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Proceedings of the 3rd International Conference on E-Health and Bioengineering - EHB 2011,

24th-26th November, 2011, Iai, Romania


Global Telemedicine and eHealth

(A Synopsis)
M. Jordanova1,2, F. Lievens3,4
Space and Solar-Terrestrial Research Institute, Bulgarian Academy of Sciences, Bulgaria
Educational Program Coordinator, Med-e-Tel,
Board Member, Secretary and Treasurer of International Society for Telemedicine & eHealth (ISfTeH), Switzerland
Director, Med-e-Tel, Belgium,

Abstract- The presentation uses as a baseline the importance

of Telemedicine and eHealth for the optimization of all possible
levels of existing healthcare systems and for the development of
efficient, timely, optimal, patient-centric healthcare worldwide.
The paper is focused on global aspects of Telemedicine and
eHealth adoption such as successful practices and cost
effectiveness and is also focused on obstacles for worldwide
implementation of telemedicine.
The importance of improved and continuous international
cooperation and coordination is also emphasized. Attention is
dedicated to the necessity always to be aware about what is
globally going on trough international networking initiatives
such as the International Society for Telemedicine and eHealth
(ISfTeH, and Med-e-Tel (The International
eHealth, Telemedicine and Health ICT Forum for Education,
Networking and Business,
The global overview of Telemedicine and eHealth
development supports professionals in influencing local policy
when the role of telemedicine/eHealth in the health care sector is
concerned; building public awareness about eHealth and its
potentials; building multi-stakeholder consensus on principles,
policies, and strategies related to effective eHealth
Keywords: eHealth, telemedicine, networking



Within the last decades information and telecommunication

technology (ICT) has become an integral part of healthcare.
Decision makers, patients, providers, etc. often present ICT
applications in the health sector as one of the panaceas for
reforming healthcare and improving healthcare costs, quality
and efficiency.


Telemedicine is defined as an application of ICT to provide

and support healthcare and exchange healthcare information
when a distance separates the participants [1]. The word is a
combination of two Greek words = tele - meaning at a
distance and medicina or ars medicina meaning
healing and its introduction is ascribed to Thomas Bird. In
1970s Bird had used this phrase in order to illustrate health
care delivery, where physicians examine patients at a distance
through the use of telecommunications technologies. Till the
middle of 1990s the term telemedicine was widely spread
and accepted without questions. With more involvement of
the electronic communication systems, the major

International Organizations - World Health Organization

Telecommunication Union (ITU) and European Space
Agency (ESA) - have officially adopted the denomination
"eHealth". "eHealth refers to the use of modern information
and communication technologies to meet the needs of
citizens, patients, healthcare professionals, healthcare
providers, as well as policy makers [2]. It is necessary to
underline that e in the eHealth does not stand only and
exclusively for electronic. It characterizes in details what
eHealth is all about [3]:
Efficiency - one of the strategic promises of eHealth is
to increase efficiency in health care, thereby decreasing
Enhancing quality of care;
Empowerment of consumers and patients or patientcentered medicine replacing the traditional model of
patients moving upward, unchanged for 6000 years;
Encouragement of a true partnership between the patient
and healthcare professionals;
Education (continuing medical education) through
online sources;
Exchange of information;
Extending the health care beyond national boundaries;
In addition to eHealth, one more term was introduced and
used lately as an even broader description for eHealth, i.e.
Modern Communication Health Environment (MCHE) [4]. It
combines all aspects of healthcare and ICT as well as the four
aspects of eHealth eCare, eLearning, eSurveillance and
What is the correct terminology? Unfortunately, to this
very moment, the terminology as related to application of ITC
in healthcare has neither been agreed in Europe nor
worldwide. Paradoxically even between and within EU
countries different terms are used to describe one and the
same service. Positions differ and the preferences are usually
influenced by individual experience, personal and
professional viewpoints. Thus for some authors telemedicine
and eHealth are synonyms. Others accept that eHealth is a
broader term and includes telemedicine. A third group
separate the terms, accepting that telemedicine incorporates

Proceedings of the 3rd International Conference on E-Health and Bioengineering - EHB 2011,
24th-26th November, 2011, Iai, Romania
teleophthalmology, teledermatology, telesurgery, tele-nursing,
etc, while eHealth comprises of e-Sant, Information and
Communication Technologies in health (ICT-Health), all
types of health communication services, PACS, patient
information systems, e-education, e-prescription, etc.
Further in this paper the terms telemedicine and eHealth
will be used as synonyms.



More than a century has passed since the first documented

attempts to develop telemedicine applications, i.e. W.
Einthovens successful transmissions of ECG signals via
telephone in 1905. Lots of efforts were dedicated to the
development of eHealth, thousands of projects were
conducted all over the world. Since mid-1990s,
telemedicine/eHealth programs have become common
throughout the world in nearly every area of healthcare radiology, pathology, education, homecare, emergency care,
mental health, rehabilitation, cardiac monitoring, surgery, etc.
Time proved that telemedicine may help solving the
healthcare dilemma, i.e.:
Steadily increasing elderly population in developed
countries, going hand in hand with relative decrease in
resources (fewer taxpayers) and increasing percentage
of chronic patients with multiple disease;
Increasing healthcare expenses due to development of
new technologies, necessity to secure health services to
the increasing world population; increasing amount of
chronic patients and elderly living alone; growing
number of individuals with limited health and/or
physical disabilities but with the ambition for
independent living; quicker spread of diseases due to
worldwide connections;
Governmental healthcare expenditures growing faster
than economic growth;
Decreasing amount of health care professionals as
compared to the demand of healthcare services;
Ensuring access to health care for all individuals as one
of the basic human rights;
Ensuring the continuity of healthcare [5].
telemedicine/eHealth has the potential to change our lives. A
survey performed by International Business Machines
Corporation (IBM) in 2006 asked 150,000 people from 104
countries to list the technologies that will be the breakout hits
in near future. The company narrowed the results down to the
five innovations that were the "most impactful and they
were: the 3-D Internet; mind-reading cell phones;
nanotechnology for energy and the environment; eHealth
(telemedicine); and real-time speech translation [6]. eHealth
was included among the top five technologies that are
believed to be able to change our future.
Scientific studies also support the increasing acceptance of
eHealth applications in various areas of health care such as

chronic heart failure [7-8], wound care [9], psychiatry [1013], psychology [14], surgery [15], chronic disease and care
for elderly and house bound patients [16-17], electronic
health records [18], mobile eHealth solutions [19], etc.
Cost effectiveness of telemedicine, which is its major
promise, is also confirmed. Especially interesting and
convincing are long duration studies performed in countries
with large territories such as Russia and Brazil. According to
the estimates of West Siberian physicians, the patient paid
approximately 40 times smaller fee for the virtual
consultations rendered by a Moscow expert, than it would
have taken to make a trip to Moscow to consult this same
expert. The quality of the service is the same [20-21].
Another brilliant example is the tele-cardiology service at
the State of Minas Gerais in Brazil (territory equivalent to
France, population 19 M inhabitants living in 853 cities). It
has been operating since June 2006 in 82 remote and isolated
villages in the state. Preliminary results of the evaluation of
economical feasibility of telehealth systems have shown that
the savings resulting from a 1.5% reduction on the number of
treatments outside the village are sufficient to cover the
operational cost of the system [22-24].
Wisely chosen eHealth applications are beneficial
everywhere. Lets cite one more study from a comparatively
smaller region in Italy. In 2001 24-hrs 7-day-a-week tollfree telephone hotline service for children and adolescents
with Type 1 diabetes was organized in Parma region. An
extensive survey, study carried out from 1st January 2001 to
31 December 2006, showed that the total number of children
receiving help was 421 (mean age 10.83.8, mean duration of
diabetes 4.53.5 years). Within the 5 years period 20 075
calls were recorded, or an average of 11 calls per day! 52% of
the calls were emergency calls. Thanks to the available
service, the admittance to hospital for a Diabetic ketoacidosis
fell from an average of 10 cases per 100 children per year to 3
cases per 100 children per year. Thus the costs for admission
decreased of 60% [25]. A more detailed analysis of costeffectiveness is provided by [26] for those that are interested.
It is already proven that telemedicine/eHealth is able of:
Optimizing healthcare delivery and making it quicker,
timely, high quality and affordable for all, everywhere,
at any time;
Decreasing the difference in healthcare services between
developed and developing countries;
Optimizing the work of healthcare staff;
Closing the gaps between healthcare demand and
available services due to shortage of healthcare funds
and staff;
Reduction of healthcare budgets;
Enhancing education to empowered citizens and many
more. (For more evidence based results the reader may
refer to the Knowledge Resource section of Med-eTel. This free of charge virtual library is available at
urces&page=info and summarizes over 2000 abstracts,
papers, books and Power Points on various

Proceedings of the 3rd International Conference on E-Health and Bioengineering - EHB 2011,
24th-26th November, 2011, Iai, Romania
telemedicine/eHealth topics. The database is searchable
by year, topic and country and is updated on an annual
Despite of undoubted telemedicine/eHealth advantages
humanity is still far away from the world of cyber healthcare,
from extensive application of telemedicine/eHealth for the
benefit of all. Experts admit that telemedicine/eHealth has a
vast and still unrealized potential. The question is what are
the obstacles hindering the wide application of telemedicine.


The future of telemedicine/eHealth depends on overcoming

the various challenges.
1. Regulatory
Telemedicine/eHealth generates serious regulatory
challenges. Those challenges are already complex where the
provider and receiver are in the same country, yet even more
so, when the provider is not in the same country as the
A 2009 USA court case raises questions illustrating this. In
brief, a Colorado psychiatrist Christian Hageseth received a
nine-month prison sentence for prescribing an antidepressant
to a California teenager over the Internet without a California
medical license [27]. The teenager later committed suicide.
Carleton Briggs, Hageseth's attorney, said the case, believed
to be the first of its kind, could hinder telemedicine "because
no one would dare practice telemedicine without being
licensed in all 50 states." The court decision was based on the
requirement of the American Medical Association that states
that physicians, who practice online prescribing, have to have
an existing relationship with the patient and the appropriate
2. Legislation
Information on country-level telemedicine policies and
strategies is not easily accessible. In general specific laws
focused on telemedicine/eHealth applications are lacking in
most countries with some exceptions:
Malaysian Telemedicine Act is a specific telemedicine
legislation, included in the Laws of Malaysia. The aim of the
Act 564 or the Telemedicine Act of 1997 is to provide the
regulation and control of the practice of telemedicine and
aims to protect citizens from doctors or others who might not
be clinically competent. Unfortunately the Act imposes
impractical restrictions such as requiring health care
providers to register with Malaysias Director General, a
measure that can limit practices and practitioners from other
countries [28].
India is another leader in telemedicine legislation. Its
eHealth law 35, which is still under discussion, includes
mutual recognition between countries for the medical license
granted by a physicians home country and allows reciprocity
between countries to allow licensed doctors to practice
telemedicine in both countries. The law underlines that
registration, which would ensure that physicians are liable

under medical negligence and malpractice laws in the country

where the telemedicine patient resides or communicates
from [28].
France is yet another example. Section 78 of the 2009
HPST law (Hospitals, Patients, Health and Regions) defines
and authorizes telemedicine services. A year later one more
decree, a Decree No. 1229 was accepted for further regulation
of telemedicine applications.
Unfortunately these are just the first steps towards the
development of laws exclusively regulating telemedicine
applications. In many other countries there are attempts to
include some aspects of eHealth legislation in the regulation
of telecommunication, general healthcare or social services.
Nevertheless that these national legislations reflect local
traditions, local health and social welfare goals and systems,
local aspects of available or pre-planned telecommunication
accesses, etc. they are steps forward towards development of
worldwide telemedicine laws.
When a cross border application of telemedicine is
discussed, the European Union is a good example. Despite of
wide discussions and decades of investment in
telemedicine/eHealth EU has not yet adopted specific
telemedicine legislation valid for the entire community. On
the other hand, the increasing mobility of EU citizens makes
it a must to ensure quality medical care beyond national
borders. Thats why EU-27 and the members of the European
Economic Area adopted, on 19 April 2007, a common
declaration on their commitment to pursue structured cooperation on cross-border electronic health services across
Europe. Telemedicine/eHealth services are partially included
in two important documents the European Innovation
Partnership (EIP) announced in October 2010 and especially
in Digital Agenda for Europe, adopted in May 2010 by the
European Communication.
The Digital Agenda for Europe plans to foster development
and application of EU-wide standards, interoperability testing
and certification of eHealth systems by 2015 through
stakeholder dialogue. In addition, Digital Agendas Key
Action 13 underlines the commitment of EU to undertake
pilot actions to equip Europeans with secure online access to
their medical health data by 2015 and to achieve by 2020
widespread deployment of telemedicine services. The Key
Action 14 goes even further and proposes a recommendation
to define a minimum common set of patient data for
interoperability of patient records by 2012.
The first steps in EU legislation are facts but when cross
border legislation is concerned, it is always necessary to
remember that the issues of the conflict of laws have also to
be taken into consideration. The private international law
addresses four important questions:
Where can the parties sue each others? That is;
which courts may have jurisdiction over the dispute?
Which countrys law will govern the dispute?
Can a chosen court decline to exercise its
jurisdiction over the dispute?

Proceedings of the 3rd International Conference on E-Health and Bioengineering - EHB 2011,
24th-26th November, 2011, Iai, Romania

Where can the resulting judgment be recognized and

enforced [29]?

3. Standards and guidelines

The lack of widely accepted and applicable standards for
the use of various telemedicine/eHealth services is another
significant obstacle for it worldwide adoption. For years the
creation of standards involves numerous organizations. Some
of them are:
Not-for-profit organizations such as the American
Society for Testing and Materials (ASTM); the Health
Level Seven International (HL7) that is a global
authority on standards for interoperability of health
information technology with members in over 55
countries; the Healthcare Information and Management
Systems Society (HIMSS); the European Committee for
Standardization (CEN) etc.;
International examples are the International
Telecommunication Union, International Organization
for Standardization or
National such as the Standards Australia e-health;
Office of E-Health Standards and Services, US
Department of Health and Human Services or the
American Telemedicine Association (ATA) to name
It is worth listing some of the standards and guidelines
developed by ATA as an example to be followed:
Core Standards for Telemedicine Operations (February
2008) including the fundamental requirements to be
followed in providing remote medical services,
interactive patient encounters, and any other electronic
communications between patients and practitioners for
the purposes of health care delivery [30];
Evidence-Based Practice for Telemental Health (July
2009) is an educational tool to aid practitioners in
providing appropriate mental health services via
telehealth technologies [31];
Practice Guidelines for Teledermatology (December
2007) that aimed to support the development and
practice of coherent, effective, safe and sustainable
teledermatology practices [32];
Telehealth Practice Recommendations for Diabetic
Retinopathy (May 2004) is a roadmap of technical
standards, clinical guidelines and administrative
procedures [33].
Another interesting example comes from Russia: In 2010
implementation of electronic health records (EHRs) by
dedicating 24 billion Rubles for the next two years to
stimulate the start up of EHRs application. The plan has fixed
the period 2011-2012 as introduction of electronic records;
years 2012-2015 will be used for detailed filling in of EHRs,
including past medical history and by 2015-2020 all providers
have to work in automated mode. But the first step of the
Russia government was to approve a national standard for
development of EHRs in 2006 (GOST R 52636-2006) [34].

If the standardization problem has to be summarized, its

core is that:
Various data standards exist standards in clinical
practice, standards for bioscience tests, standards for
picture transmissions etc.
For some services too many different standards have
already been developed and yet there is a lack of unified
standard just to use as an example distributing and
viewing any kind of medical image - ASTM, ANSI X12
(EDI); CEN, DICOM, are part of the applied standards;
Lack of common strategy in developing standards and
as a results the community is a witnessing multi-level,
multi-scale developments, competing initiatives,
fragmentation, lack of information, lack of
computability, etc.
4. In addition
The above listed obstacle for telemedicine/eHealth
implementation does not cover all problems.
Main challenges for wide implementation of eHealth still
Language differences;
Traditions and routines in medical practices;
Ethical issues;
Licensing lets not forget that medical license is
geographically restricted;
Privacy - health information is regarded as particularly
sensitive information and has to be strictly protected;
Taxes and insurance issues;
The right of the patient of informed consent to the
procedure - each country has different understanding
and approach to what constitutes informed consent.
In the light of the above mentioned obstacles the
importance of improved and continuous international
cooperation and coordination is essential.


Within the world of telemedicine/eHealth, it is crucial for

all the players to be aware what is globally going on.
Therefore cooperation and networking are most important
factors going hand by hand. Lets focus on two specific
networking enabling initiatives:
The International Society for Telemedicine and eHealth
(ISfTeH, is a not-for profit membership
organization of national, regional, international associations
and others, institutions, organizations, corporations,
individuals and students, established under Swiss law.
ISfTeH is the international representative body of national
and international Telemedicine and eHealth organizations and
is dedicated to broadly promoting telemedicine/eHealth
around the world. ISfTeH supports the start up of National
Associations or Societies and facilitates their international
contacts. Its aim is to disseminate knowledge, information
and experience and to provide access to recognized experts in
the eHealth field worldwide. As part of ISfTeH educational
activity, a Working Committee Education is functioning.

Proceedings of the 3rd International Conference on E-Health and Bioengineering - EHB 2011,
24th-26th November, 2011, Iai, Romania
The mission of this Committee chaired by Prof. M. Mars
from South Africa is:
Listing existing programs on eHealth;
Establishing basic eHealth templates for fundamental
training programs;
Coordinating eHealth educational efforts around the
Assisting the set up of new courses in eHealth;
Defining the needs of universities and specialists for
basic and continuous education.
eHealth science, practice and market need a meeting place.
Such a place is Med-e-Tel (The International eHealth,
Telemedicine and Health ICT Forum for Education,
Networking and Business, www.medetel.elu). Med-e-Tel is a
highly specialized event that brings suppliers of specific
equipments and service providers together with buyers,
healthcare professionals, decision makers and policy makers
from many countries around the globe and provides them
with hands-on experience and knowledge about currently
available products, technologies and applications. Med-e-Tel
is a forum where state-of-the-art products, ideas, projects, etc
are presented and discussed. Year after year it becomes a
nesting place for new co-operation and partnerships between
scientific groups and institutions, small, medium and large
size enterprises, etc from all over the world. Annual editions
called together participant from over 50 countries. WHO, EC,
ESA, ITU, UNOOSA, are only part of the major players that
took part in the event.
The next and 10th edition of Med-e-Tel will take place at
Luxexpo in Luxembourg, April 18-20, 2012 and will follow
the standard format including exhibition, scientific program,
media corner.
Med-e-Tel provides lots of educational opportunities
through its extensive program of presentations, panel
discussions, workshops and satellite symposia. It is accredited
by the European Accreditation Council for Continuing
Medical Education (EACCME) to provide European external
CME credits for medical specialists. EACCME credits are
recognized by the American Medical Association as well as
by some countries in Asia and Middle East. This is the
highest possible recognition of the extreme value of Med-eTels Education program.
ISfTeH and Med-e-Tel are working together. They are as
the two sides of a coin. They both lead the way from needs to
practical applications, highlights quantitative numbers and
results, serve networking meeting real people, real business,
real achievements, real products, discussing real problems,
and education for business, science, practitioners and citizens.
ISfTeH and especially Med-e-Tel are the perfect
organizations for following what globally is going on and
what are the new trends in the area of eHealth.
Of course there are many other events covering this field.
In fact, there are hundreds of them each year! For the purpose
of this paper, we are concentrating specifically on Med-e-Tel.
One can find references to other events, supported by ISfTeH,

on the International Society for Telemedicine and eHealth

website (


Telemedicine/eHealth is already a must, with no way back,

a fantastic and broad challenge for the future but it requires
cooperation and coordination at all possible levels, it requires
networking and planning, readiness to learn from the others
and no need to re-invent the wheel.
The coordination in telemedicine remains a challenge, i.e.
to make all the possible players representing business,
administration, science, insurances, etc., to coordinate their
skills and efforts to achieve an optimal development within
the health environment using modern communication
systems. No doubt, this is a Sisyphean task. But when this is
achieved, the benefits will be for all of us as tax payers since
citizens will rely on high quality affordable healthcare at
anytime, anywhere.








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