International Working Conference, Hotel La Reserve, Bellevue/Geneva, Switzerland
THE USE OF INTERNET AND WORLD-WIDE WEB FOR TELEMATICS IN HEALTHCARE
Rapporteur'’s notes Thursday, September 7, 1995
(Dr. Edith Safran - CIH - HUG, Geneva, Switzerland)
Chair: Mr. Mark SELBY, President IAHIT
Co-Chair: Professor Jean-Raoul SCHERRER, President-Elect, EFMI
Mr. Carpentier, I am indebted to the research projects you started. I know the importance of validating pilot studies. What do you see as the major obstacle to this work ?
This problem is very different in Europe compared to the United States. I see two main obstacles.
The first one is psychological and sociological because of the medical education and training that has been given for years, especially to physicians, there is the fear that too great a use of new equipment and technology will take over our brain and our intuition. In fact, it is «man who remains king»!
The second obstacle concerns the sensitive issues of confidentiality and standards, they have been a matter of strong debate for a long time. It is important to reconcile the question of confidentiality, which is of great importance in the field of healthcare, with the service given to the population as a whole.
Concerning the problem of budget, it is an advantage to have to cope with this problem now, since it will favour less costly medicine in the longterm.
One difficulty I see is the question of who will pay the cost of future telecommunications. If it remains as costly as it is, we’ll «kill the goose with the golden eggs».
The opening-up of telecommunications to competitors will be given effect at the end of 1997. One problem we face is how to reconcile this evolution with the role of universal service. There will be a mix of commercial rules and implementation of conditions and principles for competitors to include universal services. Those will be included in directives for licensing.
Telematics has a dependency on the computer and telecommunications industries. Both industries have a dependency on the semi-conductor. It is interesting to note that the price/performance of semi-conductors has improved 1,000 fold since the introduction of the personal computer. The computer industry has passed almost 100% of this benefit to the consumer while the telecommunications industry has only passed approximately 15% of the benefit to the consumer. Reductions in telecommunications charges will significantly benefit the adoption and growth of telemedicine.
It is important to consider the problem of cost-benefit and, in particular, how we measure the cost-benefit of telemedicine.
It is really important to document the benefits of telemedicine. What are the benefits? Who gets them? What are the alternatives?
Thirty years ago, communications were too expensive. Now communication costs are less important, but we still have to prove the question of cost-effectiveness. My agency has funded several projects with an emphasis on evaluation, to find out if there has been a good use of public funds. One example of cost effectiveness I have been given was the case of a trauma, for which the cost of moving the patient to a hospital was $4’000.-.
Who is going to pay for telemedicine ? At the beginning, it will be public and industrial money. At the end, the social security systems should pay. But it is difficult to change the social security systems - even if the cost-effectiveness has been shown.
Concerning evaluation, we have either global studies, or micro-examples, such as the saving of money due to reduced transportation. We need careful monitoring of cost-effectiveness. We will do that over a period of four years.
I represent a multinational society. In my experience, there should be a global agreement beyond the G7. It is worthwhile being global and this permits the economy of scale. On the otherhand, there is the problem of language at the various levels including the level of nurses, patients or social security. Dr. Lindberg, you spoke of UMLS. How will communication be implemented between the US and other countries ?
When we understand the medical meaning, translation is relatively easy. This has already been proved with organisations in other countries.
Dr. Lindberg, on one of your presentation slides (showing the metathesaurus), we saw the increase per year in the number of new words and new concepts. Over the year, the increase in the number of new concepts was much larger. Therefore, translation work still comes back to how to manipulate new concepts.
Any system which is used, as ours is, will improve. We are constantly receiving mail from authors all over the world advising us of the misindexing of their papers. We regularly update the files, therefore, for distribution on an annual basis.
Having had a kidney transplant myself in Geneva, I can tell you about my own positive experience, for while I was staying this summer on the Iles Marquises in the Pacific, I was able to communicate quite easily with the hospital in Geneva for a medical consultation.
Referring to this anecdote reported by Mr. Segond, our Minister for Health for Geneva, there were three scenarios proposed in the European Union project on telemedicine, and the first one was identical to the one just reported by Mr. Segond.
In Geneva, we have several international organisations, for example: the International Telecommunications Union, the International Labour Office, the World Intellectual Property Organisation to name just three. All these organisations should work together on the technical and legal problems relating to telemedicine.
We are planning to work during the next few weeks on the question of liabilities and license.
I have one comment on the original topic of cryptography. Everybody realises that cryptographic technology will be commercialised, but there is tremendous resistance against allowing good cryptographic methods to be available to the public.
Concerning liability, it is interesting to observe that the legal community has been late to realise what is happening in telematics. In fact, these are not new issues, and the question of across-border responsibility has already been known for some time. The existing law still applies, but there has been no practice nor much experience so far in these situations.
Cost is a key issue. We are witnessing a dramatic change in technology. Many services which were until now separated are being progressively unified. Thanks to standards, systems are becoming more open and inter-operable. Telecommunications and networking are converging to become a single «telecomputing» field. The world-wide popularity of TCP/IP has elevated it to the status of a universal communication protocol.
In this context, it is important to avoid the pitfall of building dedicated infrastructures for specific applications. In Geneva, there is a remarkable example of a group of twenty international, regional, academic and public institutions which have joined forces with a local telecommunication operator to build a high-speed metropolitan area network, called the «Geneva MAN». The network will be able to carry all kinds of traffic, whether data, voice, or video, and will be available for all types of purposes, whether telemedicine, real-time process control, remote learning, enhanced Internet services, and access to distributed databases. The project started one year ago, and a pilot will be presented at Telecome 95, the world exhibition of telecommunications.
The Geneva MAN, and similar generic projects, present great opportunities. The adoption of common solutions implies the co-operation of various groups, from different disciplines, with different interests, and across traditional boundaries. This type of co-operative approach should be from the outset built in projects in which health information is a key component.
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