Telemedicine for everyone is just around the corner…
Telemedicine initiatives are popping up all over France. Each one attracts significant media attention. In recent days, there has been coverage of the Santé Landes platform in Mont-de-Marsan andthe equipment installed at a nursing home in Chartres.
Roxana Ologeanu-Taddei, University of Montpellier and David Morquin, University of Montpellier
The prime minister, however, highlighted the benefits of telemedicine during the presentation of his plan to combat medical deserts, on October 13. As early as September, the Court of Auditors had pointed out in its report on the subject the many expected benefits of this new approach to medicine via screens: the modernization of the healthcare system, cost savings through the implementation of remote patient monitoring, and improved patient care people living in remote areas or in detention. The Court noted, however, that the experiments conducted in recent years were a diverse set of initiatives that yielded “modest results.”
What is behind these disappointing results, and more importantly, how can they be improved? We believe that a key factor lies in an overly idealistic view of telemedicine. The use of telemedicine is often treated as a “magic bullet,” ignoring the problems that inevitably arise when implementing changes that are both technical and organizational.
The simplistic view that the practice remains unchanged but is conducted remotely
The definition of telemedicine set forth inArticle L6361-1 of the Public Health Code, which is cited in many scientific articles, speaks for itself. It refers to “a form of remote medical practice utilizing information and communication technologies.” These terms perpetuate the simplistic view of an unchanged clinical practice that simply takes place “remotely.” They underestimate the transformation of the practice itself through its digitization. This obstacle inevitably arises when a successful pilot program must be transformed into a sustainable system. We must then tackle pragmatic aspects that are less glamorous and more tedious.
The new telemedicine software adopted by a facility, for example, must fit into the existing technological ecosystem. We may dream of “dematerialized” medicine, but in reality, this poses very tangible problems: the necessary storage capacity, compatibility with already installed programs (operating system, browser versions, and other office applications), the bandwidth required for data transfer, data transmission security, backup procedures, and data hosting.
When announcing the plan to address medical deserts, the Prime Minister also highlighted the importance of internet connectivity, stating that the problem would be resolved by future nationwide coverage.
12 different software programs for stroke care
Choosing the right software is another practical consideration that arises when deciding to enter the telemedicine field. The Observatory for the Listing of Software Publishers and Integrators in the Healthcare Market (RELIMS) reports a wide variety of options in the healthcare sector, with 301 registered companies and 840 software solutions available on the French market. No fewer than 135 publishers, for example, offer software for home hospitalization! And if we look at a very specific segment such as telemedicine devices for stroke care, there are currently 12 different software programs…This proliferation raises questions about their long-term viability and the consequences for customers in the event of a publisher’s bankruptcy—how to recover data, for example.
What could be the objective selection criteria? One could be certification according to one of the international quality standards (ISO), as in other economic sectors. There are even specific ISO standards for healthcare software. But software publishers are not very interested in them, or not yet—and this is true worldwide. The British telemedicine platform SOS thus boasts of having been, in 2015, the first company in the world certified under the ISO standard for service quality in telemedicine.
In France, the Haute Autorité de Santé (HAS) has not established any specific certification. No regulatory requirements exist, with the exception of software intended to be certified as medical devices, which qualifies for reimbursement by the national health insurance system. Currently, only one diabetes-specific app, Diabeo, has obtained this certification. The HAS recently published a set of best practices for software and apps in “mobile health, ” but these are not mandatory. Upon reading this guide, customers and potential users learn that assessing reliability, security, and service quality is essential for such software. However, publishers’ documentation provides little assurance regarding these criteria.
Usability and ease of use are among the requirements that should apply to all software, as the HAS guide also notes. The goal is to avoid the risk of errors associated with misuse, or simply the time wasted due to a large number of clicks. As early as 2012, an international study showed that 17% of incidents related to patient care safety were attributable to usability issues with the software used. Numerous articles highlight the “silent errors” caused by re-entering information, poor usability, or healthcare providers circumventing software that is ill-suited to their workflows.
Software that is incompatible with each other
One final, very practical issue that hinders the growth of telemedicine stems from incompatibilities between software systems that are unable to automatically exchange data with one another. This lack of technical and semantic interoperability (meaning of the information) between software programs poses a growing problem as they proliferate for different purposes and on different platforms, ranging from electronic health records to software linked to medical devices. These software programs pile up in layers, leading to an excessive workload for healthcare professionals.
In Quebec, the lack of interoperability between the various software systems supporting electronic patient records has caused major problems. The Minister of Health therefore decided two years ago that all hospitals in the province must migrate to a single software system. In France, such a nationwide decision is not possible due to the 1989 circular on the computerization of public hospitals, which allows institutions to choose their own IT provider.
Today, there are two solutions to facilitate data exchange between software systems. Either impose a standard on all software vendors, which the HAS could decide to do. Or impose a single software system across the entire country, which seems difficult due to the circular mentioned above.
What liability do software publishers face if a patient experiences a problem?
Another question arises with the expected widespread adoption of telemedicine. If a patient experiences a problem due to a software glitch, who is liable: healthcare professionals or the software developers? To what extent can developers be held liable if their software crashes or does not function as intended? It is worth recalling that in 2011, the The death of a patient was attributed to a software error. The publishers’ representative, a delegate from the Association of Health and Social Information Systems Companies (LESIS), had raised concerns about training and best practices in the use of this software. However, following this incident, starting in 2014, the HAS began certifying the prescription support software.
When it comes to implementing telemedicine, once again, a A best practices guide is availableFar from painting an idyllic picture, he offers a glimpse into the obstacle course that such a project entails. He thus emphasizes the importance of accounting for human resources for maintenance and technical support, as well as for coordination among professionals. For the biggest mistake is to imagine that technology, through the automation of data processing, could single-handedly meet all these needs.
In his plan to combat medical deserts, the prime minister cited the example of remote diagnosis of moles, or teledermatology. To make this possible, reliable software must be developed, “databases” must be set up to store photos of patients’ moles, a technical-medical protocol based on clinical studies must be defined—for example, establishing the minimum resolution required for the photo to be usable—and professionals capable of making the diagnosis must be coordinated.
So the wonders of telemedicine won’t just magically happen before our eyes. They require technical and organizational changes. And in those areas, everything still needs to be built from the ground up.
Roxana Ologeanu-Taddei, Associate Professor with the authority to supervise research in Management Sciences at Polytech Montpellier, University of Montpellier and David Morquin, Hospital physician at Montpellier University Hospital, doctoral candidate, University of Montpellier
The original version This article was published on The Conversation.