Sessions 3-4, abstracts

Session 3:

Presenter: Melby, Line
PLANNING FOR THE FUTURE - ELECTRONIC INTERACTION SUPPORTING INTEGRATED CARE

Authors: Melby, L, Snøfugl, G
Norwegian Centre for Electronic Patient Record Research (NSEP), Trondheim, Norway

The background for this paper is NSEP's work for Nasjonal IKT (National ICT) on electronic interaction between the Regional Health Authorities (RHA) and the municipalities. Based on literature reviews and dialogue with actors in the health care sector, we have identified areas where interaction between RHA's and municipalities takes place, and looked at experiences with electronic interaction between the actors. On this background we outline areas/groups that we consider especially challenging in terms of needing health care services from a number of different actors; that is a need for integrated care. We furthermore suggest solutions to support the development of electronic interaction between RHA's and municipalities.

In this paper we focus on one particular group, elderly people. The number of elderly people is significantly increasing in the coming years and thus represents a major challenge for the organisation of health care services. Elderly people are regularly admitted, discharged and readmitted to hospitals and they often need municipal care services after discharge from the hospital. In this paper we therefore elaborate on how technological solutions may support the interaction between RHA's and the municipalities, focusing on elderly people.

Presenter: Voss, Henning
FROM POINT-TO-POINT PILOTS TO A PAN-EUROPEAN eHEALTH MARKETPLACE

Author: Voss, Henning
Danish Centre for Health Telematics, Odense, Denmark

Most of today's telemedicine services must be characterized as point-to-point pilots driven forward by fiery souls. Instead - for telemedicine to reach its full potential - telemedicine should beyond tomorrow be facilitated in a pan-European eHealth Marketplace where supply and demand of telemedicine services are matched in a number of interconnected highly controlled brokering systems. Resource sharing and problem solving should be facilitated in dynamic and multi-institutional virtual settings with equal participation by medical professionals and patients. The Internet-based secure Baltic Healthcare Network is the first necessary step towards an eHealth Marketplace, as it solves a major interoperability problem by connecting more than 200 hospitals from the Baltic Sea Region. However, many additional steps are needed to reach the goal of a pan-European eHealth Marketplace. Virtual brokering systems are already commercially available, but they need to be interconnected and also integrated with EHR, PACS etc. Standards and terminology for this integration are largely defined but there is a lack international consensus on how to use these. Another major issue that needs attention at international level is accreditation of medical professionals and services - this is crucial when the demand side has no personal experience with the supply side.

Presenter: Shannon, Gary
TELEMEDICINE: THE VISIONARY PERIOD

Authors: Shannon, G1, Bashshur, R2
1 - University of Kentucky, Lexington, USA
2 - University of Michigan, Ann Arbor, USA

Many dream of being able to predict the future and it is tempting to present visionary 21st Century scenarios of telemedicine. In this paper, however, we look backward to the visionary futures of telemedicine or "medicine at a distance" held in the early part of the 20th Century. Importantly, we (a) examine these predictions within the context of the changes taking place in society, medicine and technology during this period; and, (b) we attempt to demonstrate the connection between the visionary concepts of these early futurists, both scientific and non-scientific, and the contemporary stages of development in these sectors. In so doing, we propose that such an investigation may provide a framework for and contribute to a more informed imagining of the future of telemedicine today. Changes in the spatial interactive dimensions of society and medicine as influenced by the radio, telephone, and experiments in "radio transmission of pictures," are considered for their contribution to the visions and actual development devices such as the radio doctor, the portable electrocardiograph and X-ray machines, among others.

Presenter: Juntunen, Kaisu and Leinonen, Eeva
ARE WE SENSITIVE ENOUGH FOR THE WEAK SIGNALS OF PHENOMENA IN ICT DICIPLINE?

Authors: Juntunen, Kaisu and Leinonen, Eeva
University of Oulu, Oulu, Finland

The aim of this paper is to describe the Kainuu Experiment and what does it mean in the well-being point of view. In this paper we review in an analytical way those different influences of the Kainuu Experiment and ICT by using SWOT-analysis. That Kainuu experiment is unique in Finland and it gives remarkable possibilities to research wellcare technologies in Kainuu area. We have conducted a literature survey on different wellbeing phenomena and we have also participated in various seminars dealing with healthcare and wellbeing. The key questions in our study are followed. How can we support those ageing - senior people in enabling them to live well and independently in their own homes as long as they are willing to? What role would ICT play in providing these services for the ageing people in the future? By listening the weak signals, with the help of the swot-analysis and the car-case example we want to make some visions and images of the future possibilities in Kainuu region.

Presenter: Fensli, Rune
EFFICIENT TELE-HOME-CARE SOLUTIONS CAN BE IMPLEMENTED AS SERVICES WITHIN THE NATIONAL HEALTH NETWORK, BUT WILL REQUIRE NEW FINANCIAL MODELS TO BE IMPLEMENTED

Authors: Fensli R.(1), Gunnarson E.(2), Gundersen T.(3)
1 - Agder University College, Faculty of Technology and Science, Grimstad, Norway
2 - Ullevaal University Hospital, Department of Anaesthesia, Oslo, Norway
3 - Sørlandet Sykehus HF, Medical department, Arendal, Norway

Measurements of vital sign parameters performed from patients out-of-hospitals for early diagnostic purposes or follow up a planned treatment shows a clear upcoming trend, and new technological solutions will lead to changes in medical services (1, 2). This will have a positive impact in outcome for patients with chronic heart disease with a continuous follow up (3). However, there are administrative challenges in adoption of new technological solutions for tele-home-care (THC). The important question is: Who is responsible for the patient, and who will get paid for performing the necessary clinical services. The value-added services will move the specialized diagnostic services into tele-medical solutions, and the cost in patient administration will partly be moved towards a lower health care level. But this trend will require corresponding changes in the payment structure in Norway which in the future should be incorporated into a broader DRG-code systems and fees from the National Insurance Administration.

Description of work to be presented
Several interesting projects have focused on mobile solutions for vital signs monitoring in developing next generation e-Health systems. It is a clear trend of individualization in treatment and medication, with a need of close follow-up after hospital treatment. This will require continuous monitoring of patients with a need of mobility, and where the actual information is available for involved health care givers regardless of administrative belongings. An actual example is patients with a chronic cardiac disease, where investigation of ECG-recordings normally is done by a hospitals cardiology specialist. However, the patient does not need to appear at the hospital by himself, as the new THC solutions can perform continuous ECG-monitoring with automatic arrhythmia detection systems and transmission of the signals to the hospital as a tele-medical service. The patient can be followed up by his regular General Practitioner (GP) and from the local community home-nurse service. They all need to share a common "core" electronic health record, where the advices and actions from the cardiology specialist need to be performed by the local care givers responsible for the patient.

One reason for developing new solutions is the aging in population and the need of new value-added services, with both in- and out- of hospital diagnostic capabilities and patient follow up. This requires changes in the treatment chain where the specialists at the hospital with their competence and use of tele-medical diagnosis give support to the GP responsible for the patient. The value-added services give the opportunity to move the information in stead of the patient, and speed up time used for diagnostics, treatment and rehabilitation.

Such solutions opens up for a new paradigm in patient treatment, with a need of improved logistical changes in the health-care service, but obstacles from traditional methods and existing payment structure need to be overcome if this service is to be a future routine. Clinical trials should be performed in order to verify the possibilities for new tele-medical interactions between different health-care levels, where the important aspect is to obtain reliable and secure out-of-hospital-treatment, and to perform cost-benefit analysis of such services.

References
1. Rubel P, Fayn J, Nollo G, Assanelli D, Li B, Restier L, et al. Towards personal eHealth in cardiology. Results from the EPI-MEDICS telemedicine project. Journal of Electrocardiology 2005;38:100-106.
2. Fensli R, Gunnarson E, Gundersen T. A Wearable ECG-recording System for Continuous Arrhythmia Monitoring in a Wireless Tele-Home-Care Situation. In: The 18th IEEE International Symposium on Computer-Based Medical Systems; 2005 June 23-24, 2005; Dublin, Ireland; 2005. p. 407-12.
3. Salvador CH, Carrasco MP, González de Mingo MA, Carrero AM, Montes JM, Martín LS, et al. Airmed-Cardio: A GSM and Internet Service-Based System for Out-of-Hospital Follow-Up of Cardiac Patients. IEEE Trans. on Inf. Technol. Biomed. 2005;9, no 1(March):73-85.

Relevance to the conference topics
This work addresses healthcare politics and strategies for the future in focusing on new services requiring new payment solutions for the services given but focuses also impact in innovations within telemedicine and e-health.

Presenter: Gammon, Deede
E-AVERTING IN-PERSON MEDICAL ENCOUNTERS FOR HEALTH'S SAKE

Authors: Gammon, D
Norwegian centre for telemedicine, Tromsø, Norway

Under headings such as telemedicine and eHealth, doctors and patients are using computer-mediated communication (CMC) to interact. The good doctor-patient relationship is associated with better health outcomes, compliance, satisfaction, and fewer malpractice claims. How will this relationship fare when it is mediated through technology, even if only as a supplement to face-to-face (f2f) consultations? Some are deeply sceptical, arguing that e-mediation will interfere with compassion and trust, that it is a threat to the moral integrity of the physician-patient relationship. Others (including the current author) suggest the contrary, that CMC can enhance the doctor-patient relationship by facilitating the voice of the patient. However, most CMC research on interpersonal relationships is generated outside the domain of healthcare. Thus, despite relatively strong assumptions about the role of technology in the patient-physician relationship, they remain largely unstudied.

As this new field evolves, it is important to explore varying perspectives. In this presentation, CMC's potential for rationalising administrative interactions (e.g. booking, prescription renewals) is ignored. Rather, the idea that averting in-person medical encounters might be healthy for the patient-physician relationship is explored. First, a grim diagnosis of today's f2f-based patient-physician relationship is offered and discussed in light of the premises for the f2f-paradigm in healthcare. Approaches designed to remedy problems in doctor-patient communication typically go under headings such as patient-centeredness and shared decision making. We argue that features of CMC (e.g. visual anonymity, narrative processes, self-disclosure) may enhance these approaches.

Obviously in some circumstances, f2f will remain the only feasible and/or ethically acceptable mode of communication. However, future doctors will be armed with an arsenal of tools for helping patients help themselves outside the doctor's office. "Prescriptions" will include links with passwords to evidence-based psycho-educational and self-help programs, cognitive therapies, interactive narrative support and lifestyle monitoring/feedback. These types of tools can be used as an acknowledgement of - and in alliance with - the patients' own resources. Hopefully we will gain the knowledge necessary in discerning under which circumstances it is superior, and under which circumstances other modes are more conducive in building good working relationships. A good place to start may be patient-physician dyads struggling with medically unexplained disorders, chronic conditions and risk-related lifestyles.

Session 4:

Presenter: Mucic, Davor
TELEPSYCHIATRY PROJECT IN DENMARK

Author: Mucic D
Behandlingscenter Den Lille Prins, Kastrup, Denmark

A telepsychiatry service , using broadband (sHDSL) , is under establishing in several communes/hospitals in order to provide psychiatric assessments or/and treatment of , primarily, reffugees and immigrants in Denmark but also Danish patients. Reffugees/immigrants are the group with very specific needs wich are results of traumatic experiences and lack of language abillities . Limited acess to a clinicans that speak their language and understand their background make assesment and treatment sub optimal. Clinicans involved in Telepsychiatry project had ethnic background that made it possible to treat patients on their own language, without using translators. In the first year of this 3-years project all participants reported a high level of acceptance and satisfaction with telepsychiatry regardless their ethnicity or educational level. Economic benefits of the method were presented by reduced transport - and translator expencies. Danish patients reported high level of satisfaction primarily because of possibility to get in contact with clinicians without waiting too long or traveling.

Presenter: Søgaard, Nielsen, Anette
TELE-THERAPY: ALCOHOL REHABILITATION BASED ON VIDEO CONFERENCE BETWEEN PATIENT AND THERAPIST

Authors: Nielsen A. S., Pedersen C. D. and Wanscher, C. E.
Alcohol Rehabilitation Centre, Odense, Denmark
MedCom, Odense, Denmark
Danish Centre for Health Telematics, Odense, Denmark

When seeking treatment for alcohol abuse, it is often viewed as stigmatising and if there is a great distance to the alcohol rehabilitation centre, the alcohol dependent may postpone seeking treatment. The Alcohol Rehabilitation Centre at the County of Funen offers therapy to alcohol dependents living in the County, including tele-therapy to the inhabitants on a series of small islands located in the South of Denmark. In order to make it both easy and discrete for alcohol dependents to seek therapy, video conferencing facilities have been established between different units in the County of Funen. Via this equipment and a safe Internet connection over the Danish Health Data Network alcohol dependents on the two small islands of Aeroe and Langeland can receive professional therapy in local, non-stigmatising surroundings and they do not have a time-consuming transportation to the Alcohol Rehabilitation Centre far away.

Since October 2005, twenty alcohol dependents have received tele-therapy. The project is still in its pilot phase, but the promising experiences have already lead to planning another project that offers hospitalised alcohol dependents professional tele-therapy while still hospitalised. In the future the service can be extended to other locations, e.g. the GP or even the patient's own home.

Presenter: Trondsen, Marianne and Sandaunet, Anne-Grete
DOING ACTION-RESEARCH ON ONLINE SELF-HELP GROUPS - ADVANTAGES AND LIMITATIONS

Authors: Trondsen M, Sandaunet A-G
Centre for Telemedicine, Tromsø, Norway

This paper offers some reflections on advantages and limitations of use of action-research (AR) in studies of online self-help groups. AR represents a practice-oriented form of evaluation in which the researcher participates actively in ongoing changing processes. AR has lately gained more attention as a tool to evaluate new forms of health care delivery. The paper draws on experiences from two action-oriented studies which aimed to explore potential health-effects of online self-help groups. The first study included establishment and management of a group for breast cancer patients, while the second addressed adolescents with mentally ill parents. Study participants were recruited through self-selection. Within the framework of AR, the authors of this paper administered and moderated one group each. Our possibilities to continuously evaluate and readjust our roles as moderators generated further insight about how online self-help groups should be facilitated. However, many of the participants in the study were in a vulnerable situation which required a continuous consideration of how we carried out our roles as moderators. We conclude that use of action-research in studies of online self-help groups extend the access to information, but require considerable awareness towards ethical aspects of this involvement.

Presenter: Sandaunet, Anne-Grete
NON-USE AND WITHDRAWAL FROM ONLINE SELF-HELP GROUPS

Author: Sandaunet, A-G
Norwegian Centre for Telemedicine, Tromsoe, Norway

Online self-help groups multiply peoples' possibilities to receive and provide information. They are thereby assumed respond to the needs of the "new" health care user, which is a key issue in contemporary health politics. Several studies of online self-help groups still report high drop-out rates, and the knowledge about why this happens is scarce. This paper examines non-use and withdrawal from an online self-help group for Norwegian breast cancer patients. It draws on an action-oriented study which aimed to explore the potential of online self help groups in the rehabilitation of breast cancer. Forty women diagnosed in different stages of breast cancer were recruited through self-selection. Twenty-nine women withdraw or chose to not use the group. Data were gathered through participant observation and qualitative interviews. Four recurring themes were identified in reflections on non-use and withdrawal: the need to avoid heavy details about breast cancer, the challenge of establishing a legitimate position in the group, the need to distance the illness-identity and the organisation of everyday life. I argue that this material reveals important thresholds related to participation in online self-help groups. I further suggest that the adoption of the new patient role should be closer considered.

Presenters: Lintvedt, Ove, Sørensen, Kristian & Østvik, Andreas
THE NORWEGIAN VERSION OF MOODGYM: VALIDATING THE EFFECT OF AN INTERNET BASED INTERVENTION PROGRAM PREVENTING DEPRESSION

Authors: University of Tromsø, Norway
Lintvedt, O, Sørensen, K, Østvik, A, Waterloo, K & Wang, C

Following an assessment of students' need for a planned Internet based intervention program preventing depression (MoodGYM; Christensen, Griffiths, & Jorm, 2004) from the autumn of 2005 (Lintvedt, Sørensen, Østvik, Verplanken & Wang, 2005), a validation study is being performed from January to April 2006. During the recruitment phase, approximately 10.000 students (every student at the University / University college of Tromsø) have received an offer to participate in the validation study. According to the project plan 200 students, willing to participate, will be divided into three conditions: two experimental and one control condition. Selection will be based on depression score on the Kessler psychological distress scale (K10) and participants will be randomly assigned to the conditions. The first experimental condition will receive a Norwegian version of MoodGYM, the second experimental condition will receive a Norwegian version of MoodGYM with the additional offer of making direct contact with the project and receiving face to face counselling. The control condition will receive no intervention. Participants in all conditions will complete pre and post intervention questionnaires. Preliminary results from the validation study will be available by early June 2006 and presented at TTeC 2006.

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