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Fragmentation to Integration: The Telemedicine Industry in Australia (Mitchell) was released in July 1998 and reprinted three times. A total of 10 000 printed copies were distributed on request by early 1999, demonstrating the widespread interest in the topics raised in the report.

The 1998 report was used as the basis for a series of Telemedicine Industry Development Workshops held in Sydney, Brisbane, Melbourne and Adelaide in November 1998 and in Canberra in May 1999. The workshops were managed by DIST and then by NOIE, with John Mitchell of John Mitchell and Associates. Support was also provided by the Federal Department of Health and Aged Care and each State and Territory Government. Further workshops are scheduled for Hobart, Perth and Darwin. The following discussion includes excerpts from the Workshops' Outcomes Report prepared by Catherine Higgins, E-commerce Project Manager, NOIE.

Summary

The workshops were very successful, with 53 speakers drawn from industry, government and the health professions. Over 400 participants (both industry and health professionals) attended the workshops. The intention was to encourage the debate about the direction of the telemedicine industry in Australia and to form an action agenda for ongoing work, at the State and Federal Government levels, and for industry. This report on e-health is a direct response to feedback from the workshops.

The workshops provided participants with a view of the telemedicine industry and an update from industry representatives and Government officials, including representatives from the Australasian Telehealth Committee, the Federal Government (NOIE, DIST and the Department of Health and Aged Care) and each of the State and Territory Governments.

Key recommendations

Several key recommendations arose during the course of the workshops. An Action Agenda evaluation sheet was handed to all participants at the close of the workshop, with suggestions invited for Federal Government policy and projects, State Government policy and projects and Industry projects. Broadly, workshop participants identified a need to:

• work with the Federal Department of Health and Aged Care on a number of key policy issues, including the need for evaluating and proving the business case for the use of telehealth and incorporating telehealth services into the Medicare Benefits Scheme and other policy and operational issues.
• work with the respective State Governments including the Australasian Telehealth Committee to encourage and coordinate the use of e-health in the public health system.
• work with the National Office for the Information Economy to develop an industry forum that is representative of the disparate and emerging players in the field. This industry forum would champion the Action Agenda for the development of the e-health industry in Australia. The Agenda would incorporate many aspects of e-health development including commercialisation of research, partnering between large and small industry players, 'branding and profiling' the industry, providing a focal point for working with the health customers, working on standards and interoperability issues and working with the health professions on a code of conduct for e-health in Australia.
• create an industry forum to be chaired by a prominent advocate from the industry, who could assist with providing a high profile for the work and objectives of the industry forum.
• encourage NOIE to collaborate with key industry associations to promote and develop the industry in Australia.

Key themes from the workshops

The Telemedicine industry has developed significantly since the Department of Industry, Science and Tourism (DIST) first took an interest in the area in 1996. Some key trends emerging from the workshops are:

• Integration (telemedicine activities are becoming integrated into the mainstream of using IT for health applications). Further integration is desirable and occurring at all levels. There is now less talk of 'pilot projects', as this is not seen as a successful or sustainable way of furthering e-health.
• Mainstreaming. Telehealth projects are occurring in many areas, particularly telepsychiatry, teleradiology and telerenal, which have proven cost-benefit cases.
• E-health is a more inclusive term than telehealth and represents the use of both telecommunications and information technology. E-health is a trend that follows the broader development of the information economy.
• The rise of home based e-health. This trend is increasing at a strong rate, and mirrors developments in the USA. It also mirrors the trends evident in other areas of the information economy where consumers (working from home with PCs and Internet technologies) are driving the changes, in concert with parties such as health insurance companies that want patients to have easier access to health information and services.
• The emerging role of General Practitioners and the need for them to take up online technologies and to drive the development of e-health services. General practitioners are central to the delivery of new Internet-based services to consumers. In Australasia online consulting services have emerged such as the "doctorglobal" service at http://doctorglobal.com. This mirrors similar developments in the USA and will have an impact on the delivery of General Practitioners' services in the Australian market. Many General Practitioners are now leading the change and beginning to deliver their services in non-traditional ways. It is likely that General Practitioners will form new hybrid models of consultancy in the coming years, combining face-to-face consultations with online communications.
• All States and Territories in Australia have undertaken public sector projects in different ways. However, there is a marked contrast between that of Queensland where numerous telehealth projects abound and NSW where a more centralised approach has been adopted. The Australian New Zealand Telehealth Committee provides coordination and researches some policy issues such as a national approach to evaluation and standards.
• Australia is positioned among the leading nations of the world in the use of e-health. There is a feeling that Australia has made the most of its remote locations, with a low population base. It is interesting that many rural and remote telehealth projects are now used as models for metropolitan projects. There is a growing recognition that Australia is part of the global health economy where, increasingly, there are no borders and health services will be sourced globally as well as locally.
• Regulatory issues are being dealt with as business cases emerge for the delivery of new services online. For example, the medico-legal issues arising from medical practice across State and Territory boundaries are being addressed in the case of telepsychiatry practice in Australia. Workshop participants and speakers (including practitioners) indicated that medico-legal issues need not block the development and growth of e-health service delivery in Australia. However, participants also indicated that additional awareness raising and educational work is required in this area, in consultation with the Australia Medical Association and international bodies. There is increasing interest among Australian General Practitioners about cross-jurisdictional issues due to the increase in the number of General Practitioners selling their services over the Internet (the gp.com websites).
• Collaboration. There is a need for the Federal, State Governments and industry to work together in implementing an Action Agenda to ensure Australia's success in e-health. Participants at the workshops agreed that the recommendations should be progressed during 1999.
• Terminology. The favoured terminology is changing from telemedicine to telehealth to e-health. E-health is now the term to use when describing the rise of digital technologies, electronic transmission and the convergence of technologies. This term is all inclusive and captures the use of Internet technologies and the rise of the information economy.
• Unstoppable. E-health, involving the use of technologies to improve health outcomes is becoming more common and unstoppable. This is a trend that follows other sectors in the economy.

It was agreed that the outcomes listed would be pursued by the relevant Government agency or industry grouping, with NOIE taking the lead on the Action Agenda for the Industry. The workshops have been very successful in getting Government focussed on key policy issues needed to allow the health sector to go online. The 1998 Mitchell report and the workshops have been effective in raising the profile of the industry and debating the issues about what needs to be done to develop Telehealth in Australia.

Workshop speakers

The following list of workshop speakers from Sydney, Brisbane, Melbourne, Adelaide and Canberra demonstrates the range of stakeholders in the field of e-health.

1. Tom Dale, NOIE
2. Peter Moore, DIST/NOIE
3. Catherine Higgins, DIST/NOIE
4. Dr Ian Heath, DHAC
5. Kevin Noonan, DHAC
6. Peter Harlow, DHAC
7. John Mitchell, John Mitchell and Associates
8. Dr Bruce Swanson, Dept Human Services, SA
9. Brian Richards, ACT Division of General Practice
10. Michael Parsons, Health Insurance Commission
11. Dale Kendall, Telstra, ACT
12. John Clark, Optus Communications
13. Laurie Wilson, CSIRO
14. Arnold Simson, CSC
15. Peter Upton, Australian Information Industries Association (AIIA)
16. Dave Genner, Collaborative Health Informatics Centre (CHIC)
17. Frank Quinlan, General Practice Computer Group, AMA
18. Vlad Aleksandric, ACT Dept of Health and Community Care
19. Robert George, Dr Jones and Partners, Adelaide
20. Dr Garry Shanks, Adelaide
21. Meredith Edwards, Telstra, Adelaide
22. Dr Fiona Hawker, Rural and Remote Health Service of SA
23. Prof.Malcolm Mackinnon, Flinders University and Health Online
24. Chris Boundy, Christopher Boundy & Associates
25. Sarah Warner, Collaborative Health Informatics Centre, Brisbane
26. Dr. Andrew Wilson, High Performance Healthcare
27. Prof. Ben Freedman, Concord General Hospital
28. Prof. Branko Celler, University of NSW
29. Gordon Makryllos, PictureTel Australia
30. Margaret Zahra-Newman, JAM Software
31. John Nearhos, Health Communications Network
32. Robert Frizza, Central Data Networks
33. Deborah Oong, National Telehealth Committee, NSW Dept Health
34. Ray Hand, Australasian Teleconferencing Association 
35. Michael Hedley, Australian Information Industries Association (AIIA)
36. Lyndon Seys, National Telehealth Committee, VIC Dept. Human Services
37. Peter Young, Cardinal Group
38. Brett Bonser, VTEL
39. Kevin Morris, Australian Computing and Communications Institute 
40. Harry Gelber, Royal Children's Hospital, Melbourne
41. Bruce Bramhill, TelePacs Technologies 
42. Peter McAlpine, PictureTel
43. Terry Whelan, Australian Electrical and Electronic Manufacturers' Assn.
44. Joan Edgecumbe, Health Informatics Society of Australia (HISA)
45. Neil Thelander, Queensland Health
46. Thierry Cornevin, Integrated Vision
47. Peter Hogg, Telstra, Qld
48. Mark Brommeyer, Australasian Teleconferencing Association
49. Dr Rob Whiting, Royal Brisbane Hospital
50. Dr Ilse Blignault, Qld Telemedicine Network
51. Vicki Sheedy, Queensland Rural Divisions Coordinating Unit
52. Bruce Satchwell, Micromedical Industries
53. Judy Morgan, Med-E-Serv
54. Laurie Ffrench, Australian Information Industry Association (AIIA) 

Mental Health Information for Rural and Remote Australia

What happens when ...

a person with schizophrenia is moving from Sydney to country NSW. His GP wants to ensure that there are adequate services available in that area

or

an older woman from Tasmania wants to obtain written information on the topic of manic-depression? She wants to explain to her son, who is currently living in Victoria and showing signs of this illness, that there is a  history of the disorder in their family. She wants to convince him to get treatment.

Information and effective referral can, for some, mean the difference between life and death. It is common knowledge in the late twentieth century that people living in rural and remote areas of Australia still do not enjoy the same access to health services as people living in the major urban and metropolitan regions of the country. This is particularly true when it comes to accessing psychiatric and psychological services. For rural/remote residents, issues of physical and social isolation, expensive transport, and stigma attached to mental illness compound these access problems.

In March 1998, the NSW Association for Mental Health launched a new service designed to help country people to overcome some of these barriers. This service is called Mental Health Information for Rural and Remote Australia (MHIRRA). This service provides easy, anonymous, and affordable access to:

• Information on different mental illnesses and psychological disorders.
• Contact details for services and organisations that provide assessment, treatment or support for country people with mental health problems.

MHIRRA is a telephone-based service whose information staff use a powerful, national database to access contact details for referral to appropriate services and organisations. The database originally contained about 800 references and as of mid-1999 contains 2 730 entries. To best serve callers, the database is continually updated and annually verified.

In August 1999, MHIRRA will have a web site so that people with Internet access can link to related sites. MHIRRA's information officers use the Internet to obtain information for those callers who do not have access to the Internet. It is planned that at one point the database will be part of the website and available for sale.

The purpose of MHIRRA is to connect and integrate existing mental health information services rather than duplicate them. Depending on the enquiry, callers may receive written information - a listing of services available in their area - or a simple telephone number to assist them in their query. Where gaps in service delivery to rural and remote areas are identified, these are reported back to the Commonwealth Department of Health and Aged Care.

INTERNATIONAL E-HEALTH DEVELOPMENTS

The e-health industry is in its early stages, fuelled in the last few years by the increased realisation of the power of both the Internet and Intranets. This chapter describes recent international e-health developments, particularly in the USA.

There are a number of drivers of e-health, including increased efficiencies from improvements in business processes, improved quality of care and demand from consumers. Health care lends itself to the strategic application of online technologies because of its size, the current inefficiencies of paper-based records, the intense need for up-to-date information to provide quality health care and because consumers have indicated that they are keen to use the Internet. Consumer interest in health information is driving much of the move to e-health. Various USA surveys have indicated that the proportion of USA adults that have used the Internet for health information may be as high as 40-60 per cent of adult online users, and the trend is increasing.

Sample e-health companies

A trend in the USA is for large IT companies such as Intel and Microsoft to merge with health online companies, to form new companies exploiting the ability of online communication. In other cases, rival companies have joined forces to strengthen their position in the industry. An example of such mergers is that between Healtheon with WebMD who merged in mid-1999. Both of these companies had previously set out to be the main provider of online services for the health sector in the USA.

The types of companies that are providing e-health services can be separated into three broad, but not entirely distinct, categories: those providing content and related services; those providing business-to-business or business-to-consumer services; and those providing networks or software for e-health. The categories overlap and will do so more in the future with the convergence of technologies, but distinguishing between them now may help to highlight components of the e-health industry. Tables of sample companies from these three categories are provided below.

Table 5.1: Examples of USA e-health companies providing content and services

Company	Descriptor
Accent Health	Provider of CNN healthy lifestylie programming kiosks
America's Doctor Online	Matches patients with doctors
Health Oasis	Mayo Clinic's consumer health site
InteliHealth	Joint venture between Aetna and Johns Hopkins
Thrive Online	Joint venture between AOL and Time Inc.
HealthGate	Research journals; continuing medical education; healthy living magazines
Physician's Online	Information for doctors

Table 5.2: Examples of USA e-health companies providing business-to-business or business-to-consumer services

Company	Decriptor
Cimtek Medical	Medical supplies and equipment
medibuy.com	Medical supplies
SciQuest	Lab supplies and equipment
Drugstore.com	Online retail pharmacy
Medsite	Medical supplies
Mybasics.com	Health and beauty, pharmaceuticals
yourPharmacy	Online drugstore of Express Scripts

Table 5.3: Examples of USA e-health companies providing networks or software

Company	Descriptor
@outcome	Patient communicator software
AHT Corporation	Electronic lab results and prescription ordering
Caresoft	Disease management software
Claimsnet.com	Online claims processing
HealthMagic	Information management tools
MedicaLogic	Electronic medical record software
PointShare	Intranet services for doctors, hospitals, managed care

The above companies illustrate, in particular, the enthusiastic way the Internet is being used to deliver health services in the USA. The companies are also demonstrating the new opportunities in business that have been created by the availability of new information and telecommunication technologies.

Case studies

Set out below is a selection of case studies that demonstrate the need for the term e-health to describe the range of businesses and applications that take advantage of the combined power of information technologies and telecommunication technologies.

Case Study: Japanese Smart House

Excerpt from 'Model smart home goes for the doctor' by Joseph Coleman in The Australian, Tuesday May 18 1999, Computers Section/The Cutting Edge, p. 8

Tokyo: Ever get up in the morning and wondered about your blood sugar? Or find yourself in the dairy aisle, not sure if you've got milk in the fridge? Are you tired of turning lights on and off?

No worries: the Japanese Smart House is coming soon.

Electronic companies are hard at work on new homes strung wall-to-wall with fibre-optics connecting rooms to each other and the vast world outside: the Internet, cable TV, hospitals and travel agents.

The houses are also bursting with little high-tech perks. Lights go on by themselves when you enter rooms. The toilet weighs you, monitors body fat and measures your urine sugar.

The system revolves around an HII Station (Home Information Infrastructure), a sort of central nervous system - a depository for reams of information and the main relay station for data flowing between the house and the outside.

Through screens in every room, occupants can monitor the activities and use of appliances throughout the house, check security cameras and contact cyberspace.

For example, the bedroom has a medical consultation kit that allows the electronic equivalent of an old-fashioned house call. You key in your complaint and basic physical information and call the doctor, who makes a diagnosis based on that information and data available from your household system.

A key feature of the system is a wireless terminal - about the size of a cellular phone - that provides remote access to the house.

Cameras and sensors monitor who is where, doing what. Detailed information such as blood pressure, weight and schedules of family members are available to other family members in the main memory bank.

Case Study: A Superpower Emerges In Online Health Care

Excerpt from an article by Todd Woody, The Industry Standard, 21 May 1999

"The merger of Healtheon and WebMD will create a firm worth some US$20 billion"

Last Thursday, after a week of speculation, Healtheon and WebMD announced a 50-50 stock swap that will create a powerhouse in the nascent online health-care industry and likely spur a consolidation wave among rivals. Healtheon's stock, which was trading at US$52.13 the day Arnold and Long met for dinner, shot up to a high of US$126.19. The new company, which will have a combined deficit of nearly US$100million, finished the day with a market capitalization of US$20 billion, based on Healtheon's share price. That makes the new company, to be called Healtheon/WebMD, one of the largest U.S. health-care companies, online or offline.

The company aims to dominate the online health-care market by offering a single portal to allow doctors and patients to conduct transactions and obtain medical information. The hope is that the Internet will eliminate the trillion-dollar health-care industry's costly and inefficient paper shuffling and give consumers more control over their medical treatment. The merger will allow Healtheon to concentrate on the nuts and bolts of connecting doctors, hospitals, insurers and consumers over the Internet. WebMD, which provides medical information and transaction services to physicians and operates a consumer health-care Website, will take the lead in marketing the company.

Microsoft's investment also reflects its cold-eyed assessment of the ever-changing Internet Economy. To gain a foothold in the online health-care industry, the company has pledged not only the US$250 million equity investment, but also US$150 million for marketing. Healtheon/WebMD also will be the featured health-care company on the MSN portal - though it will have to pay Microsoft US$162 million for that privilege.

Case Study: Cancer Patients Link to Home

Excerpts from an article from www.bidmc.harvard.edu/pressreleases/feature.html (Article may now be found at http://www.hoise.com/vmw/99/articles/vmw/LV-VM-07-99-9.html)

Patients Bridge Home and Hospital with Beth Israel Deaconess's Cancer CareLink

Boston, Mass. - Patients receiving bone marrow transplants at the Cancer Center at Beth Israel Deaconess Medical Center can now take advantage of high-tech bedside computing resources that help them keep in touch with their families and connect to Internet resources.

A joint pilot project by Beth Israel Deaconess Medical Center's Center for Clinical Computing and the Cancer Center, Cancer CareLink is a World Wide Web and videoconferencing system that provides emotional and educational support for patients during their hospitalization.

During their stays in the Bone Marrow Transplant Unit, selected patients are given a bedside personal computer with a free high-speed Internet connection, an email address to use to message friends or family members, and access to a specially designed Website that provides information about the unit and links to patient education materials. The computer is also equipped with a videoconferencing component - mounted camera, microphone and speaker - that allows patients to communicate with their families, who are loaned a similar multimedia computer for the duration of their loved one's stay.

The Cancer CareLink pilot, which will determine if the bedside computing resources improve care and enhance the patients' experience in the Bone Marrow Transplant Unit, has initially been offered to women suffering from breast cancer who are undergoing bone marrow transplants, although plans are to extend the program to other cancer patients as well. The first part of the CareLink project - Baby CareLink - was piloted in March 1998 and offers a similar two-way videoconferencing and Internet system for parents of babies in the Neonatal Intensive Care Unit.

Case Study: Internet-driven Transformation in Healthcare

Excerpt from intel.com/pressroom/archive/releases/in102798a.htm

Intel, Oct 27, 1998

Intel's Internet Health Day held in San Francisco on 27 October 1998 featured a showcase of 20 Internet Health sites and technologies, along with more than 20 news announcements in such Internet Health areas as:

• new consumer health information Websites.
• online physician services.
• interactive disease care.
• Internet prescription services.
• confidential disease testing and counseling.
• personalized online wellness programs.
• e-commerce sites dedicated to health products and insurance.
• new consumer research on health care and Internet attitudes.

Case Study: Doctors' Use of Internet Explodes

Research shows 42 per cent growth in physician use of Internet in last three months: Healtheon Study Attributes Increase to Robust Content and Ease of Use. www.healtheon.com/news, 6 May 1999

SAN FRANCISCO, Calif., May 6, 1999 - Healtheon Corporation (NASDAQ: HLTH), a leading e-commerce provider for healthcare, today released findings from its Internet Survey of Medicine, revealing that 85 per cent of physicians surveyed are currently using the Internet. This is an increase in regular online activity by doctors of 42 per cent in the last three months, and a jump of 875 per cent from 1997.

Key findings from the ongoing research project, which chronicles nearly 10 000 physicians' computer needs and expectations over the last three years, were presented this morning at the Physicians on the Internet Conference in San Francisco. The conference, attended by more than 300 physicians and executives from the country's leading physician and healthcare delivery organizations, is examining the special needs and barriers as well as privacy issues surrounding the use of the Internet by healthcare professionals.

The survey data indicates that physicians, traditionally considered as slow adopters of new computer technology, have continued to embrace the Internet and online services. More than 63  per cent of the physicians surveyed use daily email and 33  per cent have used email to communicate with patients. Doctor-patient communications via email has jumped 200  per cent in the last year and nearly 20  per cent in the last three months; email for professional communications has increased by 33  per cent in the last year. Electronic communications between patients and their doctors did not even register as a significant behavior when physicians were surveyed in 1997.

More than 34  per cent of the respondents noted that security remains a primary concern in the use of email or other interactive Internet services. Other stumbling blocks for Internet adoption include: the lack of time, 49  per cent; lack of meaningful network content and services, 20  per cent; and, cost, 10  per cent.

Physicians and group practices with Websites represent approximately 30  per cent of the medical professionals surveyed; nearly a third of the specialty medical associations offer a Website for their members. An additional 16  per cent of doctors plan to post a Website for their practice within the year.

Case Study: The Present State of Electronic Medicine

Excerpt from Annals of Internal Medicine, 15 September 1998.

www.acponline.org/journals/annals/15sep98/eleccomm.htm

Kenneth D. Mandl, MD; Isaac S. Kohane, MD, PhD; and Allan M. Brandt, PhD

"Electronic Patient-Physician Communication: Problems and Promise"

Internet technologies have become useful tools for medical practice. Online, physicians can search the medical literature and find both synoptic and full-text medical journal content. Patients have access to medical information, self-help and support groups, and even medical experts. The World Wide Web can be used to link patient data across multiple institutions for retrieval by providers at the point of service or by researchers. The Internet also allows visual contact. For example, the National Library of Medicine's Telemedicine Initiative enables parents of premature infants to videoconference from home with the neonatal intensive care unit.

Although the Internet community has always resisted national and international efforts to regulate its structure or content, a motion is under way to impose an organizational structure and monitor the quality of the largely unchecked, unstructured, and unregulated volumes of medical information found on the Web. Journals, professional organizations, and the federal government have proposed monitoring medical information on the Internet and regulating telemedicine technologies. Early federal efforts along these lines include the Congressional Telecommunications Act of 1996 as well as the U.S. Food and Drug Administration's proposed oversight of telemedicine applications and clinical software.

Email can connect physicians with patients, thereby increasing access to care, enhancing patient education, augmenting screening programs, and improving adherence to treatment plans. Barriers to access often arise simply because physicians can be difficult to reach. Unlike telephone conversations, which require both parties to be available at the same time, email, like voice mail, is an asynchronous mode of communication, essentially creating continuous access to the health care system.

A widening gap is developing between the crucial need for transmitting more information and the relatively few and often brief face-to-face opportunities for communication between physicians and patients. The quality of these personal encounters is further diminished by the need for physicians to address administrative issues, such as referrals, insurance approvals, and rejected claims, during precious contact time. Inadequate communication, now more the rule than the exception, leads to increased stress, diminished satisfaction, decreased adherence to therapeutic regimens, and elevated risk for malpractice claims. Linking patients and physicians through email could increase the involvement of patients in the supervision and documentation of their own health care, processes that may activate patients and contribute to improved health. An example of electronic linkages activating patients is CHESS (Comprehensive Health Enhancement Support System), an interactive computer-based system used to support persons with AIDS and HIV infection.

Telephone and voice mail technologies have been effective in screening for mental disorders and substance abuse. For example, computer-generated telephone reminders can improve compliance with preschool immunization visits. Standard email or email with an interface allowing structured data entry may allow more effective triage and automation of messaging than voice and video mail do.

Case Study: Medical Applications Merge on the Web

Excerpt from an article by Deborah R. Dakins, Telehealth Magazine

www.telemedmag.com/topics/net3.htm

Market evolution is demanding that healthcare organizations collaborate and connect to maximize resources and survive in a cost-conscious, competitive environment. To accomplish this without compromising patient care requires that information be accessible across the entire enterprise.

The industry has had this target in its long-range sights for years, but the line of vision has been out of focus. A clearer view of the requirements needed to meet this goal is emerging, however. The Healthcare Information and Management Systems Society (HIMSS) meeting in San Diego in February demonstrated that caregivers and facilities are eagerly embracing connectivity engines such as the Internet, intranets, and World Wide Web-based technologies as a way to decentralize information.

The WWW is being used at Indiana University to enable the retrieval and display of information across an enterprise of about 30 sites. Despite the fact that individual facilities in the network operate on a number of platforms, and the data repository contains 110 million observations on about 1.3 million patients, the Web server, hypertext links, and browser allow seamless integration and speedy data retrieval, McDonald said.

For academic centers, the Internet can be a valuable tool for research, as evidenced by an application at the University of California at San Diego.

By including information about upcoming clinical trials on its Website, UCSD has increased participation in studies and dispersed information about rare medical conditions beyond regional barriers. Other applications include an online support network for hospitalized teen-agers, which helps them recover faster and feel less isolated, according to Dr. Daniel Masys, director of biomedical informatics at UCSD.

Patient education is the focus of an application at Children's Hospital of Alabama, where the WWW is used as a new forum for educating the public about vital pediatric health and safety matters. Because this information was previously communicated by physicians during care appointments, the Web page is helping the information reach a wider patient base.

In clinical practice, the WWW streamlines communications among physicians at the University of Kansas Medical Center in Kansas City, KS, and helps differentiate the hospital from its competition. Physicians use it to stay abreast of new medical information, unify the care process, and keep in touch with their patients and colleagues.

Case Study: Online doctors funded by referrals

Excerpt from the Ferguson Report. 1999 Tom Ferguson, MD.

"Free online doctors on AOL: service is funded by referrals" by Scott Rifkin, MD

America Online members can now talk to a doctor online, 24 hours a day, seven days a week - for free. This revolutionary new service is offered by America's Doctor, Inc., of Owings Mills, Maryland.

'We have a doctor waiting to talk to you, instead of the other way around' said Scott Rifkin, M.D., President and CEO. 'Sure, there's tons of medical information on the Internet. But many patients would still rather ask a doctor about their health concerns. Unfortunately, most doctors are not that easy to get hold of. They're too busy. As a result, most of us have to have a pretty serious health concern before we'll go through the hassle of scheduling an appointment and missing work to go to the doctor's office.'

AOL's 13 million member-families can now talk with a doctor anytime.

Here's how it works: Log onto AOL, click on the Health Channel, and select "America's Doctor." You will be offered the following choices:

If you click on "Ask-a-Doc", you will be asked to enter your zip code, state, and type of question. You will then be offered a choice of talking to a physician in a chat room or sending the doctor a question by email.

Visitors who choose to talk to a doctor enter a chat room where they may ask the doctor any number of health-related questions. The online docs provide medical information and explain medical conditions but can not diagnose ailments, prescribe medication, keep medical records, or provide continuity or follow-up care. The online doc then asks each visitor if he would like a referral to a local doctor who can provide additional care. If he says yes, the online doctor takes the consumer's name and phone number. A representative from a local sponsoring hospital then calls the customer within 24 hours. Those with medical emergencies are instructed to go to a local emergency room.

The service is funded by the hospitals who get the referrals. There is no cost to the patient. America's Doctor Online offers other services as well:

• If you click on "Hospitals", you will find a listing of sponsoring hospitals in your local area.
• If you click "Volunteer", you will be invited to volunteer for a medical research study through Premier Research Worldwide, a Philadelphia research firm. If you say yes, you'll be asked to provide a brief medical history and a listing of the types of drugs you are currently taking.
• If you click "free", you will be invited to sign up for a print newsletter, to list your special interests, and to make comments.
• Other choices include a list of Frequently Asked Questions, a Library of 1 200 articles, News and Events.

Case Study: E-patients training their doctors in online health

Excerpt from Vol. 1 no. 1, Jan/Feb 1999 Ferguson Report

"e-patients are training their docs in online health": 62 per cent of online MDs prescribe online health

Practicing medicine without the Internet may soon become as unthinkable as practicing without a telephone - or a stethoscope. And more and more physicians seem to be getting the message.

A September 1998 survey by Montreal's P/S/L Research found that more than 80  per cent of physicians now use the Internet or plan to use it soon. Other studies by the same group suggest that between 1996 and 1998, the number of online physicians increased by roughly 100  per cent per year. And after an initial period of ambivalence about consumers using the Internet, many of these online doctors are now actively encouraging their patients to take advantage of online health resources. Sixty-two  per cent of the Internet-connected physicians surveyed had told patients that they (the patients) could find medical information via the Internet. And nearly a third of the physicians surveyed reported that their patients had already come in to the doctor's office bringing printouts of health-related information they had found online. The researchers concluded 'these findings strongly suggest that ... as patients become ever-better informed, the demands placed upon physicians to stay abreast of medical news will grow.'

These findings suggest a dramatic change in physicians' attitudes toward their patients' use of online health resources since the previous year, when researcher Michael Brown conducted a somewhat similar study, The Health Med Retrievers: Profiles of Consumers Using Online Health and medical Information, for the New-York based research firm FIND/SVP ( http://www.findsvp.com/). At that time (the study was conducted in 1997), Brown found that only 49  per cent of physicians felt that online health and medical information could be beneficial to their patients. Brown concluded then that 'most physicians aren't nearly as enthusiastic about the Internet's benefits for their patients as they are for themselves.'

If, a year later, 62 per cent of online physicians are actively recommending online health resources to their patients, this may represent a dramatic shift in doctors' feelings about their patients using the Internet.

I asked Don Wilkie, the author of the P/S/L study, to explain this apparent about-face. 'One part of the puzzle is that online patients are now 'training' their doctors about the health resources on the Internet,' he said. 'They are going into their doctors' offices bringing information they've found online and expecting their doctors to help them make sense of it. Another part is that a growing number of docs are now seeing their peers recommend the Internet to the patients. A third factor is the fact that our whole culture is moving online at a rapid rate.'

'Doctors are beginning to understand that they are no longer their patients' sole providers of medical information,' Wilkie said. 'Helping their patients screen and filter the deluge of health information from the Internet is becoming a key part of their job description.'

Case Study: E-health on the verge of a breakthrough

Excerpt from www.brokat.com/int/ehealth/index.html

BROKAT Infosystems AG 1999

Even today, a great many company medical schemes and insurance companies spend colossal sums of money on transporting illness-related data by taxi from A to B. The greatly reduced workload in ordering and accounting for pharmacies and hospitals and also in customer care - in this case, patient care measures - will be only one benefit of the projects currently implemented by telematics working parties in the health sector.

The project 'Medico Internet' was initiated by the outpatients' clinic of the Charité in Berlin and might prove to be a pioneering concept. The outpatients' clinic of the Charité in Berlin, the IT Institute of Berlin's Humbold University and BROKAT joined forces and developed and tested a secure medical transaction concept for the Internet. Patient data, pharmacy data and other highly sensitive medical information can, as a result, be securely encrypted and transmitted via the Internet. The project was implemented using BROKAT's E-services platform 'Twister'. Consequently, the conclusion of Charité's final report was as follows: 'Medical Internet communication in an open, globally networked company can only be permitted with "high-level encryption" which is bug-proofed. In real-time operation, the media chosen are the BROKAT/Charité software entitled "Medical Protected Connection (MPC)" and "Medical Confidential Dialogue (MCD)". A firewall, conventional anti-virus software, and access management with password licensing are required'.

In view of the tremendous developments in the online area, the digital revolution in the area of health might well take place much earlier. The first pilot tests with health professional cards will start as early as 1999 and for some weeks now, 7 000 pharmacies which are connected to the VSA (German abbreviation for the payment center of South German pharmacies) have had online access to their saved prescription data via the Internet or via the German health network (German abbreviation DGN). This is particularly essential when a check has to be run on whether the correct medication has been prescribed or issued. Previously, it often took several days to access this kind of information. Now the search only takes a few seconds thanks to the VSA online service which provides a wide range of services for members and interested online users.

Case Study: Integrated Vision

Excerpt from an article, Integrated Vision by Kathy Kincade in Telehealth Magazine (Online Feature Story May 1999) www.telemedmag.com/current/feature.htm

Healthcare organizations have pursued systems-integration and data-repository strategies with the grand vision of creating a free flow of electronic information across the enterprise - improving patient care, reducing redundancies, and enhancing the bottom line. More often than not, however, the reality has fallen well short of the plan.

While interface engines and standards such as HL-7 and DICOM have eased some integration burdens, most legacy systems within a typical hospital information system (HIS) still do not communicate well with one another. And therein lies the rub at the hub of the integration issue - particularly when the goal is to make both clinical images and text-based data available in a single electronic patient record.

Over the next few years, advances in electronic patient record systems, Web-based programming tools, and industry-wide standards should have a profound impact on healthcare delivery.

Washington University has been working with BJC Health System and industry partners (including IBM, Kodak, and Southwestern Bell) to build a clinical data repository and high-speed telecom network linking BJC's 18 acute-care hospitals and 5500 physicians. The network will provide access to and permit management of patient data and images for more than one million patients in Missouri and Illinois. To date, clinical workstations have been deployed to more than 200 sites using local area networks and ISDN.

Web-based technologies are also being used at the University of Washington Academic Medical centers (UWMC) in Seattle. There, a clinical data repository that combines information from multiple departmental databases in a distributed relational data set is made available to more than 10 000 users at UWMC and its affiliates.

Most of the data stored in MIND (Medical Information Networked Database) - including demographic information, medication lists, immunization information, procedures, lab results, and radiology transcription - comes through various HL-7 sources. To facilitate enterprise-wide access to this information, UWMC researchers have developed an electronic medical record system (MINDscape), providing a platform-independent, Web-browser view of the MIND data repository. This can be easily linked to other information resources on the network, such as PubMed and the Federated Drug Reference.

MIND and MINDscape have been under development for six years. More recently, UWMC has been integrating multiple DICOM-image and PACS Web servers into MINDscape.

Because MINDscape uses a thin viewing client similar to Netscape Navigator or Internet Explorer, the images and associated reports can be distributed to clinicians anywhere within the medical center for viewing on PCs, Macintoshes, X-terminals, or UNIX computers. The MedWeb server can also be used in a teleradiology mode separate from MINDscape access.

Case Study: Promoting good e-health

Excerpt from www.oregonlive.com/technw/9811/tn98112304.html

The Oregonian, Monday, November 23 1998

By Elisa Williams of The Oregonian staff

By some counts, 43  per cent of adult Internet users go online for health-related services and information.

Initially, Intel is seeking ventures that make the Internet a more practical way to deliver information. Among those priorities is encryption technology - a way to ensure electronic records are secure - and information clearinghouses such as iVillage, a New York-based Internet publisher that focuses on women's health issues.

In the spring, Intel struck a partnership with CommuniHealth, based in Malvern, Pa., to start a project that equips diabetics to use PCs to track their blood sugar levels, diet and activity. Intel and CommuniHealth jointly financed development of the software necessary for the program, which was first used by patients of the West Jersey Health System.

For Intel, the payoff comes in the long haul. If people want to tap into the Internet to get health information and services, that makes a personal computer more useful. The more essential a personal computer becomes in everyday life - especially powerful, fully equipped computers - the more PCs people buy and the more chips Intel sells.

'We want to get people who have never owned a PC to want one to manage their health,' McGeady said.

Intel became interested in the subject at least partly because Chairman Andy Grove turned to the Internet for information when he discovered he had prostate cancer. In his now-celebrated case of patient research, Grove went online to study alternative treatments for prostate cancer and steered himself to physicians who would use a promising but not-yet-widespread method. Grove said earlier this year that his cancer is in remission and that he is in good health. McGeady introduced him in San Francisco as a "pioneer consumer of health information."

What Intel discovered is that patients are interested in using technology to make it more convenient to receive health care information and services. Doctors and health care providers have resisted because of a slew of concerns, ranging from an inability to manage the flow of email to liability generated by electronic distribution of health care records.

Although the concerns are difficult to overcome, the health care industry, long before Intel's initiative, had begun to experiment with technology-based information programs. Industry observers count 15 000 health care related sites on the World Wide Web.

The technology reaches beyond the Web, as well. For example, Multimedia Resources Inc. in Portland, which was recently acquired by High Technology Solutions Inc. of San Diego, has developed interactive kiosks on behalf of insurers who wanted more convenient ways to communicate with customers. MRI's kiosk business expanded to develop Websites. Its clients include Blue Cross and Blue Shield of Massachusetts, HealthNet, PacificCare and ODS Health Plans.

When McGeady started Intel's program, he assumed physicians would be its target. He assumed they would be receptive to technologies that would enable them to streamline communication with patients.

What he concluded instead was that real change won't be driven by doctors, insurers or hospitals but by consumers.

'I don't want to tar just doctors with this brush,' McGeady said, 'but very frankly, the health care community has not been at the forefront of change.'

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