The Human Challenge of Telemedicine

Toward Time-sensitive and Person-centered Ethics in Home Telecare

Philippe Bardy

• Publisher: ISTE Press - Elsevier
• Year: 2018
• Print ISBN: 9781785483042
• eBook ISBN: 9780081028926
• Topic: Medicina
• Subtopic: Industria farmacéutica, biotecnológica y sanitaria

Telepatients using connected objects to collect time-sensitive data about their health are not neutral carriers of diagnosable symptoms. Patients are persons, or personal beings as well as co-carers, whose personal experience, history and know-how must be acknowledged in time-sensitive telecare practices. Such practices require a relational ethics, inspired by medical ethics and an ethics of virtues, focusing on vulnerability and emotional health, to oversee telecare good practices, define a new therapeutic alliance compliant with patients' values, and reconcile the technical and human sides of telemedicine.- The ethical challenges of telemedicine in chronic patients today- The key features of a person-centered and relational ethics in telemedical settings- The concepts of "emotional health care and "chrono-sensitivity of the "connected sick body

Part 1

The Person in the Age of Telecare

1

The Advent of Digital Healthcare

Abstract

Telemedicine, i.e. the use of digital technologies by healthcare professionals for remote medical practice, has enjoyed national deployment since 2012, following its legal recognition in the Hôpital, Patients, Santé, Territoires (HPST: Hospital, Patients, Health, Territories) law of 2009 and the description of its regulatory framework in the decree of October 19, 2010. Telemedicine does not replace current medical practices but is a response to the challenges facing healthcare provision today: inequalities in access to care, medical demography, decompartmentalization of the system and economic constraints. In France, professionals in the health and medico-social fields are developing an awareness of the need for a multidisciplinary, transversal and coordinated approach to improve the health pathways.

Keywords

Chronic diseases; Device management; Digital healthcare; E-health systems; Healthcare management; Patient management; Posttherapeutic follow-up; Telecare; Tele-follow-up; Telemedicine

The more the presence of medicine is based on technique, the more the subject to which it is addressed is fiction.

Didier Sicard [SIC 02, p. 17]

1.1 Digital healthcare as an ecosystem

Telemedicine, i.e. the use of digital technologies by healthcare professionals for remote medical practice, has enjoyed national deployment since 2012, following its legal recognition in the Hôpital, Patients, Santé, Territoires (HPST: Hospital, Patients, Health, Territories) law of 2009 and the description of its regulatory framework in the decree of October 19, 2010 (see Box 1.1). Telemedicine does not replace current medical practices but is a response to the challenges facing healthcare provision today: inequalities in access to care, medical demography, decompartmentalization of the system and economic constraints. In France, professionals in the health and medico-social fields are developing an awareness of the need for a multidisciplinary, transversal and coordinated approach to improve the health pathways.¹

Box 1.1

Definition of telemedicine in the HPST Law

The HPST Law – article 78 – amending article L.6316-1 of the French Public Health Code defines telemedicine as follows: “Telemedicine is a form of remote medical practice using information and communication technologies for screening and diagnosis, consultation, expertise, conference, monitoring, transmission of images and data, and therapeutic intervention”. The law specifies that it puts in contact, with each other between them or with a patient, one or several health professionals among whom are necessarily a medical professional and, if necessary, other professionals bringing their care to the patient. Telemedicine makes it possible to establish a diagnosis, provide preventive or posttherapeutic follow-up for an at-risk patient, request specialized advice, prepare a therapeutic decision, prescribe products, prescribe or perform services or procedures, or monitor the condition of patients.

Telemedicine is one component of digital health (see Figure 1.1)². The Conseil national de l’ordre des médecins (CNOM, French National Medical Association Council), in a report in January 2009 concerning recommendations on telemedicine, states that telemedicine must be distinguished from the notion of telehealth. Telemedicine constitutes a specific subset of telehealth, the main characteristic of which is that it concerns regulated professions. However, telehealth applications are broader than telemedicine applications. This includes, for example, all sites and portals, in whole or in part related to health, that can be found on the internet. These sites, well known to patients and practitioners, offer numerous services: advice, recommendations, articles, forums, newsletters and, for some of them, online medical records.

Figure 1.1 The digital health ecosystem³

Table 1.1

Characteristics of stakeholders involved in the development of e-health in Europe (non-exhaustive list)

Telemedicine stakeholders	Telemedicine companies
Software publishers	McKesson, CompuGroup Medical, Corwin, Medisys, Meditrans
IT service providers	IT services providers/integrators such as Atos Origin or Sopra Group
Manufacturers of medical devices	Philips, Biotronik, Medtronic, Sorin, GE Healthcare, Nx Stage, Physidia
Health data hosts	2CSI, Carestream Health, Cegedim, Cerner, Sigems
Telecom operators	Orange, Deutsche Telekom, British Telecom, SFR
Telemedicine and telehealth service providers	Intervox, H2AD, Wengo Santé, N2TS, Adechotech, Hailadoc, Teckel Medical, MedGo, Phemium

According to SYNTEC NUMERIQUE (Syndicat professionnel de l’industrie du numérique [French Digital Industry Trade Union]), the telemedicine situation for chronic diseases in France is one of adapted technologies and established regulations, but also an embryonic concretization. After the publication in 2012 of a first white paper (Telemedicine 2020), SYNTEC and SNITEM (Syndicat National de l’Industrie des Technologies Médicales [French National Union of the Medical Technologies Industry]) note that chronic disease management is mainly limited to device management (reporting alerts on communication equipment) and has not integrated a broader dimension: that of patient management. The situation has since changed considerably in the direction of increased psychotherapeutic patient management.

This evolution is primarily due to the actions carried out by various organizations bringing together the knowledge and skills used in telemedicine in France and Europe, including CATEL, the French Telemedicine Society, and Agir pour la telémédecine, the European Telemedicine Society (see Table 1.2).

Table 1.2

Key professional telemedicine organizations in France and Europe

Associations and professional bodies	Missions
CATEL – Club des acteurs de la télésanté [Telehealth Stakeholders Club]	National e-health reference organization in France. Since 1997, its mission has been to contribute to the development of telehealth, telemedicine and e-health in all its fields of application^4.
Société Française de Télémédecine [French Telemedicine Society]	Developing telemedicine research to improve patient management^5.
Société internationale de télémédecine et eSanté [ISFTeH - International Society of Telemedicine and e-health]	Facilitating the dissemination of knowledge and know-how in telemedicine and digital health, as well as access to internationally recognized professionals in these fields of expertise^6.
Agir pour la télémédecine (Association loi 1901) [Taking action for telemedicine (Law Association 1901)]	Facilitating telemedicine deployment and collaboration between stakeholders^7.
Société Européenne de Télémédecine [European Telemedicine Society]	Stimulating basic, epidemiological, technological and operational research in the field of telemedicine and supporting research programs^8.

This phenomenon can also be explained by many factors: the emergence of more efficient and collaborative technologies, the explosion in the number of telemedicine projects, the creation of French Regional Health Agencies (ARSs) that ensure, to a large extent, the coordination of these projects, the deployment of e-health services through the Digital Hospital program piloted by the DGOS, the generalization of the Personalized Medical Record (PMR) led by ASIP health, the Plan National très Haut Débit (Very High Broadband National Plan) managed by DATAR at national level and by local authorities and prefectures at regional level and finally the implementation of a National Strategic Plan (NSP) in France for the deployment of telemedicine, piloted by an interministerial committee that has defined five priority projects. These five priorities are as follows: teleimaging, stroke management, prisoners’ health, care in medico-social structures or in AHH (at-home hospitalizations) and management of chronic diseases in the context of remote monitoring (diabetes, chronic end-stage renal failure, heart failure). This French National Strategic Plan for the deployment of telemedicine is piloted by an enlarged interministerial committee under the chairmanship of the Direction Générale de l’Offre de Soins (DGOS, General Management of Healthcare Provision) and including representatives of the following institutions:

• – the Délégation à la stratégie des systèmes d’information (DSSIS, Information Systems Strategy Delegation);
• – the Agence des systèmes d’information partagés de santé (ASIP Santé, Agency for Shared Health Information Systems);
• – the Agences régionales de santé (ARSs, French Regional Health Agencies);
• – the Délégati...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Acknowledgments
• Introduction: Temporalities and Psycho-Emotional Dimension of the Technicality of Care
• Part 1: The Person in the Age of Telecare
• Part 2: Telecare Phenomenology
• Part 3: Toward an Ethics of “Time-sensitive” Telecare
• Conclusion: Reconciling the Humanity and Technicality of care
• List of Abbreviations
• References
• Index