Dossier Technologique 10 – Electronic Health: concepts and achievements in 2017

Electronics was introduced in the medical field in 1915 with radioscopy (Marie Curie) and the electrocardiogram was transmitted by telephone in 1920. Today, remote medical applications (telemedicine) are developing thanks to the performance of technologies Information and communication (ICT), while the Internet Web disseminates Health information to Internet users (cyber-medicine). The evolution of this triple area is diversified.

I – Medicine and ICT

Medicine associated with ICT uses different names (E-Health, e-Health, m-Health, telehealth, telemedecine, etc.). Three categories of use can be distinguished: e-health, telemedicine and cyber-medicine. The association of ICTs and the Internet (fixed and mobile networks) makes it possible to envisage a wider dissemination of health uses for the benefit of the greatest number in all countries.

1.1 – Panorama of today’s medicines

Worldwide, available therapies generally come in three categories: conventional medicines, CAMs (alternative and complementary medicines, sometimes called alternative medicines) and pseudo-sciences (those of healers and charlatans). Each country carries out its own national selection and classification of therapies, so that what is admitted or tolerated in some countries is totally proscribed in others. Due to genetic inheritance, dietary habits, climatic variations and cultural traditions, the development of a single computer system for health management may seem somewhat utopian. On the other hand, while conventional medicine uses drugs based on chemical molecules, CAMs resort to what are sometimes called “alternative medicines”.

The traditional pharmaceutical industry is therefore faced with the rise in the latter (especially in favor of Asia and the Far East), while on the other hand recent research proposes electronic medical aids, while encouraging the participation of patients in the maintenance of their own health.

1.2 – Medical Research Framework

Today, research is focused on two axes:

– Helping current medicine to cope with the management of pathologies and aging populations, while reducing medical errors and the price level of treatments;

– Improving the development of new treatments by expanding knowledge through scientific research and population studies.

The current trend is guided by the reduction of state spendings on health management. To this end, computerization of the health system is essential. Limits should be set compatible with defined objectives. Medical standards can improve health care in three areas: simplifying administrative tasks, strengthening management infrastructures and monitoring the health status of populations, training and improving the quality of care through participatory collaboration.

II – Standards related to medical activities

2.1 – Problems of medical standards

Investment in public health is high for low economic interest. Health spending often represents a significant share of GDP that is difficult to reduce. If 5% of the GDP devoted to the public health budget allows a healthy life expectancy of 42 years, it would be necessary to reach the 30% of the GDP to obtain an average life expectancy of 81 years. From one country to another, health status, epidemiology, the essential criteria of social policy and the level of available resources are very different. Emergencies are often linked to local or professional conditions. In the field of medicine, the effort of standardization and management is linked to the political will of the State.

The management of data processing and secure data processing adds to the complexity of the art of medicine and the formulation of diagnostics. In general, the overall expenditure of the health system is reduced by management (on average 10% of frauds and 30% of administrative losses or errors), improved quality of care and better choice of care decision-makers towards urgent social measures.

The objective, expressed by the American project HIE (health information exchange) and in the French project of the DMP (Dossier Médical du Patient), is a triple challenge on the regulatory, organizational and economic levels. The DMP (or EHR), introduced in France by the Law of 2004, concerns the whole population and mobilizes all the actors of health, even in situation of mobility. It responds to the legitimate desire of the patient to have information about him.

2.2 – The current standardization effort in telemedicine

The study of telemedicine standards requires a structured and homogeneous approach and the updating of the list of relevant standards. The CEN, ISO, IEEE, etc. have been invited, together with SDOs (Standard Development Organization), to join the eHealth Standardization Coordination Group (eHSCG). The European Commission funds some 100 R & D projects related to medical activities (Horizon 2020).

The study project “Telemedicine of all countries of the world”, led by IEC (TC25), ISO (TC12) and ITU-T (CE17), is concerned in health management with the help of an expert system and telebiometric correlations involving cares offered by the various well-known medical approaches (Allopathy, homeopathy, phytotherapy, acupuncture, CAM, etc.). This vast study reflects the concern to associate the use of western medicine medicines with phytotherapy and the practices of alternative oriental medicines, including acupuncture.

2.3 – Main players in telemedecine standardization

Within their own field of competence, the three global standards entities, IEC, ISO and ITU-T, are involved in the standardization of telemedicine with the assistance of WHO experts. WHO has no responsibility for standardization. It monitors the level of health in each country and evaluates the level of epidemics (Sentinel networks).

Entity

Group

Standard Thema

Examples

ISO

TC 215 Health Informatics Five Working groups

CIM-10 and CIM-11 Standardization

« Médecine de tous les pays du monde » (ISO)

UIT

CE 16 et 17 UIT-D Telemédecine

Question 28

Multimédia applications  – Electronic transactions  cyphering  (Rec. X.1080 et X.1081 – H.810 à H.860 Interoperability)

ICE

CEI 80001 Electrical Aspects Interop Commitee

CEN

TC 251 Health Informatics Health on-line

Cenelec

TC62 Medical devices

ETSI

EG-eHealth Frequences and

terminals

Insulin pumps, neurological, muscular, cardiac pacemakers, blood pressure measuring devices, etc.

SDOs

60 entities All aspects Medical and  Surgical fields

The ICD-10 (International Codification of Diseases) standard consists of 14,400 codes divided into 27 chapters. The new update, ICD-11, should appear in 2018. The French Carte Vitale uses the ICD-10 databases. Note the success of the computerized sorting with RFID tags of medical emergencies.

Among the best known of the 60 medical SDOs are:

ASTM (American Society for Testing and Materials) – This commercial laboratory network develops technical standards on systems products and services. It brings together 30,000 members from 100 countries and is active in 130 areas of activity. Its Committee E31 deals with “Healthcare Informatics”.

DICOM was created by the American College of Radiology (ACR) and the National Electrical Manufacturers Association (NEMA) to define standards for the transmission of medical images and associated information. DICOM standards are de facto standards used by a large number of medical equipment manufacturers and image professionals: dentistry, endoscopy, mammography, ophthalmology, orthopedics, pathology, pediatrics, surgery, veterinary surgery, etc. Mainly for the purposes of radiology and cardiology.

HL7 (Health Level 7) – This committee, accredited by ANSI for all of North America, has developed a comprehensive messaging standard between Health Professionals. HL7 is a management standard in telemedicine for the transfer of files. Messages are encoded in ASCII, with redundancy. Version 3 of the standard encompasses application messages in the RIM form “Reference Information Model” and uses XML encoding.

IHE (Integrating the Healthcare Enterprise) – This group works to homogenize the profiles and interfaces of medical equipment – especially for RFID tags used by the US Army. In 1996, RSNA (Radiological Society of North America) and the Healthcare Information and Management Systems Society (HIMSS) integrated healthcare (Integrating the Healthcare Enterprise) to streamline tools and equipment offered by industry, to simplify the tasks of the nursing staff and to improve the quality of the services provided. The need for standards throughout the range of activities in this area is obvious.

IHTSDO (International Health Terminology SDO) – Terminology bank dedicated to the medical field.

III – The four electronic medicines (e-Health)

Electronic health, or medicine through web-based applications and most often associated with the mobile phone terminal, involves voluntary commitment by the patient to access information and to act accordingly. Among specialized companies take care of these volunteers, we note Intel’s digital health group and social networks, and iTunes, with its 65,000 health applications available on the iTunes Store (of which 12,000 applications related to diabetes care). With ICT, the relationship between physician and patient is strengthened. Virtual consultation, personalized and more frequent, saves time. Another challenge is the progressive aging of the world’s population. Specialized agencies assess the quality of these tools and services (AHRQ, agency healthcare research and quality).

3.1 – For sport and well-being

These medium precision materials are designed for 2-3 years of life for e-Care activities, with the support of ISO / ICE / ITU / ETSI standards and possible accreditation of devices by the FDA. The massive dissemination of these devices has brought very useful information to sportsmen and doctors. Temporal temperature measurement is part of these achievements.

3.2 – For the Hospital

These are improved versions of previous articles and more specialized equipment with a life span of ten years. Among these embodiments, numerous implantable implementations of diagnostic aids (glucometer, sensors, stroke detector, defibrillator, pacemaker, etc.) are to be cited.

3.3 – Assistance to dependent persons

These achievements are more specialized. They are designed for longer-term uses for people with disabilities (surveillance, company robot or pre-defined tasks, exercises on alertness, limb prostheses) or for virtual reality exercises.

3.4 – Special aid

These developments are of interest to patients on a case-by-case basis, for example for surgical procedures with a “virtual haptic” interface in 3D virtual reality, computer-guided, for the governance of an 8-finger humanoid robot, for the development of exoskeleton, artificial heart, & c. On another level, research is organized to produce 3D impressions of living cells (pancreas, liver, hair roots).

3.5 – Ongoing Research and Development

1 – to define better means of treatment;
2 – integrate therapies combining drugs and behavior (coaching with ICT and sensors).

IV – Telemedicine

According to French article L.6316-1 of the Public Health Code [October 2010], “Telemedicine is a medical practice that brings together, through new technologies, the patient and one or more Health professionals, (including at least one medical professional). It makes it possible to establish a diagnosis, to provide medical follow-up, to request specialized advice, teleconsultation (videoconferencing or messaging), tele-expertise, prescribe acts, perform a remote monitoring of the patient’s condition , or medical assistance, etc. “.

For example, the SAMU of Paris is in liaison with the French airplanes, TGV and Consulates, to provide medical assistance from a distance if necessary. “Medical support” covers several disciplines, including telemonitoring of kidney dialysis, telecardiology, monitoring of fetal well-being, etc. For the WHO and ITU-T, Telemedicine is divided into five families of uses:

A – Regional health alerts (eg pandemics);
B – Medical emergencies at a distance (absence of doctor on site: islands, places of fighting, ambulance patients’ journey, workplace relief, etc.)
C – Hospitalization at home (HAD) for “seniors” and persons with disabilities, Cardiac and renal remote monitoring,;
D – “Cybersanté”, free information portals of the “Medical Wikipedia” type in the context of self-medication or simple information, etc. Teleconsultation, tele-expertise, teletraining, tele-assistance and telecommunication;
E – Structured national projects using ICT and the Cloud in the practice of medical care based on the holding of a Personal Medical Record (DMP) and a Pharmaceutical File (DP) in France and by the Electronic Health Record (EHR ) Or EPR (electronic patient record) in the United States.

V – Cyber-medicine

5.1 Medical Information

5.2 Social health networks

5.3 Uberization

VI – First experiences

6.1 Developing countries

Less than 54 per cent of the population in developing countries have access to health services. There are about one doctor per 6,670 inhabitants in the world (against one doctor per 390 inhabitants in industrialized countries – and one doctor per 310 inhabitants in France). In developing countries, the maternal mortality rate is twenty times higher and the overall mortality rate is 4 to 5 times higher than in the OECD countries. Several priority telemedicine projects have been launched, some of which are of modest size, but their results show undeniable benefits.

6.2 Other experiments

The UK stopped its DMP / EHR project in 2011 due to financial problems. Australia, Saudi Arabia, Australia, Canada, the UAE, Estonia, Denmark, New Zealand, Singapore and the Netherlands are working on the generalization of DMP.

6.3 United States

ICTs in the health sector represent a strong growth opportunity for the Food and Drug Administration (FDA). The Health Information Technology for Economic and Clinical Health (HITECH) Act introduced the Electronic Health Record (EHR) or Electronic DMP project. Health expenditure is twice as high in the United States as it is in France, because the price level is high because there is no regulation of medical procedures. Health spending accounts for 27% of the annual budget of the United States. Alongside the two government health insurance services: one for veterans, the elderly, the disabled (Medicare) and the other for the poorest citizens (Medicaid), the 2009 HITECH law imposed on citizens The need to join a private health insurance system of their choice. The move to DMP has become mandatory. The political controversy persists.

6.4 France

6.5 – Outside France

Standards are placed in the face of cultural traditions.

VII – Conclusions

The use of ICT in medical practices aims to:

The priority of investments remains to be defined (Fiber, informatics or medical tools) as well as the place to be given to the Internet (teleconsultations, Internet care, electronic prescriptions, car and teletherapy via the Internet, confidentiality). The rapid development of medical technologies and ICTs makes it difficult to rapidly build a comprehensive system at the national level. The approach can only be achieved gradually and pragmatically.

References

• Basil Strategies http://www.basilstrategies.com/
• WHO  – International Classification of Functioning and Disability www.who.int/icidh/]
• Wikipedia – https://en.wikipedia.org/wiki/Sant%C3%A9
• EHTEL Association (European Health Telematics Association) [www.ehtel.org]

Techniques de l’Ingénieur, Daniel BATTU, 2015

Online on January the 16th, 2017

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