The industry companies and private agencies correspond to (4/26=15.4%) respectively. State Agencies comprise (2/26=7.7%) while Telecommunications operators/companies and the military correspond to (1/26=3.8%) respectively. The type of telemedicine services available are primarily public service sponsored and oriented as opposed to private service and enterprise oriented providers. The overwhelming majority of the participants in this survey are willing for further regular co-operation and participation in the structuring and evolution towards a European Network of Telemedicine services providers. Note: The number of responses is small and consequently statistical significance cannot be attributed to the figures provided in this report. On the other hand this information will be valuable for comparissons in subsequent surveys and in assessing the progress in the Telemedicine field. 4. THE E-MAIL PRE-SURVEY A preliminary survey was conducted before the dispatching of the Questionnaire using a two page document based on Topic 0 of the Questionnaire (Annex II) hoping to obtain sample responses and preliminary information on ongoing Telemedicine services, applications and activities. This was repeated for a second time in summer 1992, but on both instances the number of responses was rather disappointing. Encouraged however by the willingness of the respondents to participate in an information exchange network, we are prepared to establish an E-mail Telemedicine bulletin board as soon as possible and in any case within 1992. 5. RESULTS OF THE SURVEY: THE FINDINGS This chapter is a presentation of the findings stemming from the responses of the Questionnaire. The form of the presentation follows the structure and the numbering of the ten Topics of the Questionnaire for facilitating the correlation between questions and answers. The first paragraph of each reported topic is preceeded by a very short statement to clarify its content. 5.0. RESULTS OF INTRODUCTION OF TELEMEDICINE SERVICES Topic Statement: With an overall aim to obtain a clear picture and not to replace formal methods that have to be utilised in measuring the impact of Telemedicine Services in the health sector and the population, an effort is made to capture the existing enthusiasm or pessimism that surrounds this new type of health service. Results: Estimates of the percentage of medical cases requiring the support of Telemedicine range between 1%-30% and the results assessed are generally positive. Clinically involved establishments are in a better position to assess positively patient and medically related effects of Telemedicine services as compared with telecom companies and the industry who do not seem to be in a position to offer a view on this matter. The majority of parties answering the Questionnaire report that patient treatment and timeliness of patient care are improved, patient displacement and multiple examinations are reduced, research activities are increased, whereas the balance of opinion remains unsettled to whether there is an increase in accuracy and efficiency of examinations or in demand for services although most report that no measured impact on population (confidence building) is expected. 5.1. SERVICES OFFERED Topic Statement: A short description of the Telemedicine Health Care Systems and the environment of each provider shall assist in the understanding of the dynamics leading to the Service introduction as they do not necessarily share common profiles. None of the returned Questionnaires were accompanyed with material describing the envorenment in which the Telemedicine services are being implanted. Results: Telemedicine services have already been introduced by many providers or are in the process of design and implementation. The majority of introduced, under design or being planned services are in descenting order of frequency: - radiology (still b/w images) - cardiology (EKG) - teleconsulting - CT diagnostic imaging - MRI diagnostic imaging and other specifically demanded applications. In Table II a complete list of the services provided is presented. All participants have plans for expansion of their applications and services but no details are provided. Telemedicine services appear to have been introduced mainly to improve health services, while to a lesser extent cover the needs of remote/isolated populations, satisfy demand and cope with particular health requirements. Telemedicine terminals appear to be primarily used for routine cases, urgent situations, medical information access/distribution respectively, among other requirements. Telemedicine is reported to be mainly designed for use between physicians and does not involve the participation of patients, although some do plan to account for patient involved telemedicine in the future, eg. Telemedicine Services for the assistance of the elderly and the disabled, Teleconsulting services for organisations representing, assisting and caring for patient groups such as cancer patients, general medical information services for the public, etc. Most Telemedicine services seem to be presently offered on pilot or demonstrator basis with plans for continuation beyond this phase. The majority of services do not appear to have a telemedicine patient follow up although most participants are of the opinion that Telemedicine services can contribute to the enhancement of preventive medicine activities through the acquisition of faster diagnostic results, easier examination of patients cases by expert physicians, increased confidence in local services and more screening, encouraged due to telemedicine services respectively. The implementation of these services became effective due to collaboration (in descending order) between Academic, Research and Industrial establishments and involved Hospitals. Note: From information distributed via mass media it seems that there are several important activities sponsored by the private sector but very little information was collected by this survey. 5.2. INFRASTRUCTURE Topic Statement: The infrastructure component on which Telemedicine services installations have been (and will be) realised, shall represent one of the key issues on which plans for the introduction of such services will be centred in the near future, as providers and industry must cooperate in providing complete and efficient solutions. Results: Telemedicine applications seem to be mainly developed on PCs (46.8%) and DOS Operating systems (46.8%), while 34.5% of the respondents use UNIX operating system. Voice, Data and Image communications are effectuated using different bandwidths (fron PSTN to BISDN) and different protocols and standards (all these information is available to interested parties; practically every case utilises a different environment). Various DBMS are used for managing data, records/images, revealing a multiplexity of choices with no repeated preferences (Particular information is available to interested parties). Most providers use different image compression algorithms (2:1-50:1) and image sizes (from 128x128 up to 3072x3072 pixels) and mainly 256 grey levels. Most Telemedicine networks offer real-time transmission of data between terminals while the majority of the terminals used have data/image processing capabilities. The image storage needs are covered locally by the majority of systmes used. The majority of providers (57.1%) apparently do not use computerised medical records and do not make use of expert systems/KBS. Most Telemedicine terminals do not provide access to databases or libraries. Quality assurance mechanisms do not appear to be amalgamated into Telemedicine programmes. 5.3. POLICIES AND STRATEGIES Topic Statement: CEC Programmes have encouraged the propagation of Telematics and following the pioneering work of Academic and Research establishments, an increasing number of Health Authorities are now involved in policy formulation towards the implementation of Telemedicine services. The collection of relevant information and the strategic approaches formulated can assist in the realisation of a cohesive and integrated European Telemedicine Services Framework. Results: Apparently Telemedicine services appear to have been introduced following mainly initiatives by Universities (37.6%), Health Care Authorities (28.1%) followed by Research establishments (15.6%), Industry (15.6%) and private sector organizations (3.1%) with this order, respectively. No need is reported for re-organisation of the health care services by the majority of providers prior to the set- up and initial implementation of Telemedicine systems at any level (local-regional-national). The same holds true concerning the necessity for the introduction of new hierarchical structures. The majority (55%) do not find it necessary to introduce new rules and regulations for Telemedicine nor to introduce new legislation concerning Telemedicine services, at least in the initial stages of the set-up. They remain however divided by a greater gap as for the necessity to discuss new ethical issues stemming from the intoduction of Telemedicine services; 65% of the respondents feel that discussion of new ethical issues in not necessary, while the rest put forward matters pertaining to confidentiality and consent aspects eg. the transfer of information via electronic mail-box, sending of patient names and particulars between stations, etc. Feedback mechanisms have not been designed by the majority of the respondents (70%) so as to help providers or other interested parties in the implementation of Telemedicine. Promoting and inhibiting factors affecting the introduction of Telemedicine seem to be constantly identified by case application. Improvement in health services, advanced technology availability and financial support for those involved are reported to be among the main promoting factors. 46% of providers report that they include strategies for remote patient or home monitoring applications. No coordinating mechanism is reported to be in use and operating at all levels of the systems for services introduced. Over half of the respondents (54.2%) do not participate in any sort of consortium for Telemedicine applications users. Social security schemes/organizations or professional associations are reported by the overwhelming majority to play no role in the formulation and/or implementation of Telemedicine strategies. It is of particular interest the information provided that 40-60% of respondents participate in activities for establishing standards. 5.4. EVALUATION Topic Statement: In establishing a sound and efficient Telemedicine operation, proper evaluation activities ensure optimal management, resource allocations and utilisation via effective feedback mechanisms. Results: Evaluation activities appear to be incorporated in many Telemedicine services strategies but apparently few are involved with the assessment or monitoring aspects of the systems/services. The great majority of providers do not use or develop tools for assessing the medical needs and requirements for the introduction of Telemedicine services. No autoevaluation mechanism for the Telemedicine projects are reported. The majority of respondents do not appear to be aware of the existence of tools and/or mechanisms for forecasting the needs in Telemedicine services. It appears though that the majority of providers have some strategies for guaranteeing the sustainability of Telemedicine services projects beyond their initial (pilot or experimental) phase. 5.5. PERSONNEL Topic Statement: A crucial factor in determining the successful implementation of Telemedicine applications and services is the availability of properly motivated and trained personnel with prerequisites of good standing in this field. Results: Reported attitudes of medical personnel towards the introduction of Telemedicine services vary, but the general inclination is positively placed towards Telemedicine. Availability of personnel when required appears to be adequate. Foreign experts seem to be employed only by few respondents for speeding up the implementation of their projects and exchange views and experiences in the process of system set-ups. The role professional associations play towards the introduction of Telemedicine is generally assessed as positive. 5.6. TRAINING Topic Statement: The implementation of Telemedicine services by employing new technologies created new job oportunities and training requirements. Training syllabuses, activities and personnel selection must be appropriately determined for Telemedicine services to be effective from the outset. Results: The estimated number of individuals from all disciplines already trained in Telemedicine services and the estimated requirements in personnel over the next 3 years is relatively small. These personnel numbers are estimated from 3 per year locally to a maximum of 160 per year on a national scale and cover all required job descriptions. Few software products seem to exist for utilisation in personnel training. Most service providers (25-44%) do not appear to offer in-job training courses, although in-job training for physicians constitutes an exception with 53.3% of providers offering in-job training courses. Postgraduate studies in telemedicine are not adequately offered in any form, although 26.6% of providers do offer some sort of postgraduate Telemedicine curiculae. 5.7. RESEARCH Topic Statement: Basic research activities can lead to the assimilation of technological know-how in developing Telemedicine systems, which can further specifically lead to the evolution of more advanced Telemedicine networks thus providing new opportunities for technological and medical research and advancement, involving academic and research establishments, the industry and Health Care authorities among others. Results: After the installation of Telemedicine networks, research on medical issues is reported to have been encouraged only by half of the number of the respondents, in contrast to the ongoing technical research (software or hardware), which is reported by the majority of the respondents (82.3%) to have proceeded from that point onwards. This seems to be understandable since at the pilot stage of the system most troubleshooting and R&D work must be technically accomplished in order to perfect the set up (eg. software, hardware, peripherals, transmissions etc.) before medical data can start to be properly collected and utilised for research purposes. 5.8. ECONOMIC ASPECTS Topic Statement: An increasing demand for improved and efficient health services with high costs to sustain the Health Care operation, demanding costly economic issues of Telemedicine applications and services may initially play a limiting or inhibiting role until a time when fully developed Telemedicine Systems offer an efficient and worthwhile, cost- effective alternative to existing medical services. Results: Although variable economic estimates are given for setting up and operating a service, expected economic benefits due to the introduction of such services and projections on cost-containment through the use of these services cannont yet be effectively made. Only few respondents (2 out of 16 respondents ie 12.5%) reported work in the planning phase for the introduction of a new cost sharing scheme due to Telemedicine, where consultation fees and agreements are yet to be discussed. Investments in the provision of Telemedicine services by the industry is not reported to be sufficiently adequate. 5.9. INTERNATIONAL CO-OPERATION Topic Statement: EEC Programmes mainly aim at encouraging inter-EEC as well as international co-operation in Advanced Informatatic in Medicine and Telematics (thus including Telemedicine) and related fields. A resulting increase of activity in Telemedicine R&D through national and international collaboration can lead to efficient and optimally integrated Telematic systems for medical use. Results: EEC R&D policies are reported to have helped in the introduction and implementation of Telemedicine services. 62.5% of respondends participate in related European programmes. The majority of providers (61.5%) do not appear to have plans for bilateral or multilateral co-operation in Telemedicine outside EEC programmes. 6. BIBLIOGRAPHIC SURVEY Bibliography on Telemedicine and related subjects has been looked into but although activities and research in this field had been enlightening, little information has been acquired to assist in establishing contacts in the rather short period of time available between the first drafting of the Questionnaire and its dispatch to the bulk of the receipients. A bibliography search was conducted in order to review and record relevant published work pertaining to Telemedicine applications and services to date. A search on MED-LINE database on CD-ROM was carried out and library material compiled by the National Library of Medicine, the US Department of Health and Human Sciences, covering the years between 1988-1992 inclusive, was reviewed. Out of a total of 393 papers and abstracts relevant to Telemedicine applications and services covered it was apparent that Telemedicine systems are utilised for services as shown in Table III. We were able to access two other data bases containing information relevant to this work ie the Winsconsin Telemedicine Library Database and DIMDI. The search of the first has revealed 643 entries up to April 1992 and it is perhaps one of the few existing specialised ones as stated by the Library brochures. We were not able to make a cross check between the databases for the time being, but its development will be followed closely. The medical specialties with Telemedicine services and applications listed include: - clinical image transfer - dermatology - pathology and anatomy services - radiology patient care - military applications - emergency medicine - fetal heart rate telemetry diagnosis - space medicine patient care - PACS - conferences- teleconsulting - laboratory managment and information system operaations - handicaped telephone line transmission The German Institute for Medical Documentation and Information (DIMDI) database was accessed via the Greek National Documentation Centre in an attempt to reveal European entries pertaining to Telemedicine. Although there seems to be an overlap with information retrieved from other medical databases, this search (covering a period from 1983- 92) provided five (5) abstracts of European origin pertaining to Telemedicine systems applications and services. 7. ANALYSIS OF THE SURVEY RESULTS In sections 5 and 6 we have presented the information collected from the completed Questionnaires and the bibliographic search. In this section we will make an attempt to analyse the results and present a picture of Telemedicine services which hopefully can lead to a better understanding of the underlying dynamics. We are aware that this is not an easy task and unavoidably the results will be subjective. The presentation will follow the structure of the Questionnaire. In the second version of the report we will try to be consistent with the ODP approach to the extent developed in Workpackage 6. 7.0 Introduction of Telemedicine Services Overall we have witnessed very positive attitudes in introducing Telemedicine services. Despite of the fact that the Survey did not have the privilage of receiving responces from all those working in Telemedicine services and applications, we are confident from the information obtained from different other sources that there are many activities in this field. A prime source of information in the future will be conference proceedings and the CEC Telematics Programme Deliverables. They will be available in late 1992 following the Programme's execution timetable. It is clear however that the work delivered to date is of such a nature that cannot easily lead to publications and thus the bibliographic surveys cannot provide the latest information. The problem of information exchange and distribution must be of prime concern to the CEC and ways of timely distribution and fast access have to be devised. E-mail is possibly an easy and quick means for abstract distribution. Vtx service will eventually provide a better solution. 7.1 Services It is doubtfull if the status of a complete Telemedicine service can be awarded to many of the activities claiming it. This is due to the fact that not a widely accepted Telemedicine Framework exists. It is exactly its absence that gave birth to the FEST projects and its subsequent funding from CEC. Our opinion is that having already significant developments in this direction, CEC and other competent national and international authorities and organizations have to promote the implementation of large scale pilots preferably across Europe. Many of the present activities will face important obstacles and possibly unsurmountable difficulties in passing from the pilot phase to the service phase in any given medical or administrative environment. This step necessitates new skills to be incorporated in the teams working towards this direction. Better and faster results might be obtained if carefull planning at a strategic level can be formulated and implemented. An activity environment has to be provided by attacking simultaneously the medical, scientific, technical, economic, social and organizational aspects of Telemedicine. 7.2 Infrastructure The existing infrastructure, either medical or technical, in informatics and communications, does not appear to pose insolvable problems within the economic restrictions of the present budgets for health care provision. The achievements and progress in telematics is fast and provide very increasing opportunities for applications in health care either locally (ie confined to health care units of every size) or at regional and national levels, or across boarders. It is obvious that the pace of introduction of Telemedicine services will be accelarated if provisions are taken to use widely accepted standards for interconnections and transportability of the applications. The indication obtained from this Survey is that a significant number of the respondents participate in standardization activities, an observation which may lead to the conclusion that rapid developments in the field have to be expected. At the same time the responsibility of the CEC to encourage and coordinate in an efficient way the establishment and promotion of standards in: - quality assurance - remote maintenance/control - medical audit - hospital information systems - health care information systems/primary care is of paramount importance. 7.3 Policies and Strategies Although the present state of affairs in the EEC might not allow a well structured and efficient coordination of the Health Care Policies in the Member States, no restrictions seem to exist in working towards a consensus promotion and guidelines formulation towards that goal. These two activities will be of foundamental importance and will provide guidance to National Health Administrations in creating a promotional environment facilitating the necessary restructuring of the organizational procedures. Aspects like cooperation between PTT service providers and medically and socially acceptable ethical practices have to be worked out and encouraged for smooth and easy implementation. CEC policies concerning future activities in telematics in Health Care have to take note of the significant facts prevailing in this Survey, namely, CEC Framework Programmes have provided an important platform for promoting telematics in Health Care in Europe. Important items that policies and strategies have to take into account are among others, the following: - ethical issues - electronic data protection - legal personnel protection - minimising disturbance in necessary restructuring of Health Care existing systems - promotion of HC restructuring due to innovations - the special needs of primary care - co-operation between public and private sectors - multilingualism 7.4 Evaluation In the present situation of awareness concerning the difficulties imposed by demographic factors, social acceptance and medical services quality requirements and accessibility, proper evaluation mechanisms must be incorporated in any new attempt for improving effectiveness and efficiency in health care. It is important that suitable evaluation tools and procedures are made available to those committed in implementing new types of medical services, procedures or incorporating new knowledge in todays practices. The results of the CEC (and in particular DGXII) work in the field of assessment and evaluation (programme MONITOR/SPEAR) can provide a wealth of knowledge and guidelines for auditing, monitoring, autoevaluation etc. at all stages of projects and programmes, either at national or international level. 7.5 Personnel Telemedicine activities in Health Care necessitate that medical personnel at all levels be adequately exposed to the advantages and the requirements imposed for efficient medical care in a new environment where opportunities offered by the new technologies can be exploited. Many problems originating from the existing structures and procedures of health care provision can be adequately faced by means of the new possible solutions offered. Underserved geographical areas, populations, seasonal population variations, scientific isolation, unwillingness to serve specific specialities and/or specific environments, removing uninteresting tasks or unnecessary activities from particular personnel duties will result in better services and will offer opportunities for better quality of the services provided. Obviously new personnel policies for recruitment, formation, motivation, education, in-service training etc. have to be designed and implemented. It is important on the other hand that the administrations have to provide a safe environment for medical workers with respect to the new technologies as they will be incorporated in the medical practice. 7.6 Training The new telematic technologies offer unique opportunities for education and training of medical workers and patients. Guidelines for education and training have to be produced as soon as possible and new curriculae and standards have to be worked out and promoted. The number of people who have to be trained in the new methods and technologies is enormous and therefore there will be an acute need to train educators. In view of this fact, new training methods complementing the conventional ones have to be devised. Interactive multimedia technologies can offer alternative solutions. In this case training material and methods have to be discussed and agreed upon at European level. 7.7 Research Telematics is idealy positioned for encouraging medical research, information exchange and access to scientific literature. Research in the field of telematics itself is already promoted through the CEC programmes and can further be developed via telematic networks. In the field of medical research new perhaps protocols have to be worked out and implemented. Such arrangements will eventually lead to better medical services provision and will facilitate acceptance and use of new knowledge in the medical practice. 7.8 Economic Aspects It is not obvious, due to absence of relevant studies, when the breaking point of return on investments can be achieved by the introduction of Telemedicine servises. In the public sector the time scale might be much longer than in the private one, since it predisposes more efficient decision and management support mechanisms. Better results for the efficiency of Telemedicine services might be achieved by removing existing, if any, obstacles of collaboration between public and private sectors. At the same time Telemedicine will offer new opportunities for investments, job creation and product development. New methods of financing telemedicine activities have to be investigated; borrowing of methods and procedures from other sectors of the economy can in this respect be looked into. 7.9 International Co-operation Although international co-operation between groups or individuals from Member States has been already achieved to a significant degree, mainly thanks to the CEC programmes, due attention has to be given to cooperation between EEC countries and trird countries such as the USA, Eastern countries etc. This cooperation might lead to new opportunities for extending the entrepreneurial activities of EEC industry and health care in several domains including services, communications, research and training. 8. THE PARTICULAR CASE OF GREECE , ITALY AND MDIS The case of Greece and Italy deserve special attention since in these two countries there are important initiatives from both the public and the private sector in the field of Telemedicine. 8.1 GREECE 8.1.1 THE TELEMEDICINE PROGRAMME OF THE GREEK NATIONAL HEALTH CARE SYSTEM Abstract At present the Greek Telemedicine Programme provides through the Sismanoglion General Hospital in Athens, expert support to 12 remote Health Care Centres (see Map I). The support includes: - diagnosis and medical support in emergency situations - consultations to resolve difficult diagnostic problems - remote in-job training The support is provided using leased lines of the national PSTN network for voice communications and still video image transmission and voice conferencing, using an advancded PBX for the in-job training activities. In addition an ISDN type network is at its first stages of operation for image transmission between the Telemedicine Centre of the Hospital and its various departments. The ongoing pilot phase will provide an optimized model for a regional Telemedicine node configuration. Subject to approval by the Ministry of Health, the Programme's main funding source, at least 6 additional nodes will be established to cover the needs of the approximately 50 most remote Health Care Centres in the Country. The results obtained so far indicate that the aims of Telemedicine in Greece are perfectly achievable and a number of first class services can be offered using the existing communications infrustructure. Due attention however has to be paid to the organizational aspects of Telemedicine and the related implementation strategies. The programme has benefited considerably from its international cooperation activities and it is expected that in the near future services can be provided across the boarders. Introduction The Greek Telemedicine Programme is an initiative of the Medical Physics Laboratory (MPL) of the School of Medicine of the University of Athens since 1988. During its experimental phase a central telemedicine terminal in the Sismanoglion Hospital and reciprocating terminals in three different remote Health Care Centres (HCC) were installed during different periods. This phase was financed by the Ministry of Health, the General Secretariat of Research and Technology and the NATO Science for Stability Programme. The results were considered more than satisfactory and since spring 1990 the programme is financed by the Ministry of Health and the Greek Telecommunications Organization. There are now a total of 14 telemedicine terminals installed in various HCC all over Greece, while Sismanoglion Hospital provides support to the remote physicians via two telemedicine terminals installed in the Telemedicine Centre of the hospital, organized for this purpose (see Map I). In addition, since spring 1990 the NATO Science for Stability Programme finances the hardware and the technical assistance provided for the development of a pilot LAN for the transmission of medical images inside Sismanoglion. The LAN is expected to be operational by the end of 1992. Programme Objectives The Program aims mainly at providing improved medical services in remote and/or isolated areas. This is achieved by offering diagnostic support to remote physicians and to in-job training opportunities for medical workers. As a consequence, it is expected that remote populations will have increased confidence to the services offered locally, resulting in new opportunities for regional development. Technical Means The primary strategic objective of the Greek Telemedicine Program is to exploit the possibilities offered by the installed telephone network. The HCCs are the smallest well organized medical units which provide primary health services and have sufficient technical infrastructure of more or less, adequate medical, technical and administrative personnel. Thus the decision to install telemedicine terminals to these units is a sound one. The physicians of the HCC which participate to the Program can seek support from the experienced medical personnel of the Sismanoglion hospital on a 24-hours basis. Communications are supported by a DEFINITY 75/85 advanced PBX of AT&T and leased lines. The PBX allows voice conferencing between the hospital and 4 remote HCC, a facility which will be exploited for in-job training activities. In addition and most importantly, the same PBX will be used as server of the hospital LAN. It is clear that voice communications alone between specific units and particular physicians constitute a "network of people" which can offer substantial services to its members and through them to patients. At the Sismanoglion Telemedicine Centre there are two terminals, similar to those installed in the remote HCC. Each terminal is composed of: . a PC (386, 33MHz), colour monitor, 80 Mbyte hard disk, incorporated modem (19.2Kbps) and frame grabber . a video camera (1280 x 1040 pixels and 256 grey levels ) . a B/W 19" high resolution screen . a light box The telemedicine software allows acquisition of still video images (eg. of X-ray film), storage, retrieval and processing of the images. In addition images can be transmitted to another telemedicine terminal provided that communication has been established before hand. The average transmission speed is ~ 6Kbps resulting at approximatelly 8 min of transmission time per full uncompressed (~ 1.4Mbyte) video image. JPEG compression can reduce this time to ~ 2 min per image while quality is still acceptable to physicians. The SISMANOGLION LAN At its pilot phase the hospital LAN is star shaped ISDN type with a DEFINITY 75/85 PBX as its server. The network has 4 terminals installed in the A' Internal Medicine Dpt., the Radiology Dpt., the Cardiology Dpt. and the ICU functioning mainly as viewing stations. The LAN host computer is an IBM RISC 6000 with 800 Mbyte hard disk, additional optical disk, a tape streamer and a juke-box. The department terminals consist of IBM PS/2-70s or IBM PS/2- 40s and b/w IMLOGIX high resolutions screens with processing power (4 x 4 Kbytes memory, 1 x 1 K pixels display). The terminals are connected to the PBX via the hospital telephone cable lines and the transmission speed is 64 Kbps. The LAN operation necessitates the DEFINITY Generic 3.0 software which was installed in October this year. The ISDN network being limited to the hospital area is used for image transmission and voice conferencing. LANs based on 802.3 (Ethernet) and ISDN are connected by means of X.25 and in future ISDN constituing metrobolitan inter- hospital Network. Different types of connections are tested, from simple point- to-point to multi-client-server and different protocols are in use. Special attention is paid to ISO Open Systems Interconnection (OSI) standards. Their implementation is tested in parallel with protocols in use. The ongoing pilot phase will provide an optimized model for regional Telemedicine node configuration. At the digitizing of images side, particularly for research purposes, a digital, computer driven, very high resolution CCD colour camera (3.0 x 2.3K pixels) was installed at Sismanoglion Hospital. Organizational Aspects One can safely state that the success of the introduction of telemedicine applications for providing medical and health services will be governed by the ability of the providers and the administrations to incorporate the new technology and the related procedures into the existing health care structures. Technology is advancing quickly and appropriate solutions are now offered by the industry. It is on the other hand true that there is still a number of open questions that have to find solutions. Things are becoming even more complicated when telemedicine applications and services are to be offered across boarders which is of course one of the long term goals. Mention has to be made of legal and ethical issues related to telemedicine, standards, validation procedures, evaluation methods and procedures, etc. Pilot or demonstrator projects are designed for cost efficiency, they have limited resources and in many occasions tend either to ignor or to diminish the importance of the above mentioned problems. As a result the development from the pilot phase to an applications or services phase is not at all without serious complications. The Greek Telemedicine Programme from its experimental phase designed a particular strategy for paving the way for its implementation in the Greek Health Care System with the minimum possible negative interference. The main points of the strategy designed by MPL for Telemedicine are: . approval and financing from the Ministry of Health . medical and administrative support from a large hospital . support of the programme's R&D activities . support and financing from the Telecommunications Operator . national and international co-operation . promotion and publicity The Ministry of Health has established, based on our proposals, a Telemedicine Committee as an advisory body to the Minister of Health. In addition MPL has been nominated as the Telemedicine Reference Centre. The Centre has no legal status but it may well have in the future especially if plans for wide application of Telelmedicine in Greece will be implememted. Our efforts to widening our technological basis by collaborating with Greek groups of the public or private sector with specific expertise in various aspects of the telemedicine activities have been successful and the Telemedicine consortium established for this purpose, including 14 partners, is financed by the STRIDE programme of CEC. The in-job training activities of Greek Telemedicine Programme were supported financially in 1991 by the European Social Fund and in 1992 by the EUROFORM programme of CEC. The problems of the organization at the supporting hospital, the acceptance by medical workers and other related ones have been left out intentionally from this discussion. Both issues necessitate ample provision of information to the interested groups (including the personnel of the remote HCC), full commitment of the hospital administration and flexibility from the side of the Ministry in establishing rules and procedures. Last stage arrangements are now under discussion; reporting on these issues will be possible in the near future. 8.1.2 THE ENCEPHALOS PRIVATE DIAGNOSTIC TELEMATIC NETWORK Summary ENCEPHALOS (Brain in Greek) the biggest privately owned diagnostic facility in Greece operates for now a year, a network of 10 diagnostic units in different Greek cities, offering local diagnostic services and diagnosis by expert personnel located in the ENCEPHALOS headquarters in Athens. The pictures from different modalities are transmitted via the national PSTN network (see Map II). Scope According to its founder's statement the Encephalos Diagnostic Telelmatic Network has been facilitated due to the possibility of providing expert diagnosis from distance. The Network The ENCEPHALOS Network consists of 10 diagnostic units established in 10 cities in Greece (see Map II) while 3 more units will be operational in early 1993. The effort is an 16 mio ECU investment so far. The staff of the Network in the periphery consists of approximatelly 100 persons with the following synthesis: 35% physicians, 45% technical and paramedical and 20% administrative personnel. The small number of the administrative personnel is due to the central management capability build in and provided by the network itself. The workload per diagnostic unit is on the average between 300 to 1200 cases per month, the variation being due to the population characteristics of the area serviced and the time elapsed since the first operation of each unit. The number of transmitted images at the central ENCEPHALOS facility is on the average 300 per day (images here, correspond to film pictures as produced by the modality). The peripheral diagnostic units are equiped with: - CT scanner - Mass Bone measuring equipment - Mammograpy unit - U/S (for heart, abdomen and vessels examinations) - Biochemical/Haematological analysers in addition, one of the units (Heraklion/Crete) is equiped with MRI and Gamma camera and two other cities, with a Gamma camera (Pirgos and Tripoli both in Peloponnese). The network communications are covered by leased 4-wire lines of the Greek PSTN. Mode of Operation Local physicians provide diagnosis statements but in difficult to diagnose cases or in cases that at patient's demand diagnosis is requested from the expert personnel of the ENCEPHALOS facility in Athens, the images are transmitted and diagnosis is made. Using this procedure it is clear that local physicians have a unique training opportunity as was stressed by the ENCEPHALOS Management. All physicians in the network work on a fee for service basis. The central facility in Athens collaborates with physicians holding University level credentials. A particular case pertains to the events requiring the intervention of a neurosurgeon, a speciality not available in the hospitals operating in the cities of the Network but a field that ENCEPHALOS service at an expert level. In these cases examinations are sent to Athens for diagnosis. It is not a rare event that patients are kept for treatment locally under the remote supervision from Athens ENCEPHALOS physicians. Very recently, in the framework of a new Telemedicine proposal initiated by the Medical Physics Laboratory of the University of Athens, an agreement is being formulated for making the public Telemedicine Network and the ENCEPHALOS network compatible for image transmission. 8.1.3 ITALY Italy has a number of industrial research centres in the fields of information technology, telematics, and biomedical instruments, many of them being highly specialised in Telemedicine applications. The TELEMED consortium is considered to be of particular importance in the encouragement and support for the implementation of Telemedicine systems, applications and services in the country; it includes a group of organisations and firms which use new technologies in both the social and health care areas. Plans have been made to participate in the TELEMATICS programs approved by the EEC Commission in 1991, for the period 1991-1993. This will support the process started under the STAR program while also improving the infrastructures already created in the South of Italy. A funding of 6.5 mio ECU has been provided for conducting experiments with Telematic services in the hospital sector. For this, the SIP Telemedicine sector is working on the TELEMISM project for the creation of a telematic link between all minor islands in Southern Italy, using Telemedicine systems. This project includes the marketing and maintainance of 24 Teleconsultation systems, 255 Cardiology sets, 2690 " Teleocoorso" nets and 3 Hospital mobile units. Italian Telemedicine projects are participating both on a National and European level. The outline of Italian National projects is summed up as: - TELECOS (Hospital Teleconsultation) - TELEMISM (Tele-emergency services for small islands) - Telematic system of the Catholic University, Rome - Emergency medicine Telemedicine system at the La Sapienze University of Rome-S. Eugenic hospital - G.I.E.C. (Cardiological Emergency Care Unit) - C.I.R.M. (The Italian Medical Radio Service) - C.R.I. (The Italian Red Cross) It is considered significant to point out that under project TELECOS the hospitals of Friuli, Marches and Basilicate Regions have been equiped with transceivers and are connected to specialist supervision centres in: - Orthopaedics - Gynaecology - Radiology - Organ Transplantation - Oncology - Nephrology - Haematology - Anaesthesia and Rescuscitation Experience in the field of Cardiology and Cardiological emergencies has led to the creation of about 3000 stations throughout the country participating in relevant national projects. At present there are 20000 Telesoccorso terminals operating in Italy, operated by SIP, TVS, Tesan Co. in the Veneto Region (which focuses on the needs of particular categories of citizens eg. the elderly, the handicapped and the disabled, cardiac patients, the seriously ill,etc.), and other companies in participation with National projects. Italian projects participating on a European Telemedicine level which are in the planning phase are outlined as: - E.P.I.C. (European Prototype Integrated Care) - T.I.D.E. (Technology for the socioeconomic Integration of the Disabled and the elderly) - F.E.S.T. (Framework for European Services in Telemedicine) - TELEMATIQUE (Data-communications for regional development) Evaluation of the situation and perspectives for Telemedicine systems applications and services was carried out so that European Telemedicine projects can be utilised in order to promote health care improvement. The Ministry of Universities and Scientific Research (MURST) reported in 1991 that over the time period of 1992-95 a potential market for social health management information systems with an attributed value of 300 thousand million liras, which was estimated in 1989, would expand with a rate of between 4% to 41%. A feasibility study carried out in Italy (TEKNIBANK 1991) made sociological analyses and assumed situations, according to existing data and information, in order to identify the most representative issues and areas of interest for Telemedicine applications and services. Particular interest was taken in the parameters pertaining to the image and attractiveness of the Telemedicine operation, while at the same time opportunities for SIP involvement and selection criteria for determining switable locations for establishing the services centres were investigated, especially on a territorial level where data would be centralised. As a result, about one thousand "areas" composed of several communes each were initially identified, where then by a "filtering process" through utilising statistical variables such as financial status and standard of living, demographics - and especially % of the elderly in the population -, road access, level of industrialisation,residential density, social health infrastructure, etc., a limited number of 50 Teleassistance/ Telemedicine Centres had been selected for the introduction of Telesoccorso, Teleconsulto, Teledialysis and Telecardiology centres. PROGRAM OBJECTIVES: Although the main feilds of Telemedicine applications and services in Italy entail implementation in: - Emergencies (first aid) - Home telemonitoring (heart, dialysis, pregnancy, Telesoccorso, etc.) - Health information systems (making appointments for tests, creation of specialist files for integrated diagnosis, etc.), the particular plans for realising Telemedicine systems operation for the years 1991-95 concern applications/services in Telesoccorso, Telecardiology (and Cardiobip), Teleconsulto, Teledialysis and the utilising of Videophone. TELESOCCORSO: Telesoccorso service centres operating on a 24-hr basis are planned to be put in operation during the period 1992-95 in the 50 principal high opportunity areas identified by the feasibility study. Total or partial replacement of over 11000 Telesoccorso systems already installed and operating in the Veneto Region (Televertice) and the expansion of 100 remaining operational (SIP) centres in other Italian Regions is being assesed. Special system provisions will be made for particular user groups such as the elderly, the handicapped and disabled, patients at risk, etc. TELECARDIOLOGY: It is contemplated that Telemedicine cardiology equipment will be installed in 20% of the 350 Cardiology Specialist centres, for the reception of one-dimensional electrocardiographic signals using the cardiotelephone and X-ray images transfered through dedicated software. About 20% of the existing 657 national health nursing homes will be covered, while an attempt to cover an estimated 20% of public and private health units will be made as well. The CARDIOBIP, a very small portable apparatus for recording, memorizing and transmitting various types of arrhythmia which is simply operated by the patient, will be allocated in numbers of 3 to 4 sets per Telecardiology station. TELECONSULTO: Teleconsulting nets with facilities for integration, processing and remote transmission of biomedical images are expected to be installed during 1992-95 throughout Italy according to studies conducted. Up to 1000 such systems may be required but as the market for such Teleconsulting nets is reported somewhat "unsettled", the penetration for providing end user services may deviate to below the number of systems initially estimated. TELEDIALYSIS: Non-hospital dialysis demand in Italy represents quite a substantial part of such specialist medical service offered nationwide. A further 135 Nephrology departments with about 1200 bed capacity are operating throughout the country. Dialysis telemonitoring systems, which make it possible to follow, in real time and from a single centralised point, the progress of dialysis treatment given at a Dialysis centre whether in a General hospital, at other hospital dialysis rooms with limited assistance, or at home, are expected to be installed in about 20% of the operating Nephrology departments thereby enhancing the dialysis services offered nationwide. VIDEOTELEPHONE: This system allows users, with a single dialing operation, to be connected in audio and video with a distant correspondent using two "B" channels of an ISDN basic access or two RFD/N lines. A more effective communication is hence effected which can also be accompanied by the transmission of non-phonic information which cannot be transmitted on normal telephone lines. This is achieved by a terminal which basically consists of a telephone with an integrated keyboard, a colour monitor and a CCD television camera. 8.1.4 THE MEDICAL DIAGNOSTIC IMAGING SUPPORT SYSTEMS FOR MILITARY MEDICINE (MDIS) This project aims to achieve the objective of implementing filmless medical imaging systems at several military medical treatment facilities by 1994. It was created to exploit the results of extensive imaging research efforts over the past ten years. Filmless medical imaging systems are believed to be a superior alternative for health care delivery when compared to film based image management systems which are inherently limited by film as a hard copy media. Enabling technologies will make it possible to system integrate an effective filmless system for military medicine. These filmless MDIS systems are being acquired from industry through a contracting approach. The interesting aspects of this programme are its size and its innovative implementation approach, aspects that might be relevant to possible future wide European Telemedicine networks. As such it is not easy to report in detail about it but a contact has been established and its progress will be followed. 9. FUTURE WORK Through the continous setting up of a database of addresses of Telemedicine involved parties, an archive of Telemedicine services, applications, research and development providers is steadily being created. This is an ongoing process and the results will be made available to interested parties at their request. Future work will entail the following steps: - re-designing of the Questionnaire based on the reactions received and the developments of the Framework model developed in Workpackage 6 - definition of a new survey strategy with alternatives, aiming to acquire 150 responces in 1993 - review of the information contained in AIM projects' Deliverables and Project lines activities - review of Telemedicine activities in Australia and Japan - study for the possibilities of analysing the responces with the use of computer 10. TABLES I&II TABLE I SURVEY OF TELEMEDICINE SERVICES AND APPLICATIONS QUESTIONNAIRE DISTRIBUTION LIST |-----------------------------------------------------------| |STARTING DATE: MAY 27, 1992 STATUS: 30/11/1992 | |------------------|-------------------|--------------------| | COUNTRY | QUEST. SENT | QUEST. RECEIVED | |------------------|-------------------|---------|----------| | EEC Countries | | (+) | (-) | |------------------| |---------|----------| |1. Belgium | 19 | 1 | 2 | |2. Denmark | 12 | 1 | 2 | |3. France | 20 | 3 | - | |4. Germany | 4 | - | - | |5. Greece | 29 | 3 | 3 | |6. Italy | 16 | - | - | |7. Ireland | 12 | 2 | 2 | |8. Luxembourg | 4 | - | - | |9. The Netherlands| 31 | 2 | 3 | |10. Portugal | 7 | - | - | |11. Spain | 15 | - | - | |12. United Kingdom| 24 | 1 | - | |------------------|-------------------|---------|----------| | EFTA Countries | | | | |------------------´ | | | |13. Austria | 2 | - | - | |14. Finland | 9 | 3 | - | |15. Norway | 5 | 1 | - | |16. Sweden | 8 | 1 | 2 | |17. Switzerland | 6 | 2 | - | |------------------|-------------------|---------|----------| | Other Countries | | | | |------------------´ | | | |18. Canada | 7 | 2 | 2 | |19. U.S.A | 12 | 4 | 1 | |------------------|-------------------|---------|----------| | T O T A L | 248 | 26 | 17 | |-----------------------------------------------------------| TABLE II |-----------------------------------------------------------| | SURVEY OF TELEMEDICINE SERVICES | | REPORTING TIME: NOVEMBER 1992 | | (for geographical coverage please see Table I) | | | | TELEMEDICINE SERVICES OFFERED | | | |----------------------|-----------|-------------|----------| | | IN USE | UNDER | BEING | | | | DESIGN | PLANNED | |----------------------|-----------|-------------|----------| |- Cardiology (ECG) | 6 | 4 | 3 | |- Cardiac angiography | 1 | - | - | |- Surgery (EEG) | 2 | 2 | - | |- Fetal monitoring | 3 | 3 | 3 | |- Radiology (still | 8 | 5 | 2 | | b/w images) | | | | |- Computed Radiography| 1 | - | - | |- Teleconsulting | 5 | 4 | 4 | |- Dermatology (still | 1 | 3 | 2 | | colour images) | | | | |- Dialysis | - | - | 2 | |- U/S diagnostic | 1 | 1 | 4 | | imaging | | | | |- CT diagnostic | 4 | 3 | 2 | | imaging | | | | |- MRI diagnostic | 2 | 3 | 2 | | imaging | | | | |- PTCA | 1 | - | - | |- Transplantation | 1 | - | - | | check | | | | |- Telepathology | 1 | 1 | 1 | |- Psychiatry | 1 | - | - | |- Encoscopy | 1 | - | - | |- Lab computerisation | 1 | - | - | |- Medical Office | 1 | - | - | | Computing Administ- | | | | | ration | | | | |-----------------------------------------------------------| 11. MAPS I&II MAP I NATIONAL HEALTH HCC - MPL TELEMEDICINE SERVICES MAP II THE ENCEPHALOS PRIVATE DIAGNOSTIC TELEMATIC NETWORK 12. ANNEXES I, II, III & IV ANNEX I ANNEX II THE E-MAIL PRE-SURVEY ANNEX III |-----------------------------------------------------------| |TELEMEDICINE SERVICES AND APPLICATIONS BY MEDICAL SPECIALTY| | AS REPORTED IN BIBLIOGRAPHY BY MED-LINE 1988-1992 | |-----------------------------------------------------------| | Medical Specialities | |-----------------------------|-----------------------------| |- Obstetrics |- Paediatrics | | eg. autepartunm | Teleconsultation (1) | | foetal monitoring (1) | | | | | | intrapartum foetal |- Oncology & Cancer treatment| | monitoring (2) | (1) | | | | | perinatal monitoring (1) |- General Practics | | | GP intercommunication - | | uterine activity monitoring| teleconsultation (6) | | (2) | | | central monitoring (1) | | | |- Laboratory medicine (1) | | Total 10 | | | | | |- Radiology |- Epidemiology (2) | | eg. Teleradiology (21) | | | | | | Radiol. image and/or image |- Cytology | | enhancement (11) | eg. morphometry (1) | | | | | Multimedia radiological | | | reports (2) |- Pathology | | | eg. Telepathology (1) | | Total 34 | | | | | |- Cardiology |- Health & Nutrition (1) | | eg. monitoring arrythmia | | | (12) | | | Teleausultation (1) |- ENT (4) | | |- Gastroeuterology (1) | | Other cardiac (6) |- Pulmonary medicine (1) | | |- Neurology (4) | | Paediatric cardiology: |- Psychiatry (2) | | * monitoring (2) |- Dentistry (3) | | |- Orthopaedics (1) | | * echocardiography (1) |- Diabetes Mellitus (3) | | |- Dermatology (1) | | Total 22 |- Emergency Medicine (3) | | | | |- Internal Medicine | | | Physician inter- | | | communication - | | | teleconsultation (4) | | | | | | Total 4 | | |-----------------------------------------------------------| |-----------------------------------------------------------| | Primary Care (8) | |-----------------------------------------------------------| | Teleconsultation Services | |-----------------------------|-----------------------------| |- Ship-land teleconsultation |- Audio teleconferencing | | (2) | (2) | |- Naval teleconsultation |- Multimedica medical | | services (1) | applications/services | |- Video teleconsultation | (2) | | services (5) |- Teleconference (1) | |-----------------------------------------------------------| | Total 13 | |-----------------------------|-----------------------------| | Expert Systems/Diagnosis (3)| Medical Record-MMDBS (6) | |-----------------------------------------------------------| | Local Telemedicine Services (6) | |-----------------------------------------------------------| | Military Telemedicine Services (2) | |-----------------------------------------------------------| | Health Education (21) | |-----------------------------------------------------------| | Library - Interlibrary Teleservice (2) | |-----------------------------------------------------------| Numbers in bracket designate reported Telemedicine systems, applications/services in each case. ANNEX IV TELEMEDICINE PROVIDERS Questionnaire Respondents Address Archive EEC Countries 1). Country: BELGIUM Administration : University of Leuven Div. of Medical Information Responsible Person : Prof. Dr. J. L WILLEMS Full address : U.T. Garthinisberf 49, Herestraot 3000 Leuven, Belgium. Tel. 32-16-213801 Fax 32-16-213796 2). Country : DENMARK Administration : DEPARTMENT OF DIAGNOSTIC RADIOLOGY Responsible Person : ANNE GRETHE JURIN MD CONSULTANT RADIOLOGIST. Full address : Noerrebrogade 44 8000 AARHUS DENMARK TLF : 45-86125555 fAX : 45-86-185239 3). Country : FRANCE Administration : COSYMED S.S. Capital 2.000.000 F. 5-7 La Canebiere - 13001 MARSEILLE. Tel. 91 90 94 78 SIRET 383 833 591 00011 Responsible Person : Ductem Buchet TEL. 91-90-34-78 FAX. 91-90-33-16 4). Country : FRANCE Administration : Institut Gustave -Roussy Type: unite la Grange 77176 SAVIGNY LE TEMPLE (France) Responsible Person : Dr. BENAHMED. MD Tel. (1) 60 63 90 33 - Telefax (1) 60 63 83 24 5). Country : FRANCE Responsible Person : DR. C. RAFFOUX Director of France Greffe de Meelle EMDIS Project Manager France Greffe de Malle Hospital Saint-Louis 1, avenue Claude Velle Faux 75010-Paris 6). Country : GREECE Responsible Person : Protopapa E. METAXAS MEMORIAL CANCER INTITUTE OF PIREAUS-st. Botsari 54- 185 73 Pireaus- Greece. TEL. 451.84.11/ 451.62.33 FAX:453.89.53 7). Country : GREECE Administration Person : DIMITRIS SOTIRIOU. Assistant Professor. 75, Mikras Assias str., Goudi Athens 115 27, Greece Tel.: ++30.1.77.88.199 - 77.93.273 Fax.: ++30.1.77.93.273 8). Country : GREECE Administration : V. MARKOLULIS 2 ADRIANIOU & PAPADP STR 11525 ATHENS, GREECE TEL. (01) 6917763 extn. 270 FAX : 6925259 9). Country : GREECE Administration : Institute of Social and Preventive Medicine 24, Dimokritou st., 10673 Athens, Greece tel. 301-3604894 Fax. 301-3604894 10). Country : IRELAND Administration : IRISM MEDICAL SYSTEMS Responsible Person : BRIAN ENNIS. MANAGEMENT DIRECTOR CLARA HOUSE, GLENAGEARY PARK, CO.DUBLIN, IRELAND Phone + 353- 12840555 FAX + 353-12840829 11). Country : IRELAND Administration : HOSPITAL Responsible Person : PAOF ROEY O' MOORE Full address : C.P.C FDVH/ST JANES'S HOSPITMS DUBLIN 8 IRELAND P.O BOX 795. FAX +353-1- 537594 12). Country : THE NETHERLANDS Administration : Rogan B.V Responsible Person : Drs. R. Langenhuysem Frans van Mierislaam 4 3712 AX Hnis ter Heide Metherlands Tel (31) 3404-31067 fax (31) 32404-32170 13). Country : THE NETHERLANDS Administration : Eemland Hospital Responsible Person : Dr F.H BARNEVELD BINKHUYSEN Hilvertswes 305, 1214 S6 Hilversum Netherlanch tel. 31-33-222345 31-35-245413 (private) fax . 31-35-231439 14). Country : UK Administration : National Health Service Responsible Person : DR. A. T. Zarneh (HEAD OF DEPARTMENT) MEDICAL PHYSICS DEPARTMENT. DEWSBVRY DISTRICT HOSPITAL. DESWBVRY W. YORKS WF13 4HS UK EFTA Countries 15). Country : FINLAND Administration :MIIDDLE FINLAND CENTRAL HOSPITAL Responsible Person : JUKKA PUOLAKKA MD. Keski-Suomen Keskussairaala, 40680 Jyvaskyla Tel: (941) 691-143 Fax: (941) 691-098 16). Country : FINLAND Administration : TECHNICAL RES- CENTER OF FINLAND MEDICAL ENGINEERING LABORATORY Responsible Person : VARI VILTANEN P.B. 316, 33101 TAMPERE, FINLAND TEL. 358-31-163350, FAX 358-31-174102 17). Country : FINLAND Administration : Radiology Dpt. Univ. Hospital, Turlen Responsible Person : MARTTI KORMANO, PROF.CHAIRMAN Full Address : Dept. of Diagnostic Radiology Univ. Hospital, Turkn 20520 FINLAND Tel. 358-21-611950 Fax. 358-21-612950 18). Country :NORWAY Administration :Norwegian Telecom. Responsible Person :EIVIND RINDE, Research S Full address : Norwegian Telecom Research, P.O BOX 1156 N-9001 TROMSOL, NORWAY Tel. +478310260 Fax. +478310262 19). Country : SWEDEN Administration : Dept. of Radiation Physics Responsible Person : Mats Nilson, Ass. Professor Allmanna Siukhuset, S-21401, Malmo, Sweden Tel. +46 40 331236 fax. +46 40 963185 E-mail Mats. Nilsson @ Rfamas. Lu. Se 20). Country : SWITZERLAND Administration : Dept. of Dermatology University of zurich Responsible Person; PD DR. P. Elsuer PD DR. PETER ELSNER Dermatologische Klinik Universitatsepital Zurich Gloriastr. 31 CH-8091 ZURICH TELL. 01/255 33 06 FAX 01-2554412 21). Country: SWITZERLAND Administration: Hopital Cantonale Universitaire de Geneve Responsible Person: Prof. Jean-Raoul Scherrer 24, rue Micheli-du-Crest 1211 Geneve 4 Tel. (022) 22-62-01 Fax (022) 47-64-86 Other countries 22). Country : CANADA Administration : memorial University of New Foundeland Canada Responsible Person : Dr MAX HOUSE. CHAIRMAN TELEMEDICINE 23). Country: CANADA Administration: Alberta Health Responsible Person:Jane Curry, Manager, Data Management Christa Harstall, Information Management consulting P. O. Box 2222 10025 Jasper Avenue Edmonton, Alberta Canada T5J 2P4 24). 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