power point

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PUBLIC LECTUREKENYATTA UNIVERSITY

• CHANGING MEDICAL ETHICS IN ICT ERA AND
  PATIENT-DOCTOR-COMMUNITY RELATIONSHIP
• DR JOSEPH ALUOCH F.R.C.P. E.B.S.
• SEPTEMBER 25th 2014
• NAIROBI

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A Brief History and Overview Of Biomedical
Ethics
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WHAT IS BIOMEDICAL ETHICS?
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MEDICAL ETHICS

• Ethics expresses the ways in which we examine,
  explore and attempt to understand the moral life.
• What are the moral obligations of health
  professionals in a world of advancing technology
  and promise.
• Allows us to reflect on the relationship between
  the professional and the patient.

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MEDICAL ETHICS

• Ethics a generic term for the various ways of
  understanding and examining the moral life
• Moral Choices
• what values, what reasons and what language

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MEDICAL ETHICS

• Applied Ethics a practical discipline
• Investigates ethical issues which arise in
  medicine and healthcare by applying the
  principles and methods of moral philosophy to
  these problems

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MEDICAL ETHICS

• The doctor patient relationship
• What makes a good doctor / professional?
• What choices, values and traits

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HOW SHOULD ONE LIVE?(SOCRATES)

• How doctors should treat patients rests on
  general moral principles about how a person
  should treat another person
• Thus
• Biomedical ethics grounded firmly in the study of
  moral philosophy

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WHAT IS BIOMEDICAL ETHICS?

• Species of practical normative ethics
• Norms standards of right and wrong action
  behaviour
• Normative ethics is concerned with how people
  ought to act, what sort of person one ought to be
  or what sort of policies ought tot be implemented.

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WHAT IS BIOMEDICAL ETHICS?

• Species of practical normative ethics
• What one is obligated or permitted to do, or
  prohibited from doing, in different contexts of
  biotechnology, medical practice and research.
• So we employ principles and theories of normative
  ethics to motivate and justify actions and
  policies in biomedicine.

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WHAT IS BIOMEDICAL ETHICS?

• Species of practical normative ethics.
• Objectivity
• Impartiality

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WHAT IS BIOMEDICAL ETHICS?

• Descriptive ethics
• Descriptive ethics is concerned with how people
  actually behave, not how they ought to behave.

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WHAT IS BIOMEDICAL ETHICS?

• Metaethics
• Metaethics is focussed on the nature of morality
  concerned with the point of ethics, i.e. what do
  the terms good, bad, wrong, right mean..

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CONTEMPORARY MEDICAL ETHICS

• ...the student begins with the patient,
  continues with the patient, and ends his studies
  with the patient, using books and lectures as
  tools...
• Sir William Osler, Canadian Physician(1906)
• As quoted in Singer, P, Viens, AM, Cambridge
  Textbook of Bioethics (2008)

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ETHICAL REASONING

• Clinical Ethics is learnt in the same way as
  clinical medicine is learnt, at the coalface,
  through meeting patients and their families,
  being involved in their cases. It is a practical
  discipline.
• The doctor must learn to recognise the ethical
  aspects of his/her clinical (and scientific
  research work), and to make reasoned decisions
  about this work within the framework of the law
  and medical council guidelines.

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CONTEMPORARY MEDICAL ETHICS

• Society allows doctors a degree of personal
  freedom in making decisions and in their
  interactions with patients. But in giving doctors
  that freedom society expects them to be able to
  defend their decisions and actions with
  reasons...Doctors must be able to show how their
  decisions and actions relate to the law and to
  the relevant guidelines.1
• 1Hope, Savulescu, Hendrik, Medical Ethics and Law
  (2008)

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ETHICAL REASONING LEARNING TO REASON

• Scientific Reasoning
• The skill of evaluating the scientific evidence
  available and applying it, using clinical
  judgement to the clinical scenario at hand. This
  is a fundamental part of your medical education
  and later practice.

• Ethical Reasoning
• In the same way, ethical reasoning is a skill
  required to allow you to identify and negotiate
  ethical problems, using an organized framework of
  ethical methods or tools in the clinical setting.

Ethical reasoning must stand up to scrutiny, (in
court if necessary) in the same way as the
scientific aspects of decision-making.
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• Traditional Medical Ethics

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2500 YEARS OF MEDICAL ETHICSA BRIEF HISTORY

• Timeline

460 BC
2009 AD
Hippocrates
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THE SCHOOL OF HIPPOCRATES5TH CENTURY BC

• Hippocrates The Father of Medicine
• Medical School (Greek Island of Cos)

460 377 BC
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THE HIPPOCRATIC OATH
c.1595
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HIPPOCRATIC OATH I

• I swear by Apollo, the healer, Asclepius,
  Hygieia, and Panacea, and I take to witness all
  the gods, all the goddesses, to keep according to
  my ability and my judgment, the following Oath
  and agreement
• To consider dear to me, as my parents, him who
  taught me this art to live in common with him
  and, if necessary, to share my goods with him
• To look upon his children as my own brothers, to
  teach them this art.

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HIPPOCRATIC OATH II

• I will prescribe regimens for the good of my
  patients according to my ability and my judgment
  and never do harm to anyone.
• I will not give a lethal drug to anyone if I am
  asked, nor will I advise such a plan and
  similarly I will not give a woman a pessary to
  cause an abortion
• But I will preserve the purity of my life and my
  arts.

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HIPPOCRATIC OATH III

• I will not cut for stone, even for patients in
  whom the disease is manifest I will leave this
  operation to be performed by practitioners,
  specialists in this art.
• In every house where I come I will enter only for
  the good of my patients, keeping myself far from
  all intentional ill-doing and all seduction and
  especially from the pleasures of love with women
  or with men, be they free or slaves.

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HIPPOCRATIC OATH IV

• All that may come to my knowledge in the exercise
  of my profession or in daily commerce with men,
  which ought not to be spread abroad, I will keep
  secret and will never reveal.
• If I keep this oath faithfully, may I enjoy my
  life and practice my art, respected by all men
  and in all times but if I swerve from it or
  violate it, may the reverse be my lot.

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BENEFICENCE AND NONMALEFICENCE

• Hippocratic Oath
• Established the principles of Beneficence and
  Non-maleficence
• Prohibited poisons and potions for abortion or
  euthanasia
• Maintain confidentiality
• Avoid exploitation
• Pursue best interests of patient

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THE HIPPOCRATIC OATH

• However no acknowledgement of the patients
  rights (e.g. truth telling or consent)
• Does not deal with welfare of society or of others

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THE HIPPOCRATIC OATH

• The Oath of a closed, self-protecting guild1
• an old boys club?
• Tradition of altruistic doctors practising
  paternalistic medicine...?

1Harris, J, Bioethics (2001) OUP
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THOMAS PERCIVAL, ENGLISH PHYSICIAN

• Beginning of modern professional ethics
• First used the term Medical Ethics in his book
  on the subject (1803)
• Somewhat of a misnomer at this point conflicts
  between practitioners were endemic at this time
• c.f. Manchester doctors dispute
• Tripartite structure of medicine at the time
• Physicians, Surgeons and Apothecaries

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THOMAS PERCIVAL

• Expanded the Hippocratic focus on the
  doctor-patient relationship to a broader social
  ethic of medicine emphasizing the professional
  responsibility of the physician.
• Influenced the early ethical codes of AMA, BMA
  and the WMA up until 1940s

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MEDICO-ETHICAL ASSOC. 1800S

• Manchester Medico-ethical Assoc.
• BMA medico-ethical committee 1853
• The attempt to produce codes of professional
  ethics to deal with certain recurrent problems
  they faced in the practice of their profession.
• Colleague control

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AMA CODE OF MEDICAL ETHICS 1849

• Revised to AMA Principles of Medical Ethics 1903
• Leading with revised editions to a code embodying
  a set of principles that in the spirit of
  Percival, emphasize not only nonmaleficence and
  beneficence but also doctors responsibility to
  the medical profession and to society at large.

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MEDICAL ETHICSFOUNDATIONS I

• Traditional codes of ethics
• Doctors as independent, self-sufficient
  philanthropists, whose beneficence is analogous
  to generous acts of giving.

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• MODERN /BIOMEDICAL ETHICS

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20TH C NAZI GERMANY AND US

• Experimentation on Humans
• Without their consent
• Perverse extension of the authoritarian nature
  of paternalism (Glannon)

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NUREMBERG CODE (1947)

• The judgment by the war crimes tribunal at
  Nuremberg laid down 10 standards to which
  physicians must conform when carrying out
  experiments on human subjects.
• 1. The voluntary consent of the human subject is
  absolutely essential

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NUREMBURG CODE (1947)

• Informed Consent enshrined in Medical Ethics Code
• Patient oriented approach for the first time
• Medical ethics ceased to be the sole domain of
  doctors now tested against the principles of
  society (Kennedy, 1981)

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CHANGING SOCIETY 1960S

• Less deference to authority
• Anti-war movements, Vietnam, Cuban Missile
  crisis, CND, hippies, public demonstrations for
  rights, civil rights movements, feminism
• Generally more assertive attitudes to individual
  rights and self-determination

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CHANGING MEDICINE

• Technology progressing to offer more expensive
  treatments, life-prolonging, scarcity of
  resources with increasing costs (Dialysis, Organ
  transplant, Artificial ventilation)
• Reproductive control with contraception and
  abortion concept of reproductive rights

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BIOETHICS (1971)

• a new discipline that combines biological
  knowledge with knowledge of human value systems
  (Potter, 1971)
• The study of the ethical dimensions of medicine
  and the biological sciences

Medicine

Science
Ethics
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BIOETHICS

• A growth in Academic comment with a shift in
  Moral philosophy increasingly from metaethics to
  applied ethics
• Increasing ethical issues for society as a whole,
  prompted by the new technologies (IVF, Genetics,
  Stem cell technologies, etc.)
• Non-medical commentary (philosopher, sociologist,
  ...) on how medicine and science should be
  regulated and how doctors and scientists should
  behave

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MODERN MEDICAL ETHICSFOUNDATIONS II

• Moral Philosophy
• Contemporary Medical ethics
• 1960s Moral problems of modern society
• CND, Vietnam, ...
• Personal and public responsibility for happens to
  the world
• Patients have rights and entitlements

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BENEFICENCE AND NONMALEFICENCE

• Early interpretations
• excessively paternalistic
• Now tempered with the recognition of other
  principles

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AUTONOMY

• Gradual shift in decisional authority from doctor
  to patient
• Introduced the patient based principle of
• AUTONOMY
• To sit alongside and complement physician based
  principles of beneficence and non-maleficence

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AUTONOMY

• auto self
• nomos law
• Moral Self Rule
• Having the capacity and the right to
  self-determination to formulate and follow a
  life plan of ones own making

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Sovereign over own mind and body Individual
freedom can be restricted only if risk of harm
to others
Respect for persons as autonomous
ends-in-themselves Capacity to Reason Apply the
moral law unto ourselves
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JUSTICE

• In context of a changing society,
• equality involves the concept of equal access
  to society's goods,
• i.e. scarce and expensive healthcare resources
• How can these be justly allocated?

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ETHICAL CHALLENGES OF THE ICT IN HEALTHCARE IN
A CHANGING SOCIETY
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INTRODUCTION

• The primary objective of the medical profession
  is to render service to humanity reward or
  financial gain is a subordinate consideration.
• AMA Principles of Medical Ethics
• Codes of Medical Ethics Current Opinions with
  Annotations, 1997.

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ETHICS MEDICINE - PART 1

• Ethics can be viewed as a prerequisite for the
  success of medical practice, much the same way
  that safety is a prerequisite for the success of
  airline travel.
• Dyer, KA. JMIR 20013(2)e23

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Modern Biomedical Ethics

• Modern bioethics reformulates the fundamental
  moral problems as a problems for society, rather
  than merely ones of professional self-regulation.
• Takes the patients perspective as its starting
  point.1

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ETHICS MEDICINE - PART 2

• In both cases, if the prerequisites are not in
  place to ensure trust in the product or services
  provided, consumers will not utilize the product
  or service.
• Dyer, KA. JMIR 20013(2)e23

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MEDICAL ETHICS

• Most physicians are governed by their own
  internal code of ethics.
• The commitment to help and serve others has
  traditionally taken precedence over economic
  interests.
• Medicines code of ethics is considered to be far
  more stringent than the law.
• Professional organizations have more formalized
  codes to ensure that their members behave
  ethically.

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MEDICAL ETHICS ON THE INTERNET

• Online entrepreneurs, business medical,
  rushed to cash in on the Internet bonanza, with
  its promise of great potential wealth.
• Investor shareholder interests are often
  placed above the welfare of patients.
• These actions are in direct conflict with many
  of the existing medical codes of conduct.

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MAJOR AREAS NEEDING GUIDELINES IN MEDICAL
INTERNET ETHICS

• Doctor-patient, provider-patient,
  therapist-client relationships
• Online medicine, online therapy
• Online research
• Quality of information on medical and healthcare
  Web sites
• Ethical conduct of medical and healthcare Web
  sites
• Privacy and security

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QUESTIONS RAISED BY PROVIDING HEALTHCARE SERVICES
ON THE INTERNET

• Does a physician, provider or therapist
  consultant to a website have an ethical
  obligation to site visitors?
• At what point does the a patient-provider
  relationship begin?
• Does an online relationship require that an
  off-line one exists?

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MORE QUESTIONS RAISED

• Do any of the ethical guidelines that guide and
  protect the patient-provider relationship apply
  in cyberspace?
• Is the relationship reduced to a medical or
  healthcare provider-consumer one?
• What are the limits of online medicine or online
  therapy?
• What is the ethical obligation of dealing with
  unsolicited e-mail?

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WHOS TRAVELING OVER THE INTERNET?
Patient
Clinician
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MEDICINE HEALTHCARE ON THE INTERNET

• Medical websites, more than any other type of
  site on the Internet, should ensure visitors
  personal privacy and prevent personal medical
  information, including patterns of use and
  interests, from being sold, purchased, or
  inadvertently entering the hands of marketers,
  employers, and insurers.
• Principles Governing AMA Web Sites
• Winker MA JAMA 20002831600-1606

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GUIDELINES FOR QUALITY MEDICAL AND HEALTH WEBSITES

• 1996 - Health on the Net Foundation Code of
  Conduct
• 1999 - Medscape The Ethics of the Medical
  Internet
• 2000 - AMAs Guidelines for Medical and Health
  Information Sites on the Internet
• - Internet Healthcare Coalitions
  International Code of Ethics
• - MedCERTAIN development of an trustmark
• 2001 - URAC Hiethics Fee-based Health Website
  Accreditation program

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ETHICAL CONDUCT OF MEDICAL AND HEALTHCARE WEB
SITES

• Medical website designers, writers, backers,
  consultants, e-health marketers, healthcare
  providers and physicians must understand the
  unique position they are in with online
  healthcare consumers.
• Online entrepreneurs and non-medical
  professionals should be educated not to exploit
  online patients or clients and follow a Medical
  Internet professional code of conduct.

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PRIVACY SECURITY

• Without enforceable guidelines for creating
  healthcare sites and ensuring privacy, and
  standards for conducting online research,
  Internet users risk their private life
  unexpectedly becoming public and face potential
  repercussions if insurance companies, employers,
  friends or family discover confidential
  information about their health.

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CONCLUSIONS - PART 1

• The major areas identified for further
  examination study in this paper include
• How privacy, security, confidentiality should
  be ensured when visiting a website or conducting
  transactions over the Internet.
• How website visitors can determine the quality of
  information at a website.
• How the doctor-patient, patient-provider, and
  therapist-client relationships should be
  translated into practicing online medicine and
  online therapy.

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Conclusions - Part 2

• How website designers, developers, sponsors
  managers should develop maintain ethical
  medical and healthcare websites.
• How online medical and healthcare businesses
  should be ethically conducted.
• How online research should be ethically
  conducted.
• How all the professions involved in the medical
  or healthcare Internet should ethically comport
  themselves.

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• INFORMATION COMMUNICATION TECHNOLOGY IN HEALTH
  CARE

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PILLARS OF HEALTH INDUSTRY
Chemistry
19th Century
Physics
20th Century
ICT
21st Century
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ICT IN MEDICINE
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ICT IN HEALTH CARE DELIVERY
Growing

• Globalisation
• Health care economics
• Patient process
• Medical profession
• New technologies (mobile videophone, mobile
  networks)

2000 2010
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69

• Impacts ICT include-
• Medical informatics
• Telemedicine
• Medical Information
• E-Learning

Functions of Internet
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MEDICAL INFORMATICS

• This is a term used to describe how medical
  information is handled, accessed, manipulated and
  retrieved.

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WHAT IS HEALTH INFORMATICS?

• Healthcare informatics is a combination of
  computer science, healthcare science, information
  science and cognitive science

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TELEMEDICINE

• This is the delivery of healthcare where
  distance is a critical factor by all health care
  professionals using information and communication
  for the exchange of valid information for
  diagnosis treatment and prevention of disease and
  injuries, research and evaluation and for the
  continuing education of healthcare providers, all
  in the interest of advancing the healthcare of
  individuals and their communities. 2

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HEALTH INFORMATION

• Medical professionals are better informed
  implying that information can get to them faster
  and from anywhere using internet.

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THE IMPORTANCE OF INFORMATION

• The healthcare of our clients is largely
  dependant on information.
• Every action taken depends on previous
  information and knowledge.
• The delivery of health care requires information
  about
• Science of type of care (nursing)
• Patient or client
• Provider
• Outcomes
• Process and systems for delivery of care

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THE IMPORTANCE OF INFORMATION

• Patient or client
• Information on the client is required for his/her
  individual care.
• The assessment process consists of gathering
  information.
• The use of technology can assist in collecting
  this information.
• Information on the client can be found in the
  patient record, the patients history, lab
  results.
• Information on the client changes and grows over
  time.

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E LEARNING

• ICT has also presented innovative educational
  delivery methods which have overcome the
  traditional barriers to continuous medical
  education.
• The virtual campus
• Podcasts
• Video conferencing

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GENERAL BENEFITS

• Elimination of chart-pulling, chart-filing, chart
  loss.
• Easy electronic review of patient information
  before visits.
• Notification of completed diagnostics and labs to
  review.
• Notification of required follow-ups, tests, etc.
• Potential reduction in medical errors with
  decision support and easier access to relevant
  information.
• Reduction in prescription errors and subsequent
  time lost communicating with pharmacies.

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GENERAL BENEFITS

• Easy communication with patients other providers
  specialists, hospital visits, etc.
• More complete and detailed information available
  for claims, malpractice suits, etc.
• Potential reduced costs for labor and supplies
  related to charts and chart maintenance.
• Improved flow of information between staff
  members.
• Accountability

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E-HEALTH
Quality of care
Access to care

• Image assistant by computers
• Continuos education
• E-prescription

• Telemedicine
• Teleconsultation

• Home care
• Monitoring

• Electronic health record
• Digitalized health system
• Hospital information systems
• Regional networks
• e-reimbursement/procurement
• Smart cards

Economy of care
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E-HEALTH INCLUDES

• Health/hospital information systems
• Health surveillance
• e-learning for health care professionals (medical
  continuing education)
• Remote patient monitoring
• Telehealth/Telecare
• Telemedicine

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GET YOUR ICT STRAIGHT
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DIGITAL TECHNOLOGY

• DIGITS( NUMBERS)
• DIGITS( LATIN- FINGERS)
• HISTORICALLY BEACONS
• SMOKES (analogue)
• DRUM SOUNDS
• INFORMATION HANDLED IN NUMBERS
• DIGITAL SIGNALS NOT VISIBLE
• RECOGNIZE( images sounds and words)
• DIGITAL Vs ANALOGUE

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A BIT ABOUT BYTES
bit bit 0 or 1
byte B 8 bits
Kilobyte KB 1,000 bytes
Megabyte MB 1,000 Kilobytes
Gigabyte GB 1,000Megabytes
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WHAT IS FIBER OPTICS?

• Transmitting communications signals over
  hair thin strands of glass or plastics

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FIBER OPTIC APPLICATIONS

• Fiber is the least expensive, most reliable
  methods for high speed and/or long distance
  communications
• Fiber optic systems transmit using infrared
  light, invisible to the human eye, because it
  goes further in the optical fiber at those
  wavelengths

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PATIENT RECORDS

• One obvious use of ICT in medicine is the
  introduction of databases to store patient
  records

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. . the future of the library is that there is
no library -- at least not as we know it today
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THE INFINITE LIBRARY
If youre over 50, todays libraries are
probably nothing like the ones you remember ...
Enter any major library today and youll find an
armory of computers and ,,,,,,,,,,,,,,,,
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ICT NURSING

• Improves ability to efficiently and accurately
  assess treat their patient
• Nurses largest group of health care worker,
  leading edge of transformation or health care
• Diminishing professional nurses
• Use of lower cadre nurses in e-nursing

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WHAT IS TELEMEDICINE?

• . . . the use of electronic information and
  communication technologies to provide and support
  health care when distance separates the
  participants . . .

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TELEMEDICINE AND THE FUTURE

• Education (Virtual University)
• Clinically in everyday practice, education,
  remote
• Patient oriented, in practise, education and
  monitoring at home
• Network, between doctor ,pt., pharmacy and all
  health personnel
• Disasters, catastrophes,e.g.earth quake
• Telesurgery

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TELEMEDICINE APPLICATIONS

• The main application areas of telemedicine
  systems are
• telehomecare and telecardiology,
• teleradiology,
• telepathology
• ...
• (There are other specialties that use
  telemedicine services, as teledermatology,
  teleophthalmology, telesurgery, telepsychiatry
  etc., but these are poor of applications at the
  moment).

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TELERADIOLOGY

• Radiology is one of the fields where telemedicine
  has been more developed
• Teleradiology is the most widely used
  telemedicine service at present
• Teleconsoluting
• TeleDiagnosis
• E-Learning

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KEEP YOUR ICT COOL
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EMERGING APPLICATIONS

• Telepharmacy
• Teledentistry
• Broader Home Health
• Remote Surgery

99
TYPES OF TELEMEDICINE

• Synchronous-Describes interactive video
  connections because the transmission of
  information in both directions is occurring at
  exactly the same period. (Live Telemedicine)
• Asynchronous-Describes store and forward
  transmission of medical images or information
  because the transmission typically occurs in one
  direction in time. (Store and forward
  telemedicine)

100
LIVE TELEMEDICINE
ADVANTAGES DISADVANTAGES

• Multiple specialty use.
• Interactive.
• High quality video and audio.
• Patient provider relationship.

• Scheduling constraints.
• High equipment costs.
• Expensive line charges.

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DONT LET ICT PULL YOU DOWN
102
STORE AND FORWARD
ADVANTAGES DISADVANTAGES

• No scheduling constraints.
• Less burdensome technical requirements.
• Low connection and equipment costs. (POTS)
• Information stored centrally, more secure.

• Limited Specialties.
• Delay in getting feedback.
• No patient provider interaction.
• Incomplete view of the case.

103
CORE PRINCIPLES OF TELEMEDICINE

• Is only a tool (like a stethoscope)
• Must be physician directed
• Must be integrated into established clinical
  operations and routines
• Physician-patient relationships must be preserved

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TELECARE

• Tele-Home Care allows to offer medical assistance
  to the patients directly to their home
• Tele-Home Care may improve the quality of life of
  patients
• Home-care and community based health service are
  becoming an increasingly important part of the
  healthcare services, allowing the so called
  Continuity of care

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TELE - PATHOLOGY
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TELE - MONITORING
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TELEMONITORING DEVICES
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DEVICE FOR GLUCOSE MONITORING


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MEDICAL PERIPHERALS
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CHALLENGES OF HEALTHCARE PROVIDERS (PUBLIC AND/OR
PRIVATE)

• To improve quality and treatment and care of
  patient and of life of the citizens.
• To reduce costs (expenditure control).
• To use advanced diagnostic and therapeutical
  technologies (CT,MRI, etc.) for a large number of
  patients/citizens.

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Rabbit, where are you going?I am going to
kill the Elephant Can you do that?Well, Ill
try, and try again. Tanzanian, ProverbThank
you
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WHAT IS E-HEALTH??

• ICT in healthcare
• Mostly Iinternet
• Healthcare telematics
• Medical records
• Telemedicine
• Digital imaging
• In fact re-organising healthcare

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EXAMPLES

• Electronic medical records
• eHealth platform portal site
• Register for physiotherapy and nursing
• Electronic medical prescriptions

116
EXAMPLES EMP

• Electronic Medical Prescription
• Avoid erroneous interpretation
• Possibly concurrently with paper
• Avoiding fraud, theft, forging
• Over-medication can be discovered
• Diverse added values possible, requiring law
  changes

117
THANK YOU IF YOU HAVE BEEN LISTENING
118
WHAT IS TELEMEDICINE?

• . . . the use of electronic information and
  communication technologies to provide and support
  health care when distance separates the
  participants . . .

119
TELEMEDICINE AND THE FUTURE

• Education (Virtual University)
• Clinically in everyday practice, education,
  remote
• Patient oriented, in practise, education and
  monitoring at home
• Network, between doctor ,pt., pharmacy and all
  health personnel
• Disasters, catastrophes,e.g.earth quake
• Telesurgery

120
EMERGING APPLICATIONS

• Telepharmacy
• Teledentistry
• Broader Home Health
• Remote Surgery

121
TYPES OF TELEMEDICINE

• Synchronous-Describes interactive video
  connections because the transmission of
  information in both directions is occurring at
  exactly the same period. (Live Telemedicine)
• Asynchronous-Describes store and forward
  transmission of medical images or information
  because the transmission typically occurs in one
  direction in time. (Store and forward
  telemedicine)

122
LIVE TELEMEDICINE
ADVANTAGES DISADVANTAGES

• Scheduling constraints.
• High equipment costs.
• Expensive line charges.

• Multiple specialty use.
• Interactive.
• High quality video and audio.
• Patient provider relationship.

123
STORE AND FORWARD
ADVANTAGES DISADVANTAGES

• Limited Specialties.
• Delay in getting feedback.
• No patient provider interaction.
• Incomplete view of the case.

• No scheduling constraints.
• Less burdensome technical requirements.
• Low connection and equipment costs. (POTS)
• Information stored centrally, more secure.

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TELEMEDICINE EQUIPMENT
Power Zoom Push-button 1-50x zoom allows both
close focus and wide angle images. Auto Focus
The camera automatically stays in focus for ease
of use. Freeze Frame Freeze frame produces the
clearest possible image, making it ideal for both
low- and high-bandwidth solutions. Accurate
Colors One button white balance sets highly
accurate colors quickly and easily. Polarization
Elimination of surface skin reflection allows
camera to see into epidermal layers. Touch and
View The AMD-2500 includes manual or automatic
iris control to maximize image brightness.
AMD 2500 General Examination Camera
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QUALITY IMAGES
Pictures taken by AMD 2500 General Examination
Camera
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HOW IT WORKS

• Video conference system
• Cameras each end
• TV screens/computers each end
• Various medical peripherals
• Video connection
• T-1 line
• Satellite
• Phone line (POTS)
• Internet

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) ) ) ) ) ) ) ) ) ) ) ) )
Hub Site
Remote Site
T-1
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CORE PRINCIPLES OF TELEMEDICINE

• Is only a tool (like a stethoscope)
• Must be physician directed
• Must be integrated into established clinical
  operations and routines
• Physician-patient relationships must be preserved

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TELEMEDICINE APPLICATIONS

• The main application areas of telemedicine
  systems are
• telehomecare and telecardiology,
• teleradiology,
• telepathology

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TELECARE

• Tele-Home Care allows to offer medical assistance
  to the patients directly to their home
• Tele-Home Care may improve the quality of life of
  patients
• Home-care and community based health service are
  becoming an increasingly important part of the
  healthcare services, allowing the so called
  Continuity of care

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PATHOLOGY

• Histology slides can be transmitted to
  pathologists using a digital camera attached to a
  microscope

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LIVE TELEMEDICINE EQUIPMENT

• General Examination Camera
• E-Stethoscope
• ENT Scope
• Ophthalmoscope
• X-Ray Digitizer
• 12 lead ECG machine
• Spirometer

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ECG WITH PERSISTENT MEMORY
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DEVICE FOR EMERGENCY


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OTHER DEVICES
Magnetic stirrer
Heat ramp pressure probe
Organ bath
Algae fluorometer
Negative pressure tank
Solar Powered Datalogger
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ADVANTAGES

• Specialist advice without the patient having to
  travel to the central hospital
• Cost saving in transport and patient
  accommodation
• Better utilisation of specialist resources
• Educational opportunities

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DISADVANTAGES

• Incorrect diagnoses
• Cost of hardware
• Need good telecommunication network
• Training of staff
• Medicolegal concerns- patient confidentiality

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PITFALLS

• Cost- digitizers are expensive
• Telecommunications limited in many parts of
  Africa and Asia- satellite shows promise
• Medicolegal issues- patient confidentiality
• Training of physicians

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FUTURE DIRECTIONS

• Digital cameras may replace digitizers and are
  much cheaper
• Wireless communications are rapidly expanding in
  developing countries
• Internet II may provide sufficient bandwidth for
  telemedicine
• Offers many educational opportunities

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MOZAMBIQUE PROJECT

• January 1998 First ITU Telemedicine project was
  implemented in Mozambique, connected two
  hospitals (one in Maputo, the capital of the
  country, and the second in Beira) for
  teleradiology.

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MOBILE EHEALTH IN RURAL AREAS

• There are two solutions
• Mobile phone can be used for management and
  consultations related to medical services.
• Mobile eHealth care clinics/units traveling in
  rural areas from one village to another and
  connected to nearby hospital by wireless
  communication for consultations.

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MOBILE TELECOMMUNICATION IN DEVELOPING COUNTRIES

• The number of mobile phones in many developing
  countries is drastically increased during the
  last five years offering technical platform for
  many mobile eHealth services to be organized.

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MOBILE NETWORK COVERAGE IN SELECTED COUNTRIES
(ITU, 2007)

• Combodia 87, Gambia 85, Guinea 80, Kenya 77,
  Pakistan 90, Rwanda 90, Senegal 85, Togo 85,
  Uganda 80, Zimbabwe 75.

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GOALS OF TELEMEDICINE

• To provide consultation and interpretation in
  regions of demonstrated need
• To provide specialist services in hospitals
  without on site support
• To promote educational opportunities for
  physicians

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Conclusion 1

• Experience demonstrates that there is no single
  solution that will work in all settings. The
  complexity of technologies and the complexity of
  needs and demands of healthcare suggests the
  gradual introduction, testing and refining of new
  technologies.

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Telemedicine in Developing Countries

• Telemedicine has the potential for offering to
  developing countries both qualitative and
  quantitative improvements.
• Many developing countries have inadequate
  health-care and medical services. Developing
  countries suffer from a shortage of doctors and
  other health-care professionals.
• Developing countries are inevitably short of high
  level hospital infrastructures. The geographical
  distribution of existing hospitals and health
  services is far from ideal usually they are
  limited to urban centres at county or district
  level.
• For countries with limited medical expertise and
  resources, telecommunications services and
  network have the potential to provide a solution
  to some of many problems. Increasingly, there is
  a recognition that health services must be
  provided close to the people who need them and an
  integrated, cost-effective approach is necessary.

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• The state of health of population is a direct
  determinant of development. Access to better
  health services reduces poverty and increases
  productivity. Investment in health is a
  prerequisite to economic and social progress.
• Population growth and the emergence of new health
  problems are increasing the demand for health
  services and for more expensive treatments.
  However, increasing demand and rising health care
  costs have not been matched by the funding of the
  health sector in most developing countries.
• About one billion people worldwide do not have
  regular access to local health services.

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MEDICAL ETHICS IN CHANGING SOCIETY

• Society-complex
• Individual Patients right awareness
• Patients critical consumers

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MEDICAL ETHICS

• Doctors V Patients
• Doctors V Society
• Medicine the art of healing
• Service to humanity
• Doctors as businessmen

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CHANGING FACE OF MEDICINE

• ART To Science
• Service To business
• Patient To consumers
• Lawyers Decision Makers

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WHAT IS ETHICS

• Ethics or moral philosophy is the systematic
  endeavour to understand moral concepts and
  justify moral principles and theories
• Ethics builds and scrutinizes arguments settings
  forth large-scale theories on how we ought to
  act, and it seeks to discover valid principles
  and the relationship between those principle

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MORALITY AND ETHICS

• The terms moral and ethics come from latin and
  Greek respectively (mores and ethos). Deriving
  their meaning from the idea of custom.. There
  is also another Greek word ethos which denotes a
  character feature. Aristotle called his ethics a
  study of character traits, in sense of virtues
  and vices.

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MEDICAL ETHICS

• Is based on philosophical ethics
• It isnt any special ethics but rather ethics of
  special cases.
• Medical ethics does not concern only doctors but
  also patients and society
• The central question of medical ethics is the
  doctor- patient relationship

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THE NATURE OF MORALITY

• Moral acts are acts done benefit others, they are
  altruistic and are not motivated by
  self-interest.
• Morality makes reference to right/wrong/permissibl
  e behavior with regard to basic values

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THE ORIGINS

• The Beginnings
• The Nuremburg Code, 1948
• Earlier Points of Origin
• Babylonian codes
• Hippocratic Code/Oath
• Islamic Codes
• Jewish Codes

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SOME HISTORICAL POINTS

• Privacy and confidentiality
• Abortion/status of the fetus
• Allocation of scarce resources
• Definition of death

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SOME HISTORICAL POINTS

• Genetics issues
• Reproductive issues
• AIDS
• Animal rights
• Relationship with pharmaceutical industries

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HIPPOCRATIC OATH5-4 CENTURIES B.C

• An obligation of nonmaleficence and an obligation
  of beneficence are both expressed in the
  Hippocratic oath
• I will use treatment to help the sick according
  to my ability and judgement, but I will never use
  it to injure or wrong them

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THE SOCIAL CONTEXT WHY IS MEDICAL ETHICS SO
PREVALENT?

• Some factors
• Womens Movement
• - Male dominance of medicine
• - Focus on cure rather than care and
  prevention
• Legalization, legislation, and litigation
• Social interest in freedom and autonomy decline
  in the status of medicine

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• The moral duties of the doctor
• The duty to help cure
• The duty to promote and protect the patients
  health
• The duty to confidentiality
• The duty to protect the patients life
• The duty to respect the patients autonomy
• The duty to protect privacy
• The duty to respect the patients dignity

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• The moral rights of the patient
• The right to high quality medical service
• The right to autonomous choice
• The right to decide
• The right to be informed
• The right to privacy
• The right to health education
• The right to dignity

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1. Professionalism is a term which embodies numerous
   qualities of physicians as public servants
2. Professionalism aspires to altruism,
   accountability, excellence, duty, honour, and
   respect fro other
3. A commitment to the highest standards of
   excellence in the practice of medicine and in the
   generation and dissemination of knowledge

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• The concept of professionalism includes the
  following values as
• Honesty -Commitment to
• Altruism excellence
• Service - accountability
• Commitment -Life-long learning
• Communication

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Principles of Ethics

• Beneficence
• Non-Maleficence
• Autonomy
• Truth telling
• Confidentiality
• Preservation of life
• Justice

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IMPORTANCE OF ETHICAL ISSUES

• Increasing profile/Recent press headlines
• Increase in technology
• Better informed society
• Doctors in Management
• Public scrutiny

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AUTONOMY

• Capacity to think, decide, take action
• Mental incompetence no autonomy

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TRUTH TELLING

• In much wisdom is much grief and he that
  increaseth knowledge increaseth sorrows
• (Ecclesiastics 1,18)
• Patients do not want the truth if the news is bad
• At times there are good reasons for overriding
  truth telling principle

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CONFIDENTIALITY

• Act against this principle and you destroy
  patients trust
• Clash- when keeping confidentiality would harm
  others e.g child abuse
• Should patients have access to their notes?

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PRESERVATION OF LIFE

• At what stage does human life begin?
• Can we assess another persons quality of life?-
  Jehovahs Witness

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EUTHANASIA

• Active an active intervention end life
• Passive deliberately withholding treatment that
  might help a patient live longer
• Voluntary euthanasia is performed following a
  request from a patient
• Doctor assisted suicide a doctor prescribes a
  lethal drug which is self administered by the
  patient
• Non-voluntary ending the life of a patient who
  is not capable of giving permission
• Involuntary ending life against a patients

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GIFTS TO PHYSICIANSFROM INDUSTRY

• Is it ethically permissible to accept gifts from
  pharmaceutical representatives?
• Any gift accepted by a physician should primarily
  entail a benefit to patients and should not be
  substantial value.
• Individual gifts as long as they relate to the
  physicians work.

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ADVERTISING IN MEDICINE

• Patient information and doctors advertising
  medicine
• Commercialized health care marketing
• Doctors website
• Media coverage
• Electronic medicine

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ADVERTISING AND PROFESSIONALMISCONDUCT

• Information
• Drawing attention to achievements
• Attracting patients
• Professional advantage
• Financial benefits

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• For sale an antique desk suitable for lady with
  thick legs drawers.
• Now is your chance to have your ears pierced and
  get extra pair to take home, too
• Wanted Unmarried girls to pick fresh fruit and
  produce at night.
• Sheer stocking. Designed fro fancy dress, but so
  serviceable that lots of women wear nothing else
• We build bodies that last a lifetime
• Man, honest. Will take anything
• Used Cars Why go elsewhere to be cheated? Come
  here first!

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• TELEMEDICINE HAS THE POTENTIAL FOR OFFERING
  DEVELOPING COUNTRIES BOTH QUALITATIVE AND
  QUANTITATIVE IMPROVEMENTS.
• These include
• distance consultations, diagnosis and advice for
  treatment by medical specialists
• education and training. Rural health-care staff
  can have regular access to lessons given by
  specialists in hospitals (e.g. on the management
  of common and special diseases)
• access to international medical databases
• increasing effectiveness and efficiency, for
  example in reducing waiting times for
  consultations, and in introducing medical
  information systems.
• Health care network and telemedicine facilitate
  the provision of medical information distributed
  in health district and clinical centres and are
  useful for developing countries.

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TELEMEDICINE IN DEVELOPING COUNTRIES

• CHALLENGES
• 1.Poor technology infrastructure
• 2. Lack of funding
• 3. Lack of it education
• 4. Insufficient training for health care workers
• Resistance to change HCW patients

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TELEMEDICINE CHALLENGES

• Ethical Resource allocation cost-effectiveness
• Patient-Doctor relationship
• Effect on healthcare network
• Sustainability at Donor exit

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• Telemedicine in developing countries not a
  panacea
• Clinical Diagnostic Therapeutic
• Educational Administrative
• Excessive expectations
• Unsustainable funding models
• Lack of trials andevaluation data

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TELEMEDICINE IN RLC.

• Why is telemedicine worth considering in
  developing countries
• Telemedicine deserves consideration because of
  the real needs of developing countries for
  healthcare access.
• There is also the ethical imperative of trying to
  obtain the best possible healthcare in a
  resource-constrained environment

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TELEMEDININE IN Dev.Count.

• Now that worldwide satellite communication is
  available at reasonable cost, telemedicine can be
  used in many different ways such as improving
  healthcare access, supporting health workers in
  isolated settings or addressing the shortage of
  specialist doctors.
• Telemedicine thus works toward the concept of
  only one class of medicine, which transcends
  boundaries

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CHANGING FACE OF MEDICINE
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PATIENTS DEMANDS
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IF YOU HAVE BEEN!
THANK YOU FOR LISTENING
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HEALTHCARE AS A BUSINESS
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ADVERTISE - DEFINITIONOxford English Dictionary

• Make generally known
• promote (goods or services)
• physically to encourage people to buy or use
  them.
• Ask or offer by public notice.

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• Be demonstrably true in all respects
• not be misleading, vulgar or sensational
• seek to maintain the decorum and dignity of the
  profession
• not contain any testimonial or endorsement of
  clinical skills
• not claim that one doctor is superior to others
  nor contain endorsements for any particular
  doctor an
• avoid aggressive forms of competitive persuasion,
  such as those that prevail in commerce and
  industry.

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CHANGING FACE OF MEDICINE

• ART--------TO SCIENCE
• SERVICE TO BUSINESS
• PATIENT TO CONSUMERS

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HEALTHCARE TODAY

• POLITICAL INFLUENCE
• EXPANDING SERVICES
• QUALITY CARE
• PRIVATE CARE Vs PUBLIC SERVICE MEDICAL TOURISM

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QUALITY OF CARE

• Quality is never an accident it is always the
  result of high intention, sincere effort,
  intelligent direction and skillful execution it
  represents the wise choice of many alternatives
• 
  William. A, Forster

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MEDICINE AS A BUSINESS

• Medical care Economic transaction
• Doctors Purchasing agents
• Medical care Consumer good
• Doctors skilled vendors
• Market price/forces

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ADVERTISEMENT IN MEDICINE

• Be demonstrably true in all aspects
• Not be misleading, vulgar or sensational
• Seek to maintaining the decorum and dignity of
  the profession
• Not contain any testimonial or endorsement of
  clinical skills
• Avoid aggressive forms of competitive persuasion
  ,m such as those that prevail in commerce

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HOSPITAL AS INVESTMENT

• Selection of Area ( prosperous )
• Selection of patient location ( insurance cover)
• Procedure orientated
• Price mark-ups
• Avoiding low profit illness
• Management MBA versus MPH

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HEALTHCARE

• PRODUCTIVITY VERSUS PATIENT CARE
• How many patients seen
• Bed occupancy

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INFORMED CONSUMER

• Ideal market situation range options
• Healthcare and choice service of money health
  cover.
• Customer Service in Hospitals
• Hospitals are spending huge sums on customer
  service for competitive services
• Patients simply Customers

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• We all know that health care is big business
  these days, but did you know following?
• It is six to 10 times more costly to attract a
  new customer than it is to retain an existing
  one.
• A satisfied customer only tells five other
  people.
• An unhappy customer tells approximately 20 other
  people.
• It only takes 30 seconds for a customer to form
  an opinion.

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HOSPITAL REPORTS

• Customers
• Market shares
• Cash Flow Problems
• Product Vs Results
• Bottom line results
• Consumer Vs patient care needs
• Marketing/ Advertising and consumer service.

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