A virtual reality

The term eHealth is used increasingly as a generic expression to refer to any form of IT-enabled health system reform.

eHealth addresses both changes in the access of healthcare information and services, as well as the wider dissemination of healthcare-related skills and specialist expertise into the community, the home, and, ultimately, to the individual.

This transformation enabled by eHealth challenges the traditional roles of hospitals and clinics, where healthcare exchange has taken place historically. The next phase includes the use of mobile devices to provide a user-friendly interface and a conduit for healthcare providers to bring services directly into the personal space
of the world citizen.

NHS Connecting for Health in England is arguably the largest single eHealth project on the planet, but future developments are likely to be in mobile applications and services that are personally configured and delivered directly to each member of the community, according to his/her needs.We are entering the Bio-Intelligence age, with convergence of biological sciences, physical and engineering sciences, and IT.

The unravelling and understanding of the human genome will allow us to analyse the genetic fingerprint at, or even before, birth and thus predict health risk throughout the lifetime of an individual. Biomathematics is now being applied to the science of medicine.

The global phenomenon that is current demographic change - with a booming population of senior citizens reaching 65 years of age and beyond - is unmasking chronic and non-communicable diseases, which are swamping current healthcare services and consuming 60-70 per cent of national healthcare budgets.

This is going to get worse: in developed countries, some 16-20 per cent of the population is now over 65, and while this trend can be partially balanced by falling birth rates, in developing countries, such as Mexico, there is an increasing number of 65+ people and the birth rate is rising.

This trend will place an increasing burden on healthcare systems in the years to come, thus begging the question: who will support the health and welfare systems of the world in the future?

it's all about you

We have not yet achieved full integration of IT into healthcare around the world.

The manufacturing and financial services industries adopted IT over a period of 5-10 years during the 80s and 90s, respectively. In the healthcare sector, we are only just emerging out of the phase when networks are being developed, but complete IT integration will follow rapidly.

In our current state, the term eHealth is widely misunderstood. It is best defined by Professor Jean Claude Healy of the World Health Organisation: `eHealth is the instrument for productivity gains in the context of existing healthcare systems, but also provides the backbone for the future citizen centred environment.'

We are truly at the dawn of the age of citizen-centric healthcare systems.

your e-future...
eHealth can be allocated conveniently into four major domains: the first embraces clinical applications, including individual eHealth records, tele-consultation and the use of video conferencing, clinical decision-making support software, vital signs monitoring services for those with chronic disease, tele-homecare, the emerging field of ambulatory eHealth and the wearing of `smart' clothing (such as eWear for continuous monitoring of vital sign parameters), the deployment of national ePrescribing and eBooking systems, eNursing and National Picture Archiving Communication Systems (PACS).

The second domain addresses the use of eLearning tools and the worldwide web to deliver personalised professional continued healthcare education.

As the half-life of medical knowledge shrinks, it is important for all those working in the healthcare sector to keep their skills and knowledge base current.

The third domain addresses public health education and information: media channels are underused to promote self-help to citizens in relation to healthcare matters, and consequently change healthcare demand profiles.

The impact of appropriate healthcare knowledge imparted to the individual will reduce the demand on healthcare systems regarding conditions which could be self-treated, or perhaps treated in the community environment by increasing the involvement of pharmacists, for example, in the health knowledge pool.

The fourth domain to explore is the use of aggregated individual eHealth records, which capture longitudinal healthcare events for each individual citizen. By aggregating key elements of the data, one could achieve population-based tracking of health trends in real time, leading to advanced prediction and anticipation of hostile disease trends - and thus initiate prevention strategies.

Wellness guardian
Perhaps the biggest impact of these new models of healthcare access and delivery in the immediate future will be on the primary care teams.

Increasingly, patients will arrive for a consultation with the GP, well informed about their condition and with (possibly strong) opinions regarding its management and treatment options. Patient web communities have already been set up, where strangers with similar medical conditions communicate with each other and therefore add to the care pathway.

Indeed, I wonder if the family doctor will eventually become a `wellness guardian', with a separate service geared to respond to acute problems possibly through a call centre model, such as NHS Direct.

Change drivers
Yet, it is important to understand that telemedicine and eHealth are only two of a number of drivers which are impacting on healthcare delivery and thus changing healthcare models:

There is a universal search for cost containment as healthcare costs spiral out of control

The demographic changes are impacting heavily, especially unmasking patients with chronic disease

There is an increasing ability to provide diagnostic and treatment services on an ambulatory basis

Disease patterns are changing globally; globalisation is enabling us to share resources across international borders - and this applies to healthcare

Epicentres of medical excellence are emerging with specialist expertise, such as cardiac centres or oncology, which can now be spread regionally or indeed globally through eHealth - the differing time zones could be used to advantage by radiologists, for example, living in India, who are awake during office hours, being able to provide primary readings for hospitals in the UK during the night, thus removing the need to hire expensive UK radiologists to work or be on call during the night hours.

Diabetic e-help
A practical eHealth solution is to provide a Managed Clinical Network (MCN) which is disease-based - such as being open for subscription to all patients with diabetes (or any other chronic disease) - and a service that is both accessed and delivered virtually, bearing no relation to the patient's residential location or the service provided by the local healthcare facility, or hospital.

The diabetes MCN offers centralised monitoring of blood sugar and HbA1C, as well as other relevant parameters whereby a health contact centre (call centre) can then track disease management progress for the individual patient and suggest amendments to the dose of insulin and diet. In fact, this model has already been deployed successfully in the US by two firms, iMetrikus and Health Hero.

The major global telecoms operators are looking seriously at such services to be delivered over mobile networks, possibly by direct subscription. The benefits are an enhanced and relevant service to afflicted patients and also an easing of the burden of demands on the local health service.

It is important to recognise that such MCNs could be offered to patients who are spread globally and thus cross international boundaries. They can offer enhanced care to patients with many chronic conditions - with 70 per cent of national health budgets being spent on looking after patients with chronic disease, the benefits are clear.

Countries that have joined the European Community recently have very different levels of service delivery and healthcare outcomes. Given the ability to share healthcare resources across borders using eHealth, it may be possible to improve levels of care substantially in a number of newly acceded countries. However, this may impact adversely on Member States which currently enjoy high standards of healthcare provision.

Shifting ideas
There is a universal realisation that the present healthcare models are unsustainable in financial terms and thus need radical rearrangement. The solutions are to drive the interface point of care outwards and out of current buildings (hospitals and clinics) and to use eHealth as a platform
in order to achieve this transformation.

It will be necessary to migrate both patients and healthcare professionals across borders and to reconfigure the professional eHealthcare team as well as reconfigure the infrastructures.

The challenges for the future are not technological, but are focused upon persuading colleagues who work within healthcare to embrace new technologies, applications and services, and to consider how this might change the way they practise and work.

Additionally, patients need to move away from fixating on their local hospital and consider improved means of looking after their health and disease processes. The adoption of eHealth and the consequent health system transformation is not easy, but is viable. I think our children and grandchildren deserve better healthcare provision than we currently enjoy today.

The author
Professor Ricky Richardson (FRCP, FRCPCH) is  a  visiting  professor  in  eHealth  at  Imperial  College,  London, VP of the International Society for Telemedicine and  eHealth, and a Consultant Paediatrician