As published in December 2004

COVER STORY

Techniques that are changing patient carePDAs, knowledge-based decision-support tools, telemedical solu-tions, remote-monitoring possibilities and smart cards are justsome examples of technological developments that have an impact ontoday’s healthcare delivery. Industrial companies are greatly con-tributing to shaping the future of patient care. TXT e-solutions SpA,iMed Norwegian Telemedicine, VoxNET and Siemens Medical Solu-tions are just some of the companies that have developed techniquescapable of changing patient care.

“Healthcare has been commonly considered as being one of the indus-try sectors’ most lagging behind when it comes to adopting InformationTechnology (IT) to automate its processes, especially those directlyrelated to care delivery. Recent trends, however, show that interest is- perhaps slowly, but steadily - developing around technologies thatcan help healthcare successfully face the challenge of providing serv-ices at the quality level citizens are expecting, while reducing theiroverall costs,” writes Mr Salvatore Virtuoso, Project Manager withTXT e-Solutions (www.txt.it), the Milan based specialist in softwaredevelopment and market enterprise applications.

Greater occupational mobility and the patient-centric care models thatare being encouraged require the adoption of emerging technologies,such as wireless communications and mobile computing, in order tobring information to the point of care, while maintaining and enhanc-ing quality of care. Decentralised, shared patient care implies copingwith increasing quantities of clinical data spread over geographicallydispersed repositories that can only be managed by exploiting knowl-edge technologies to ensure efficient and consistent decision making. Two projects, co-funded by the European Commission, are being devel-oped to support these new models of care: WardInHand and Doc@Hand.

Information at the point of careWardInHand is an IT tool for supporting day-to-day, bedside operationsinside a hospital ward. It is designed to provide doctors and nurses withan advanced and easy-to-use solution to access and update patient datafrom within the hospital. It operates as a wireless extension of theexisting Hospital Information System (HIS). It also coordinates andstreamlines healthcare services by means of a configurable workflowengine/personal organiser. The use of portable devices, such as PDAs,allows for real-time access to up-to-date patient information, withreduced risk of errors linked to paper handling and duplication ofinformation, while safety and security standards are observed. Theiruse leads to better time management for an increased overall efficien-cy of the healthcare professional’s activities.

Making sense with decision-support toolsThe Doc@Hand project has completely different scope and objectives. Itaddresses the need for healthcare professionals to make informed deci-sions in a timely and efficient way, in a context where vast amounts ofinformation and knowledge relevant to the activity being performed arespread over a number of dispersed databases: hospitals, regionalhealthcare centres, universities, medical databases, clinical trialsdatabases, to name but a few.Doc@Hand aims at making use of a number of sophisticated techniques,such as dynamic user and activity profiling, push technologies andknowledge technologies, to proactively search for relevant pieces ofdata in those heterogeneous repositories with the ultimate goal of pro-viding decision makers with a snapshot of the key information theyrequire to make the best possible decision. The user does not need toknow the physical location or the format of the data. The user does notneed to explicitely ask the system to search for something. Doc@Hand

does it all, consolidating the most relevant pieces of information, pre-senting them through a graphic interface tailored to user preferencesand current activity and therefore allowing healthcare professionals toconcentrate on the use of the information rather than on its collection.

By land and by sea “Several projects have focused on maritime telemedicine, but few haveturned into successful telemedicine services. The major obstacles havebeen the bandwidth and the coordination of the service,” says Ms AaseTveito, Managing Director of iMed Norwegian Telemedicine(www.imed.no). The merMAid project aims to find a solution to bothproblems.

The passenger ship MS Jupiter is carrying up to 1200 passengers and120 crewmembers between the Norwegian city of Bergen and Newcas-tle in the UK. In July 2003, they started to use the first pilot versionof the merMAid telemedical solution as a regular part of their patientcare. The merMAid bag consists of a rugged PC with MedITSense ECG andpossibility for adding SpO2 and temperature sensors as well as a cam-era. In addition, it is possible to create a report with text-based infor-mation. The report can be customised to meet the requirements ofexisting HME procedures. The messages are exchanged as encrypted e-mail messages, allowing for sensitive information to be exchanged onsmall bandwidths. To obtain the ECG signals, a Tapuz belt is used. Thismakes it possible for any medical officer with a minimum of trainingto take good quality 12-lead ECGs. The main purpose of the merMAid solution is to help the ship’s medicalofficer and the doctor on land to give the best possible treatment to apatient. Before merMAid was introduced, the only means of communi-cation was the telephone. To be on the “safe side”, some patients withchest pains, but who subsequently were not diagnosed as having had aheart attack, were unnecessarily evacuated. An evacuation from a shipin the middle of the North Sea is not a simple procedure and should beavoided, if possible.

Several ships have access to free healthcare services over the radio ortelephone, and the market for selling telemedical services is thus verysmall. Hence, the only feasible service model was to convince the pub-lic healthcare authority to provide the service as part of their gener-al service for ships. For the pilot study, the University Hospital inBergen has been chosen, as they were the medical service provider forMS Jupiter. The bandwidth requirements are low. A message contain-ing ECG and text is less than 50 KByte and is sent as an e-mail. Thismeans that any communication satellite is sufficient.

During the first year, the system was used on 30 real cases. Thepatients are very happy about the solution, and several notes of thankshave been received.

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Similarly, the medical officers on board the ferry expressed their sat-isfaction. They state that the major benefit of the system lies in the factthat patients who fear that their symptoms may be indicative of a heartattack relax when the cardiologist does not confirm the diagnosis ofinfarct. Experiencing acute chest pain in the middle of the ocean isfrightening, especially for patients with a cardiac history. Hospital-based staff find it easier to advice the medical officers. They havereceived ECG by telefax for several years, but prefer the electronicsignal as it is of far better quality. The next step will be to integrate the service with the existing RadioMedico service provided to the merchant fleet and with other maritimehealth services. This is done through partnership between RadioMedico and Global Medical Support, a private call centre that has full-time access to medical specialists. The medical officer on the ship shallnot have to decide which service to use; the land-based personnel willhandle this in a transparent way. The project is expected to start inJanuary 2005.

Telecardiology“Stroke telemedicine is usually not practised in an integrated way.Blood-pressure (BP), pulse-oxymetry and body-temperature moni-toring are usually managed with different devices and different tech-nological platforms. The Medivox Internet model uses a single device,an easy interface supported by simple and reliable telecommunicationinfrastructure, and makes stroke treatment and monitoring straight-forward,” says Mr Fabio Buccolini, CEO of Vox Net R & D(www.voxnet.it).

The accuracy of the system for BP readings has been assessed by com-parison with readings from a standard digital sphygmomanometer in aseries of patients with hypertension and/or arrhythmia and who hadbeen discharged from the ED Stroke Unit of the Policlinico Umberto Iin Rome. Results of the clinical trials and projects with Medivox areencouraging. Thanks to Ristonet, another project from Vox Net, hyper-tensive and stroke patients are also treated and supported with a spe-cial, low-potassium diet.

The satisfaction of care with ICT technologies and their acceptabilitywere rated high, and in some cases very high, by the home telehealthpatients. Interestingly, the lack of visual and immediate contact withthe healthcare professional was not a concern for the patients. Overall,95.5% of all patients participating in the study were satisfied with thehome telehealth experience. Importantly, caregivers were also verysatisfied with the ability to communicate effectively and to gather ade-quate and accurate information using home telehealth. The homecarevisit takes approximately 15 minutes. The visit is confirmed on themedivox.it web site. If required, a visit is scheduled with a videophoneon the PSTN line. Vital-sign monitoring is carried out with commer-cial medical devices in an embedded IT solution. The medical opinion ordiagnosis is entered in the report on the web site.The project is in its early stages; the number of patients is presently

very limited, and quantitative data are not yet readily available. Large-scale studies will be necessary in the future to determine if and howimproved homecare communications reduce preventable events and leadto improved patient outcomes.

A story of smart cards Siemens Medical Solutions (www.siemens. com/medical) is developing modelprojects to test and implement an electronic health card and accompanyingtelematics infrastructure in various states of Germany. By using the smartcard, process optimisations can be introduced throughout the entire health-care system. The objective of the infrastructure is to make medical patientdata available not only within the hospital or the private practice, but on anational level. The projects are installed in a step-like fashion with the par-ticipation of social security ministries as well as regional service providersand sponsors in order to test the scalability of concepts and their use withreal patients. The health card, which will be issued to each insured person, plays a keyrole in ensuring secure access to sensitive patient data. In addition to gener-al information, a photograph and possible patient emergency information,the card primarily contains a reference to the patient electronic file. Accessto this file can be authorised in combination with a doctor’s or pharmacist’sHealth Professional Card. To ensure that medical data are protected, healthprofessionals are only allowed access to those data that are required for thespecific service they need to deliver, be it diagnostic or therapeutic. Patientscan decide whether or not they wish to give a specific medical doctor accessto their complete medical history.The card must also be equipped with a system to allow patients to apply avalid electronic signature to documents, such as consent for treatment orcost plans. This aims to guarantee the highest possible level of data protec-tion and security.The obvious conclusion is that the future of healthcare is driven by a muchcloser cooperation between hospital and private practice, as well as phar-macies and providers of health insurance.

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