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Telecommunication in trauma surgery
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.
Security measures must be taken in order to guarantee the observance of relevant medicolegal principles in telemedicine. Intensive care and emergency care physicians must cope frequently with danger to the patient's life; they are forced to decide upon diagnosis and treatment in a very brief time, often on the basis of presumable consent, because many patients are unconscious. These special conditions are discussed along with essential issues of professional secrecy and data protection as well as data security. The implementation of sufficiently effective security measures is indispensable to protect both the patient's and the physician's rights, providing conclusive evidence for jurisdiction.
Experiencing communication problems in our emergency services, we developed an innovative communication network and system - the NOAH system (NOAH, which stands for Notfall-, Organisations- und Arbeitshilfe, or emergency organization active aid system). In contrast with the currently established emergency services communication in Germany by radio wave, data are transferred from the scene in the form of an electronic record on a mobile computer by means of the wireless data communication network Modacom (mobile data communication), which is provided by German Telekom. It is received at the dispatch centre in mentioned formate and transferred to the admitting hospital without any loss of data. In a prospective study, the technical and conceptual suitability of this system was investigated. It was shown that an admitting hospital was informed more than 20 minutes in advance about the admittance of a patient. To assure the quality of transferred data, information was ranked by different criteria. This further demonstrated that much more precise information about a patient's condition was already available upon admittance in the hospital.
2006 published the German Association of Trauma Surgery (DGU) a guideline for trauma management called «Weißbuch der Schwerverletztenversorgung». There are standards applied for every hospital of each trauma level. Furthermore the guideline demands the implementation of trauma networks in Germany. Since 2012 the 2nd edition is available. 2009 the first network was certified in Eastern Bavaria. All level I and level II trauma centres and nearly all level lll/IV centres in eastern Bavaria established the Eastern Bavaria Trauma Network (TNO). Many changes and improvements in multiple fields were founded: Changes of structural environment, service schedule, improvements of diagnostic capabilities and communication, implementation of quality circles. In a scientific study it was shown, that the patient outcome is significant better since the initiation of the Eastern Bavaria trauma network. The enhancement of the quality of the treatment of severely injured patients will be increased by implementation of trauma networks in Germany.
2006 published the German Association of Trauma Surgery a guideline for trauma management called »Weißbuch der Schwerver letztenversorgung«. There are standards applied for every hospital of each trauma level. Furthermore the guideline demands the implementation of trauma networks in Germany. In 2007 all level I and level II trauma centers and nearly all level IIl/lV centers in eastern Bavaria established the Eastern Bavaria Trauma Network (TNO). Since it is not the idea to centralize all trauma care in one center, but to built a safety net, the acceptance is excellent. The network sets the goal to involve not only hospitals of any level but also small and medium size surgical outpatient units and rehabilitation facilities Each hospital of the network has to create a guideline for the resuscitation room, the time for treatment and the mortality decrease since the implementation of guidelines and use of whole-body multislice CT scans. The Department of Trauma Surgery of the University Hospital of Regensburg has introduced standard operation procedures for the workflow of every member of the staff. The enhancement of the quality of the treatment of severely injured patients will be increased by implementation of guidelines and trauma networks in Germany.
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, tiie respective message and their relation are discussed. Channels, sender, addressee, and other structural roles are analyzed for different types of electronic medical communication. The commimicative 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 intemet 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 directiy (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.
The use of portable ultrasound devices enables a better and immediate diagnostics at the scene of a mass casualty incident. The detection of free fluid in abdomen and thorax is an important indicator for the further treatment. The gained information affects the triage of casualties, the pre-clinical medical attendance and the patient management. The presented article describes an innovative approach to transmit sonographic video streams over wireless networks to a remote hospital, where the medical data is used for diagnostics. For the secure transmission of data a new network unit is designed, which gathers information with regard to the network status and the character of transported data. This "Intelligent Network" is located in the transport layer of the OSI reference model and enables a dynamic interconnection between network and application, provides an interface for functional transparency and the disclosure of parameters and establishes the basis for an universal security system.
Unlabelled:
To establish a guideline for the use of teleconsultation, which is one of the most important applications in telemedicine beeing perfomed very frequently in daily medical practice in almost any field of medicine.
Evidence:
The recommendations are based on expert knowledge, because of the lack of evidence based data in the telemedical scientific literature. In addition, scientific articles of the highest level of evidence available published between 1970 and 1999 were reviewed. DEVELOPEMENT AND CONSENUS PROCESS: A guideline draft was prepared using the attributes of clinical practice guidelines developed by the Institute of Medicine (IOM) of the National Academy of Sciences. This draft was reviewed by telemedicine experts and the content of the guideline was approved by 100% group consensus in 5 meetings held between 1997 and 2000 by a panel of members of the Subproject 4 Group of the Global Health Care Application Project of the G8 countries.
Conclusions:
The guideline gives recommendations on all aspects of teleconsultation in any field of medicine and will be updated regularly implementing new evidence.
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.
Some claim that telemedicine technologies can save "billions" in health care expenditure. This study is a review of economic studies of telemedicine applications.
In economic evaluation resource use (costs) is compared to the health benefits generated. If telemedicine technologies have lower costs and equal or greater benefits than traditional methods, the former should be chosen. If telemedicine is more costly, but generates greater health benefits, society have to judge whether the benefits justify the costs. These issues are explored in cost-effectiveness and cost-utility analyses. We started off with a review published by the International Network of Agencies for Health Technology Assessment (INAHTA). We updated this review to December 1999 by searches in various databases.
The INAHTA report included 19 economic analyses of telemedicine applications; in addition we identified 11 studies from last year. Three of the studies had been undertaken in Norway while the majority stemmed from North America. Only three studies made an assessment of health outcome while the others were various types of cost analyses. The majority of the studies were of low to moderate quality. Sixteen studies concluded that telemedicine was a cost-saver, three concluded opposite while the others had more "neutral" conclusions.
Telemedicine technologies can save costs, but their impact on health outcome is largely unknown. Whether a specific technology is a cost-saver will depend on its type, the cost structure of the health care system, patient volume, and geographic factors. Taking into account the limitations of the studies, we conclude that the cost-effectiveness of telemedicine methods is not established. The claim that telemedicine can save "billions" is not backed by research.
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.
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.
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.
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.