Telemedicine for everyone is just around the corner...
Telemedicine initiatives are multiplying throughout France. Each time, they receive widespread media coverage. In recent days, we have celebrated the Santé Landes platform set up in Mont-de-Marsan andthe equipment acquired by a nursing home in Chartres.
Roxana Ologeanu-Taddei, University of Montpellier and David Morquin, University of Montpellier
However, the Prime Minister highlighted the benefits of telemedicine during the presentation of his plan to combat medical deserts, on October 13. Back in September, the Court of Auditors had already pointed out in its report on the subject the many expected benefits of this new practice of medicine via screens: modernization of the healthcare system, savings through the implementation of remote patient monitoring, improved care people living in remote areas or in detention. However, the Court emphasized that the experiments conducted in recent years were heterogeneous initiatives, yielding "modest results."
Where do these disappointing results come from, and above all, how can they be improved? We believe that a key factor is an overly idyllic view of telemedicine. The use of this practice is invoked as a form of "magical thinking," denying the problems that arise with any technical and organizational change.
The simplistic view of unchanged practice but at a distance
The definition of telemedicine used inArticle L6361-1 of the Public Health Code, which is found in many scientific articles, is eloquent. It refers to "a form of remote medical practice using 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 computerization. This obstacle inevitably arises when a successful experiment must be transformed into a sustainable system. It is then necessary to tackle less rewarding and more tedious pragmatic aspects.
The new telemedicine software adopted by an institution, for example, must fit into the existing technological ecosystem. We dream of "dematerialized" medicine, but in reality this poses very material problems: the necessary memory capacity, compatibility with existing programs (operating system, browser versions, and other office applications), the necessary data transfer speed, data transmission security, backup procedures, and data hosting.
When announcing the plan to combat medical deserts, the Prime Minister also highlighted the importance of the Internet connection, stating that the problem would be solved by future total coverage of the territory.
12 different software programs for stroke care
Choosing software is another practical issue that arises when deciding to embark on telemedicine. The Observatory for the Referencing of Software Publishers and Integrators in the Healthcare Market (RELIMS) reports great diversity in the healthcare sector, with 301 companies registered and 840 software programs available on the French market. No fewer than 135 publishers offer software for home hospitalization, for example! And if we look at a very specific segment such as telemedicine devices for stroke care, there are currently 12 different software programs available. This multiplicity raises questions about their sustainability and the consequences for customers in the event of the 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 publishers are not very interested in them, or not yet – and this is true all over the world. The British telemedicine platform SOS boasts that in 2015 it was the first company in the world to be certified according to the ISO standard for quality of service in telemedicine.
In France, the Haute Autorité de Santé (HAS) has not implemented any specific certification. There are no regulatory requirements, except for software intended to be certified as medical devices, which entitles users to reimbursement by the national health insurance system. Currently, only one diabetes app, Diabeo, has obtained this certification. The HAS recently published a set of best practices for software and applications in "mobile health, " but these are not mandatory. Reading this guide, potential customers and users learn that assessing the reliability, security, and service provided is essential for this type of software. However, the documentation provided by publishers offers few guarantees on these criteria.
Ergonomics and ease of use are among the requirements that should apply to all software, as the HAS guide points out. The aim is to avoid the risk of errors associated with misuse, or simply the loss of time associated with a large number of clicks. Back in 2012, an international study showed that 17% of incidents related to patient care safety were attributable to software usability issues. Numerous articles highlight the "silent errors" caused by re-entering information, poor ergonomics, or caregivers circumventing software that is unsuitable for their work processes.
Software that is incompatible with each other
One final, very pragmatic aspect that compromises the growth of telemedicine is the incompatibility between software programs that are unable to automatically exchange data with each other. This lack of technical and semantic (meaning of information) interoperability between software programs is a growing problem as they multiply for different purposes and on different media, from electronic patient records to software linked to medical devices. These software programs accumulate in layers, leading to an overload of work for healthcare professionals.
In Quebec, the lack of interoperability between the various software programs used to support electronic patient records has caused major problems. Two years ago, the Minister of Health therefore decided that all hospitals in the province must migrate to a single software program. In France, such a decision at the national level 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 programs. Either impose a standard on all publishers, which the HAS could decide to do. Or impose a single software program throughout the country, which seems difficult due to the circular mentioned above.
What responsibility do software publishers have in the event of a problem with a patient?
Another question arises with the expected widespread adoption of telemedicine. In the event of a problem with a patient related to a computer malfunction, who is responsible: healthcare professionals or software publishers? To what extent can publishers be held liable if their software crashes or does not work as expected? It should be noted that in 2011, the The death of a patient was attributed to a software error.The representative of the publishers, the delegate of Les entreprises des systèmes d’information sanitaires et sociaux (LESIS), had questioned the training and best practices in the use of this software. However, this incident led to the certification by the HAS (Haute Autorité de Santé, French National Authority for Health) of prescription support software.
For the implementation of telemedicine, here again, a best practices guide existsFar from painting an idyllic picture, he gives a glimpse of the obstacle course that such a project represents. He therefore stresses the importance of taking into account human resources for maintenance and technical support, as well as for coordination between professionals. The biggest mistake would be to imagine that technology, through the automation of data processing, could meet all these needs on its own.
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 still needs to be developed, "warehouses" set up to store photos of patients' moles, a technical and medical protocol based on clinical studies defined—for example, setting the minimum resolution for a photo to be usable—and professionals capable of making the diagnosis coordinated.
So, the miracles of telemedicine will not happen before our eyes as if by magic. They involve technical and organizational changes. And in these areas, everything remains to be built.
Roxana Ologeanu-Taddei, Associate Professor authorized to supervise research in Management Sciences at Polytech Montpellier, University of Montpellier and David MorquinHospital practitioner at Montpellier University Hospital, doctoral student, University of Montpellier
The original version of this article was published on The Conversation.