Telemedicine for all, it's coming tomorrow...
Telemedicine initiatives are springing up all over France. Each time, they are widely publicized in the media. In recent days, we have been celebrating the Santé Landes platform set up in Mont-de-Marsan, and theequipment installed in 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 when presenting his plan to combat medical desertson October 13. Back in September, the Cour des Comptes reminded us that in its report on the subject the many expected benefits of this new screen-based approach to medicine: modernization of the healthcare system, cost savings through remote patient monitoring, improved patient care, and so on. people living in isolated areas or in detention. However, the Court also highlighted the fact that the experiments carried out in recent years were heterogeneous initiatives, with "modest results".
Where do these disappointing results come from, and more importantly, how can they be improved? We believe that a key factor lies in an overly idyllic vision of telemedicine. Recourse to this practice is invoked in the manner of "magical thinking", denying the problems that arise in the face of any change, whether technical or organizational.
The simplistic vision of an unchanged but remote practice
The definition of telemedicine given inArticle L6361-1 of the French Public Health Code, which is found in many scientific articles, is eloquent. It is "a form of remote medical practice using information and communication technologies". These terms perpetuate the simplistic vision of unchanged clinical practice that would only take place "at a distance". They underestimate the transformation of the practice itself by its computerization. This obstacle inevitably arises when successful experimentation needs to be transformed into a lasting system. In this case, the pragmatic aspects are less rewarding and more time-consuming.
The new telemedicine software adopted by a facility, for example, must fit into the existing technological ecosystem. We dream of "dematerialized" medicine, but in reality this poses problems of a very material nature: the memory capacity required, compatibility with programs already installed (operating system, browser versions and other office applications), the data transfer rate required, the security of data transmissions, backup procedures and data hosting.
When announcing the plan to combat medical deserts, the French Prime Minister stressed the importance of Internet connection, asserting that the problem would be solved by the future total coverage of the country.
12 different software packages for stroke management
The choice of software is another pragmatic question that arises when deciding to embark on telemedicine. The Observatoire du Référencement des Éditeurs de logiciels et intégrateurs du marché de la santé (RELIMS) reports great diversity in the healthcare sector, with 301 registered companies and 840 available software products declared 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 management, there are currently 12 different software packages... This multiplicity raises the question of their durability and the consequences for customers in the event of the publisher's bankruptcy - how to recover data, for example.
What are the objective selection criteria? One could be certification to one of the international quality standards (ISO), as in other sectors of the economy. There are even specific ISO standards for healthcare software. But publishers aren't very interested in this, or not yet - and this is true all over the world. The British telemedicine platform SOS, for example, boasts that in 2015 it was the first company in the world to be certified to the ISO standard for service quality in telemedicine.
In France, the Haute Autorité de Santé (HAS) has not set up a specific certification system. There are no regulatory obligations, with the exception of software designed to be certified as a medical device, which entitles it to reimbursement by the Assurance Maladie. At present, only one application dedicated to diabetes, Diabeo, has obtained this certification. The French National Authority for Health (HAS) recently published a set of best practice guidelines for software and applications in the "mobile health" sector, but these are not mandatory. On reading this guide, potential customers and users learn that the assessment of reliability, safety and service rendered are becoming indispensable for such software. However, publishers' documentation provides few guarantees on these criteria.
Ergonomics and ease of use are among the requirements that should apply to all software, as the HAS guide reminds us. The aim is to avoid the risk of errors associated with incorrect use, or simply the time wasted by a large number of clicks. Back in 2012, an international study showed that 17% of incidents relating to the safety of patient care were attributable to problems with the ergonomics of the software used. Numerous articles emphasize the "silent errors" caused by re-entering information, poor ergonomics or caregivers bypassing software unsuited to their work processes.
Incompatible software
A final, highly pragmatic aspect that compromises the development of telemedicine is the incompatibility between software programs that are incapable of automatically exchanging data. This lack of technical and semantic (meaning of information) interoperability between software programs is a growing problem as they proliferate for different purposes and on different media, from computerized patient records to software linked to medical devices. As a result, software is piling up like a mille-feuilles, creating a huge workload for healthcare professionals.
In Quebec, the lack of interoperability between the various software applications supporting the computerized patient record 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 package. In France, such a nationwide decision is not possible due to the 1989 circular on the computerization of public hospitals, which allows establishments to choose their IT supplier.
Today, there are two solutions for facilitating data exchange between software packages. Either impose a standard on all software publishers, which the HAS could decide to do. Or impose a single software package for the whole country, which seems difficult because of the circular mentioned above.
What liability do software publishers have in the event of a patient problem?
Another question arises with the expected widespread use of telemedicine. In the event of a patient problem linked to an IT fault, who is responsible: healthcare professionals, software publishers? How far can publishers be held liable if their software breaks down or doesn't work as expected? In 2011, the patient's death blamed on software error. The publishers' representative, Les entreprises des systèmes d'information sanitaires et sociaux (LESIS), had questioned training and best practices in the use of this software. However, in 2014, this accident led to the HAS certifying prescription assistance software.
For the implementation of telemedicine, here again, a best practice guide exists. Far from presenting an idyllic vision, he gives a glimpse of the obstacle course that such a project represents. He stresses the importance of human resources for maintenance and technical assistance, as well as for coordination between professionals. For the biggest mistake is to imagine that technology alone, by automating data processing, will meet all these needs.
In his plan to combat medical deserts, the Prime Minister cited the example of remote mole diagnosis, or teledermatology. To make this possible, we still need to design reliable software, set up "warehouses" to store photos of patients' moles, define a technical-medical protocol based on clinical studies - for example, defining the minimum resolution for the photo to be usable - and coordinate professionals capable of making the diagnosis.
The miracles of telemedicine won't just happen. They require technical and organizational changes. And in these areas, everything remains to be done.
Roxana Ologeanu-TaddeiShe is a senior lecturer in management science at Polytech Montpellier, University of Montpellier and David MorquinHospital practitioner at Montpellier University Hospital, doctoral student, University of Montpellier
Visit original version of this article was published on The Conversation.