Telemedicine for everyone is just around the corner…
Telemedicine initiatives are popping up all over France. Each one attracts widespread 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. 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: 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 emphasized, however, that the experiments conducted in recent years were a diverse set of initiatives that yielded “modest results.”
What is the cause of these disappointing results, and, more importantly, how can they be improved? We believe that a key factor is an overly idealistic view of telemedicine. The use of telemedicine is treated as a form of “wishful thinking,” ignoring the problems that arise whenever there is both technical and organizational change.
The simplistic view of an unchanged practice, but 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 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 brought about by 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. While we dream of “dematerialized” medicine, in reality it poses very tangible problems: the required storage capacity, compatibility with already installed programs (operating system, browser versions, and other office applications), the bandwidth needed 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 field of telemedicine. 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 products available on the French market. No fewer than 135 software publishers, for example, offer software for home hospitalization! And if we look at a very specific segment such as telemedicine solutions for stroke care, there are currently 12 different software programs…This proliferation raises questions about the software’s long-term viability and the consequences for customers in the event of a vendor’s bankruptcy—such as how to recover data.
What could be the objective selection criteria? One could be certification according to an international quality standard (ISO), as in other economic sectors. There are even specific ISO standards for healthcare software. But software publishers aren’t very interested in them—or at least not yet—and this is true worldwide. The British telemedicine platform SOS, for example, boasts that in 2015 it was the first company in the world to be certified under the ISO standard for service quality in telemedicine.
In France, the Haute Autorité de Santé (HAS) has not established any specific certification. There are no regulatory requirements, except for software intended to be certified as medical devices, which makes it eligible 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, potential customers and users learn that assessing reliability, security, and service quality has become essential for such software. However, the documentation provided by software publishers offers 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 points out. The goal is to avoid the risk of errors associated with misuse, or simply the waste of time caused by 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 having to re-enter information, poor usability, or healthcare providers circumventing software that is ill-suited to their workflows.
Software programs that are incompatible with one another
One final, very pragmatic issue that hinders the growth of telemedicine stems from incompatibilities between software programs that are unable to automatically exchange data with one another. This lack of technical and semantic interoperability (the 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 a complex, layered system, leading to an excessive workload for healthcare professionals.
In Quebec, the lack of interoperability between the various software systems supporting electronic health 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 providers.
Today, there are two solutions to facilitate data exchange between software systems. Either impose a standard on all software vendors—which the HAS might decide to do—or mandate a single software system nationwide, which seems difficult due to the circular mentioned above.
What is the liability of software publishers if a patient experiences a problem?
Another question arises in light of the expected widespread adoption of telemedicine. If a patient experiences a problem due to a computer system failure, who is liable: healthcare professionals or the software developers? To what extent can software developers be held liable if their software crashes or does not function as intended? It is worth recalling that in 2011, the A patient's death was attributed to a software error. The publishers’ representative, the delegate from Les entreprises des systèmes d’information sanitaires et sociaux (LESIS), had raised questions about training and best practices in the use of this software. However, following this incident, starting in 2014, the HAS began certifying the prescription-assistance software.
When it comes to implementing telemedicine, once again, a A best practices guide is available. Far from painting an idyllic picture, he offers a glimpse into the obstacle course that such a project entails. He thus emphasizes the importance of taking into account 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 a mole, or teledermatology. To make this possible, reliable software must be developed, “databases” must be set up to store photos of patients’ moles, a technical and medical protocol based on clinical studies must be defined—for example, establishing the minimum resolution required for a photo to be usable—and professionals capable of making the diagnosis must be coordinated.
So, the wonders of telemedicine won’t just happen before our eyes as if by magic. They require technical and organizational changes. And in these 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, Ph.D. candidate, University of Montpellier
The original version This article was published on The Conversation.