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Telekommunikation in der Unfallchirurgie Vernetzung medizinischer Versorgungseinrichtungen in Ostbayern
Abstract
The growing complexity of the performance processes in medicine makes it mandatory that the flow of information is faster and more consistent, especially when the sites of health care are far away from each other. The Regensburg model, a realization of lean telemedicine from a low-cost domain, using PC-based standard videoconferencing systems shows the use of modern telecommunications, especially in trauma surgery. In 203 prospectively evaluated teleconsultations between 15 participants a total of 697 images were transmitted via videoconferencing. In 95 % of the trauma cases the transmitted material was judged as at least sufficient. In project-attending evaluations the efficacy of these systems and their use were clearly demonstrated. Savings in transportation costs of up to 4,400 DM per case were achieved. Through quicker flow of information quality improvements for all participants resulted; to some extent considerable costs for health care were avoided or reduced. Based on these thoughts, a new platform of communication will be established in Regensburg as a closed medical intranet for the region of eastern Bavaria.
Growing complexity of performance processes in medicine require a quicker and more consistent flow of information, even between distant sites of health care. The Regensburg model, a realisation of lean telemedicine from a low-cost domain, using PC-based standard videoconferencing — systems shows the use of modern telecommunications especially in medical spheres. In project-related evaluations, the efficacy of these systems as well as their use can clearly be proven. Through a quicker flow of information, quality improvements for all participants resulted, and to some extent considerable costs for health care were avoided or lowered.
Es ist Aufgabe aller Leistungsträger im Gesundheitswesen, sowohl die Qualität der Versorgung ständig zu verbessern wie auch möglichst gleichzeitig Kosten zu senken. Gelöst werden soll die Verwirklichung dieser beiden sich fast widersprechenden Zielvorgaben u.a. durch den Einsatz und die Nutzung moderner Technologien wie z.B. der Telematik.
Eastern Bavaria is a rural area associated with deep forests and its national park “Bavarian Forest”. Yet it is on the technological frontier with regard to communication and cooperation in medicine: The “Telemedicine Network Eastern Bavaria” links all the hospitals in the area and the NOAH project employs mobile PCs with wireless communication links for the on-scene physicians. This paper presents the findings of the latter project. The emergency medical services in Germany are provided by ambulance cars, vehicular emergency life support, and by helicopters making it one of the best systems world wide (see Mahgsudi et al. 1999). The overall philosophy of the German emergency care system is “Stay and Treat” as opposed to “Scoop and Run” in several other countries. Due to technical and medical progress during the last years and the continued efforts to increase the educational guidance for on-scene physicians, the emergency medical services improved significantly. Despite the existing good overall medical care, there is considerable potential for improvement concerning the management of the emergency care process, communication between the parties involved (e.g. doctor-on-scene, dispatch centre, hospital) and the documentation of emergencies.
Die zunehmende technische Entwicklung verändert die Welt der Medien, und immer mehr lernen auch Ärzte, diese technischen Neuerungen für sich zu nutzen. So sind mittlerweile die meisten Kliniken und Praxen mit dem Internet verbunden. Dies kann einer schnellen Informationsgewinnung dienen. Dadurch ist es heutzutage jedem Arzt – auch außerhalb großer universitärer Zentren – möglich, immer auf dem neuesten Stand zu sein. Aber Orthopädie im Netz kann noch mehr sein als reine Informationsgewinnung. Ein kurzer Überblick über die Möglichkeiten soll hier gegeben werden.
Computer und Roboter sind aus dem Alltagsleben nicht mehr wegzudenken. In der Medizin werden Computer neben der Dokumentation und Qualitätssicherung heute auch in der operativen Medizin eingesetzt: Als computerassistierte Chirurgie (CAS) oder „image-guided surgery“ (IGS) werden Computer zurzeit überwiegend zur Navigation und zur Datenübertragung verwendet. Die Domäne der Navigation in der Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie liegt heute in der Nasen- und Nasennebenhöhlenchirurgie bzw. der Chirurgie der Rhinobasis, aber mehr und mehr auch der Otobasis. Ein weiterer zukünftiger Einsatz der CAS in der HNO-Chirurgie im Sinne von Manipulatoren und Robotern ist im Wesentlichen an die Fortschritte in der modernen Sensorik gebunden [38,39]. Als eine Untergattung der Manipulatoren könnten steuerbare Instrumente bezeichnet werden. Solche Werkzeuge sollen es dem Operateur ermöglichen, über einen minimal-invasiven Zugang auch komplizierte Operationen z. B. an der frontalen oder lateralen Schädelbasis durchzuführen.
Zusammenfassung Die Deutsche Gesellschaft für Unfallchirurgie (DGU) publizierte 2006 das Weißbuch der Schwerverletztenversorgung, in dem die
Bildung von Traumanetzwerken angeregt wird. Als erstes TraumaNetzwerkD DGU in Deutschland wurde 2008 das Traumanetzwerk Ostbayern zertifiziert. Der vorliegende Beitrag befasst sich mit dessen
Kommunikationsstruktur und -kultur. Durch die Nutzung der verschiedensten Kommunikationskanäle (Vis-a-vis-Kommunikation, E-Mail,
Formularblätter) und -ebenen (abteilungsintern, klinikweit, netzwerkweit) ist es möglich, einerseits ein Traumanetzwerk erfolgreich
zur Zertifizierung zu führen, andererseits ist in dieser Kommunikation die Nachhaltigkeit des Traumanetzwerkgedankens begründet.
Nur wenn die Mitglieder eines Traumanetzwerks zu einem Team verschmelzen, zu einem Qualitätszirkel, wird eine Eigendynamik
möglich, welche zu einer stetigen Qualitätsverbesserung führen kann. Hierbei ist insbesondere die moderne Fehlerkultur zu
beachten, bei der nicht der Fehlerverursachende am Pranger steht, sondern die Umstände erläutert werden, welche den Fehler
möglich machten.
In industry, especially in the automobile industry, improvements in efficiency could be demonstrated by quality management and quality circles. There is no doubt that in medicine, major trauma is also a very complex challenge.
The German Association for Trauma Surgery published the White Paper on the Management of the Seriously Injured in 2006. The White Paper specifies the demand for quality of care, sets the level of structural requirements for trauma care and postulates the cooperation of regional hospitals within a network of dedicated trauma centres. The Trauma Network Eastern Bavaria (TNO) was the first certified trauma network in Germany. One of the reasons for this success is the fact that cooperation between trauma surgeons has already had a long tradition in this geographic area. The key factor is communication which is supported by all technical and organisational means. The formal installation of quality circles on each level of trauma care, e.g. within and across institutions, was accepted by all partners within the network. The goal is the improvement of patient care in trauma above and beyond the guidelines of the White Paper. This paper shows the instruments used to enhance the quality of trauma care within a network.
The quality of care of seriously injured persons in Germany is nationally and internationally recognized to be at a high level. However, there are local discrepancies. In 2006 the German Association of Trauma Surgery published the White Paper for the Management of the Seriously Injured. The goal of the paper is a further increase in the quality of care of seriously injured persons. A crucial point of the publication is the call to establish regional trauma networks in Germany.
Work on this project has been carried out in eastern Bavaria since spring 2007. The first meeting of the Trauma Network of eastern Bavaria took place in July 2007. On 3rd September 2008 the university hospital of Regensburg was the first clinic audited in Germany. To date nearly 75% of all hospitals in the trauma network of eastern Bavaria have been audited. The establishment of a regional trauma network is a multifactorial event. Essential factors in the development of the trauma network were found to be the communication between the head physicians and the nomination of an appointee of the regional trauma network.
For the head physicians the 9 meetings of the trauma network since July 2007 functioned as the communication platform. These exchanges of the head physicians are necessary to animate a trauma network. The appointee of the regional trauma network – most suitably a member of staff of the speaker of the trauma network – is essential to guarantee communication between meetings and to manage prompt responses to questions from the network.
This article describes the experiences gained during the implementation of the trauma network in eastern Bavaria.
Communication theory based analysis sheds new light on the use of health telematics. This analysis of structures in electronic medical communication shows communicative structures with special features. Current and evolving telemedical applications are analyzed. The methodology of communicational theory (focusing on linguistic pragmatics) is used to compare it with its conventional counterpart. The semiotic model, the roles of partners, the respective message and their relation are discussed. Channels, sender, addressee, and other structural roles are analyzed for different types of electronic medical communication. The communicative processes are shown as mutual, rational action towards a common goal. The types of communication/texts are analyzed in general. Furthermore the basic communicative structures of medical education via internet are presented with their special features. The analysis shows that electronic medical communication has special features compared to everyday communication: A third participant role often is involved: the patient. Messages often are addressed to an unspecified partner or to an unspecified partner within a group. Addressing in this case is (at least partially) role-based. Communication and message often directly (rather than indirectly) influence actions of the participants. Communication often is heavily regulated including legal implications like liability, and more. The conclusion from the analysis is that the development of telemedical applications so far did not sufficiently take communicative structures into consideration. Based on these results recommendations for future developments of telemedical applications/services are given.
Berlin, Humboldt-Univ., Habil.-Schr., 1999. Computerdatei im Fernzugriff.
Telemedicine is still in its infancy, but undergoing rapid development. It is very difficult to evaluate telemedicine. We performed a literature survey (Medline). During the period 1990-8, over 1500 articles on telemedicine were published. Of these, 246 mentioned economic aspects in the abstract (16%). We selected 29 studies although few had demonstrated cost-effectiveness. Benefits for the patients in the form of reduced travel and waiting time must often be weighed against increased provider costs. Up to now, telemedicine in general has not had any significant effect on medical practice, or the structure and organization of health-care. In order to utilize the potential of telemedicine, its integration with traditional health-care is very important. There are country-specific variations in the health systems that make it difficult to generalize the results from one country to another.
This report presents a series of recommendations derived from deliberations of the G8 countries Subproject 4 Group (SP4 Group) of the Global Health Care Applications Project entitled, A Teleconsultation Practice Guideline. The recommendations provide an initial step toward developing a general guideline platform for the practice of telemedicine/teleconsultation.
The definition of health information is growing to include multimedia audio, video, and high-resolution still images. This article describes the telemedicine program at East Carolina University School of Medicine, including the telemedicine applications presently in use and the virtual reality applications currently under development' Included are the major design criteria that shape the telemedicine network some of the lessons learned in developing the network, and a discussion of the future of telemedicine, including efforts to incorporate telemedicine within a fully integrated health information system.
With the increasing number of users and technical improvements, there are several application scenarios of teleradiology.
To perform a cost-benefit analysis, an approach is presented, which focuses on both monetary and qualitative aspects. Process-related,
qualitative and quantitative evaluations are described. The prestudy compares the radiological workflow before and after the
introduction of a teleradiology system. A scoring model is part of the qualitative evaluation. The quantitative study focuses
on costs and savings. Amortisation and a net present value of savings versus costs can be derived using dynamic investment
methods. Savings can be achieved after a short time under ideal conditions, but there is no guarantee for a reimbursement
for all systems.
Im Zuge der Weiterentwicklung und steigenden Zahl an Nutzern von Teleradiologiesystemen ergibt sich eine Vielzahl von Anwendungsmöglichkeiten.
Um eine möglichst allumfassende Kosten-Nutzen-Analyse dieser Systeme durchzuführen, wird ein Modellansatz beschrieben, der
neben monetären Aspekten qualitative Faktoren untersucht. Der Ansatz besteht aus einer Prozeßanalyse, einer Nutzwertbetrachtung
sowie einer Wirtschaftlichkeitsmessung. In der Prozeßanalyse werden die Arbeitsweisen der konventionellen und teleradiologischen
Umgebung gegenübergestellt, um qualitative und monetäre Nutzenpotentiale zu erkennen. In der Nutzwertanalyse werden über ein
Scoringmodell die qualitativen Faktoren individuell für beide Arbeitsweisen gewichtet und gemessen. Kosten und Einsparungspotentiale
werden in der Wirtschaftlichkeitsanalyse anhand von Beispielen gegenübergestellt. Anhand Methoden dynamischer Investitionsrechnung
werden Amortisation und Kapitalwert verschiedener Teleradiologieszenarien ermittelt. Hierbei zeigt sich, daß unter speziellen
Voraussetzungen relativ kurzfristig Einsparungen zu erzielen sind, jedoch keine allgemeingültige Aussage über eine generelle
Amortisation aller Systeme möglich ist.
Evaluating telemedicine systems and services is a complex task. Safety and efficacy must be measured in a relatively controlled laboratory environment, while measurement of clinical utility and medical effectiveness requires extensive field testing. The need for large clinical trials to demonstrate utility and effectiveness presents a dilemma. Substantial numbers of cases are needed to achieve statistically valid results, yet most telemedicine programs are based in rural settings with small patient populations. One potential solution is to pool data from multiple programs by using common data collection instruments and protocols. A promising model for the performance of multi-centered collaborative telemedicine research is described. The Clinical Telemedicine Cooperative Group (CTCG) is based on the successful use of collaborative research by clinical oncology research groups such as the Southwest Oncology Group (SWOG).
As groups of physicians join networks to maximize their effectiveness with managed care systems, frequent communication and joint development of standardized clinical protocols become important. For physicians who are accustomed to being independent, frequent meetings are necessary to make these networks succeed. In larger networks, travel time becomes a significant drain on clinical effectiveness. Interactive video technology (IVT) providing full-motion two-way video communication is one potential solution to this problem of geography and time. The experience of our academic department with IVT is summarized and practical advice is provided for those considering the use of this new technology.
Today, a rural or off-site clinic, staffed with advanced practice nurses, can interact with physicians and patients via telecommunications. Telemedicine links regional, national and international markets. This two-way, audiovisual interaction brings the specialist to the patient.
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- W Gnann
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