Over the past decade, telemedicine has become an important part of medical development, with the potential to greatly improve the quality of health care in the future. People in rural areas are gaining instant access to quality of health care, which they would previously have travelled for hours to receive. ICTs and telemedicine are also benefiting vulnerable communities, such as those who need health monitoring and those who experience communication barriers. In Spain, two successful pilot projects have addressed this situation. Telemedicine is ensuring fast and efficient monitoring of heart conditions no matter where the patients may be, while developments in ICTs are opening doorways of communication for the deaf.
The term telemedicine stems from the Greek word tele, meaning ‘distance’, and the Latin word mederi, meaning ‘to heal’. Thus, it refers to the use of modern telecommunications and information technologies for the provision of clinical care to individuals at a distance. It also relates to the transmission of information to provide such health care, which includes patient education sent over computer networks (medical informatics), the transfer of images such as radiographs, ultrasound studies, patient interviews and examinations, consultations with medical specialists, and health-care educational activities.
The essence of telemedicine lies in transferring the expertise instead of the patient – the goal is to eliminate unnecessary travel. Telemedicine is often associated with the benefit of extending services to remote areas, but it can also provide opportunities for the day-to-day health care of vulnerable groups regardless of how remote they may be. For example, on the one hand, the use of new technologies can create opportunities for less powerful segments of society to contest existing social arrangements and gain an improvement in their lives. A particular example of this is the way in which information and communication technologies (ICTs) are helping deaf communities to communicate frequently over long distances. On the other hand, informatics can benefit certain groups of the population that require regular monitoring of their health condition, such as those suffering from heart disease.
Communications for the Deaf
The 120,000 deaf people that live in Spain have historically been marginalised in society due to their lack of easy communication. However, a new system, developed through trials with the National Confederation of the Deaf in Spain, is making use of today’s biggest trend: text messaging on mobile phones. To communicate across distances, deaf people have previously had to write letters or connect to the internet. This meant paying for internet connection. With the advent of text messaging, deaf users have enjoyed a freedom of communication through their ability to text message friends and contacts whenever necessary. However, typical text messaging on a common mobile phone network can become a costly enterprise when put to repeated use. A typical text message only holds 150 characters, so for a deaf user to communicate information, it can take multiple message and multiple charges.
“They need to communicate by writing and not by voice and…it takes longer to write than to speak, so a text call was very expensive for them.”
The Personal Digital Assistant (PDA) developed with the National Confederation of the Deaf has cut costs by adopting the GPRS (General Package Radio Service) system. GPRS allows typical text messages to be sent, as well as instant messaging to internet sites and e-mail addresses without paying or waiting for connection. With the trial a success, the plan is to roll out the system across Spain so that the deaf community does not miss out on advances in ICTs.
General Package Radio Service:
The General Package Radio Service (GPRS) is a new non-voice value-added service that allows information to be sent and received across a mobile telephone network. GPRS is not related to GPS (the Global Positioning System – described in the Hands On case study Health Matters: Life Line), a similar acronym that is often used in mobile contexts. GPRS has several unique advantages:
- Speed Maximum speeds of up to 171.2 kilobits per second (kbps) are achievable with GPRS using all eight timeslots at the same time.
- Immediacy GPRS facilitates instant connections. Information can be sent or received immediately as the need arises. No dial-up modem connection is necessary. This is why GPRS users are sometimes referred to be as being ‘always connected’. Immediacy is one of the advantages of GPRS when compared to Circuit Switched Data.
- New and improved applications GPRS facilitates several new applications that have not previously been available over standard networks due to the limitations in speed of Circuit Switched Data (9.6 kbps) and message length of the typical Short Message Service (160 characters).
- A mobile phone or terminal that supports GPRS (Global System for Mobile communication – GSM – phones do not support GPRS).
- A subscription to a mobile telephone network that supports GPRS. Use of GPRS must be enabled for that user. Some mobile network operators may allow automatic access to the GPRS, but others will require users to specifically opt in.
- Knowledge of how to send and/or receive GPRS information using their specific model of mobile phone, including software and hardware configuration (this creates a customer service requirement).
- A destination to send or receive information through GPRS. With the Short Message Service this was often another mobile phone, but in the case of GPRS it is likely to be an internet address, since GPRS is designed to make the internet fully available to mobile users for the first time.
Coronary heart disease is a major killer in Spain. Coronary heart disease is the most common heart defect and is caused by the slow build-up over many years of fatty cholesterol-containing deposits (called plaques) in the inner wall of one or more of the heart’s arteries. If the coronary arteries (those arteries supplying the heart with oxygen) become too clogged, the flow of blood is reduced and the heart may not be able to meet the demands placed on it to pump harder during times of exercise or stress. This is known as coronary heart disease and can lead to angina or heart attack.
Angina is temporary chest pain or discomfort, resulting from a reduced blood supply to the heart muscle. It occurs because part of the heart muscle is temporarily unable to get enough blood and oxygen to meet its needs. Many people with angina live to a healthy old age without having a heart attack. However, a history of angina is associated with a higher risk of heart attack. If not treated effectively, angina can interfere with an active lifestyle.
The heart is a muscular pump that needs a continuous supply of oxygen. It obtains oxygen from the blood, which flows to the heart muscle through arteries on the heart’s surface. These arteries are called the coronary arteries. ‘Heart attack’ occurs when a coronary artery is suddenly blocked by a blood clot and the part of the heart muscle supplied by that artery is damaged because it is starved of oxygen. The medical term for this sudden blockage by a blood clot (thrombus) in a heart artery is coronary ‘thrombosis’ or ‘coronary occlusion’ (blockage). The medical term for permanent damage to the heart muscle is ‘myocardial infarction’. Heart attacks nearly always occur in people who have coronary heart disease. In coronary disease, fatty deposits, called plaques, may narrow the artery channel considerably. If the plaque splits, a blood clot may develop at the site of cholesterol build up, blocking the artery. The associated clotting is usually the final cause of heart attack.
Heart disease is preventable. About 80 per cent of the adult population have at least one of the following risk factors: tobacco smoking; physical inactivity; high blood pressure; overweight. There is great potential for reductions in morbidity and mortality if effective preventative and treatment strategies are adopted to address these factors. However, there are some population groups that require special attention to reduce the burden of heart disease.
With the incidence of heart disease increasing with age, the elderly are a group that need attention. With an ageing population in Spain (covered in a previous case study – Health Matters: Life Line), the burden of the elderly with heart disease, hypertension, heart failure and stroke will progressively increase. Thus, the progressive ageing of the population will only increase the burden of heart disease. To approach this issue, the Airmed project was established through collaboration between the Carlos III Institute of Health and Airtel Foundation (part of Vodafone Group Foundation). The project was designed to establish the viability of communication technologies in improving the efficiency of treating health-care patients.
In 1998, the Vodafone Group Foundation and Carlos III Health Institute [ISC III – Instituto de Salud Carlos III] organised an expert exchange and personal training scheme, which became known as the Airmed project. This performed technological research and development activities related to the health care field with the aim of improving the quality and efficiency of hospital management and working methods. Five initial projects were established, including one that monitored cardiac patients through telemedicine activities. The patient’s cardiovascular data is constantly transmitted from sensors on their body to a monitoring centre at the mobile phone’s data connection. Help can be sent as soon as the monitor picks up a deviation from normal patterns that might indicate angina, heart attack or some other serious heart defect. The project uses wearable technology that is regarded by some as a forerunner to nanotechnology sensors that may be implanted (placed under the skin) to monitor health in real time.
The Airmed project was deployed in a series of phases. The purpose of phase 1 of the Airmed project was to test the technology and, in particular, the functionality and usability of mobile communications in health applications. The tele-assistance service was designed to enhance its users’ quality of life, enabling them to live safely, comfortably and for as long as possible in their usual surroundings. The project mainly sought to allow users to enjoy the benefits of the service within their daily environment, both inside and outside the home. The results of the first phase were impressive and the tele-monitoring of heart diseases was identified as the most consolidated programme with the best prospects.
The benefits established during the first phase included:
- Patients being monitored on a more regular and intensive basis than with traditional systems.
- More efficient secondary prevention protocols being brought into play.
- Treatments can be tailored more closely to patients, and do not last as long.
- More efficient drugs can be administered, although patients must be monitored more closely and the dosages must be adjusted gradually.
- Patients do not have to go to hospital so often, thus suffering less inconvenience and having to spend less on their care.
Airtel Móvil established the Airtel Foundation as an autonomous and non-profit institution dedicated to research and development within the field of mobile communication. The purpose of the Foundation is to perform research into the social benefits of communications. Airtel contributes to the development of telecommunications products and services with a view to enhancing the living conditions and integration of special groups of people.
If phase one of the Airmed project was the technological validation of telemedicine opportunities, phase two was designed as the medical validation. This followed a methodology of clinical trials controlled by health professionals. The aim was to introduce e-health innovations based on risk management in three areas:
- To increase knowledge (and therefore decrease uncertainty);
- To increase the confidence and guarantees of patients and health-care workers; and
- To boost the scope of action by means of statistical and epidemiological criteria.
The monitoring of cardiac patients was carried out under phase two in collaboration with the ISC III, Puerta de Hierro University Hospital, the San Carlos Clinical Hospital, El Escorial Hospital, four peri-urban health centres, and four rural health centres. The project approached two aspects of health care for heart disease patients in Spain:
- Arterial hypertension trial The prevalence of arterial hypertension in Spain is 25 per cent, amounting to approximately five million adults. The prevalence in other western European countries ranges from 10 to 20 per cent. For the project, 32 doctors, 12 nurses and three co-ordination officers organised a clinical trial for 480 users (in two six-monthly phases with 240 users each) in three health districts of Madrid.
- Heart failure trial Heart failure has a prevalence of one per cent in the EU, mainly affecting the elderly. Eight doctors, three nurses and three co-ordination officers participated in the design and organisation of clinical trials for 150 users selected from Puerta de Hierro hospital, El Escorial hospital and the Argüelles specialities centre.
Phase two of the Airmed project is due for completion by the end of 2004, with the results being validated by the country’s National Health Technology Evaluation Agency. This validation is one of the steps that will signal the beginning of phase three, which will pursue the supervised use of the Airmed strategy by the National Health System across Spain. Doctors across the country will be able to monitor three times as many patients, more closely and from any location. While the actual distance between doctors and patients widens, responses suggest that Airmed telemedicine brings them closer together in terms of trust and confidence.
“It is cardiology without frontiers…it is establishing closer communication between doctor and patient.”
Telemedicine represents a combination of expertise and technology that delivers medical services and information over distance. Advances in ICTs have made telemedicine more feasible as an alternative means of providing health care and sharing information with remote areas and the marginalised groups of society. For those with heart disease, telemedicine provides a security blanket that reassures them in their day-to-day activities. For the deaf, ICTs are facilitating frequent communication across any distance, thereby removing their communication barriers and empowering them in society. The use of telemedicine systems in hospital clinics, care facilities, and in the home is becoming well established and is evolving in effectiveness and efficiency. While there are technological, political, economic and professional barriers to telemedicine, these barriers can be overcome with co-operation among health care professionals, technology specialists and governments. Thus, telemedicine has the potential to have an enormous impact on the future of medicine.
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Spanish Confederation of the Deaf www.cnse.es
Vodafone Group Foundation www.vodafonefoundation.org
Donor and Supporting Organisations
Department for International Development (DFID) www.dfid.gov.uk
World Bank www.worldbank.org
Healthlink Worldwide www.healthlink.org.uk
ITDG Technical Briefs answers.practicalaction.org
Relevant Hands On case studies
Health Matters: Life Line – Spain