Dr. Schneider, what role is real time already playing in specific medical applications today?
A very large one. The repeal of the ban on remote treatment, which required doctor and patient to meet in the same place at the same time, has been doing justice to the changed care situation since May 2018. More and more doctors are retiring, more and more areas are underserved. This development can practically only be countered with ITassisted telemedical applications. Only then will we be in a position to initially examine a patient, even when they are not sitting across from us. This requires real time connectivity to a doctor who is ready to use this technology. Patients expect that today and are increasing the pressure, so to speak. A patient’s vital signs, such as blood pressure or heart rate, are basic information the doctor needs for the patient’s initial medical history but this only works when the infrastructure is in place. In the end with the patient, anywhere, regardless of where that patient is. Nothing is worse than a lack of connectivity when I need it most. This means the real need is for a health network.
What would that look like? We need a telecommunications infrastructure that offers reliable quality, stability, and service. This would absolutely allow us to improve quality of treatment in real time. It’s no longer a problem today to call up a patient’s vital signs with a tiny chip. The question remains: How does the information get to the doctor? This is why the next step in telemedicine is to shift the target group to doctor – patient communication, caretopatient communication, caretodoctor communication.
With your understanding
Prof. Henning Schneider is Dean of the Technical University Mittelhessen (THM) and Head of the Competence Center for Telemedicine and EHealth Hessen.
of real time in medical care, to what extent will patients become more challenging?
It depends on the application scenario. For patient treatment, it can be a matter of seconds. The simplest example is in the OR. Another scenario refers to the treatment decision. If I have all the information, I can make it in minutes. And sometimes I have to get this information from a distance, such as when interacting with EMS. Take stroke treatment: When a cerebral infarction occurs, “time is brain” – meaning when a vessel in the brain is occluded, every minute counts. The same applies to a heart attack. EMS often only has paramedics on the scene, and they aren’t allowed to make certain decisions. In those cases, though, I need to have someone who can assess the situation. This is why it’s important to connect to a qualified specialist – say, via video – and to give them patient information so they can decide: Is it a heart attack? Are those the symptoms of a stroke? And: Which stroke unit can take the patient at that time? I need to be able to send the patient there in real time and give the patient’s current status to the doctor on duty on the way to the hospital. This describes the time saved by what’s referred to as the prehospital solution. And it has to be managed in real time.
Then, there are also issues where we’re talking about hours or days. Such as when I want to get a second opinion from a colleague. But in all three categories, the service concept that patients – just like customers – want to be helped more and more quickly, ideally right away, plays an increasingly important role.
Patient treatment, nursing and healthcare, EMS management – Health Informatics is a broad field. What role do the points of contact play within this field?
This question is the core challenge. Until I’ve identified and engaged with these interfaces, as a doctor, I can’t do anything. The first step is to define the points of contact. How do hospital and doctor’s office communicate to exchange information? These days, we see more that the actual gobetween for all in formation is the patient. Otherwise, it would be impossible to have all the information wherever a patient goes unless the patient “acts”, as it were, as a real time information carrier: with medical file, medical history, medication regimen. So far, every concept assumes that, to do this, we need a centralized infrastructure with high availability that provides the protagonists of a dedicated process all the information they need in real time. This means the network is in place, the files work, no media discontinuity – on the other hand, the information can be examined. Unfortunately, with the IT and interface landscape of this network in mind, there’s hardly a more heterogeneous health system than in Germany. This is why we want to bring the medical files to the patient. How would that work? There’s a wide variety of models. Nearly everybody has a router at home. That fact alone has three major advantages: you have an Internet connection, the patient has their information at home, and there’s a hard drive for storing this information. This function is already a service offered by the provider of Speedport. If patients were to then be able to put the information on their cellphones before going to the doctor or access their router from the doctor’s office in real time, they would be the ones to decide who gets what information from them. This is the kind of offering that must be made to patients. If a provider said, I’m going to slap a health service on our router for 2, 5, or 10 euros a month and supply my clients with the matching app, it would take off. Of course, we’re just researchers and don’t need to sell anyone anything, but for 10 euros a month, that’s about 32 cents a day, I would elevate my personal healthcare to a completely different level.
As a side effect, everyone would practically be their own data protection officer.
That’s exactly it in a nutshell. You have a smartphone and a bar code. The person across from you can only access your information if you let them scan this bar code. The patient also decides what information is in the file. This is an entirely different angle, since we doctors can’t get information faster than a patient bringing all necessary information with them. What if a patient can no longer speak or is incapacitated? They would at least need to have an identifier on their person. Ideally, a signed consent form under the bar code. I scan it and get the patient’s basic information from their central file. In a few years, it will be normal for patients to carry their medical information with them – in the form of a bar code, a small chip or even a tattoo. That would certainly be more sensible than a lowerback tattoo. This option also needs to be considered from an ethical standpoint, but this type of medical card will come, one day. Just one provider needs to offer this kind of product for it to take hold. I’m convinced of that. It’s visionary, if you like. But it’s a vision of real time that couldn’t be more real. How far along are you in building appropriate integration centers for consolidating the data islands from the fields of medical care and research? At the outset, the goal of a 100millioneuro initiative by the federal government was to just consolidate the data that was available in the various far corners of a hospital. This included research data. Today, our data integration center in Giessen can solve this problem. The job now is to process data so a doctor can do something with it in real time, since they should be able to get the information expected from a certain keyword or hashtag from very simple algorithms without having to click through complex applications. This is what we’re currently working on with the universities in Erlangen, Greifswald, Mainz, Frankfurt, and Magdeburg. Working together in this manner, beyond the classical competition between research sites, is a first in Germany. We’ve broken up this competitiveness in the field of Health Informatics.
Going back to the health network – how long has that been under discussion?
For about a year. And EMS understood it right away. When someone dials 112 today, EMS is given the address, a general description of the patient’s condition, like “suspected soand so”, and that’s it. If we had access to the patient’s router, we could give their information to dispatch. Then, when the EMTs reach the patient, they’re already familiar with that patient’s entire medical history. The time that would be saved here would often save lives. And if we were then to use the nearly 30,000 wind turbines, we have right now in the country to expand cellphone networks, a lot would be gained in terms of network coverage. They do it in Austria, but unfortunately it hasn’t happened in Germany yet.
"Patients carrying their medical data on them – as a barcode, small chip or tattoo – will become the norm" Professor Dr. Henning Schneider, THM Gießen
Who would use the health network?
We always talk about doctors, but it’s the nurses who have far more intimate contact with patients and would possibly need to be able to decide what should specifically be done with a patient. That means we would also need a platform for nurses that would allow them to forward information on their patient to a medical center in real time. From there, a doctor can bolster their medical decision and have it carried out immediately by trained personnel on site. Another possible application is smartwatches to analyze bio signals or, as they do now, record ECGs. Millions of people today die from atrial fibrillations because it takes minutes for help to arrive. If this data were analyzed by a module in real time, it could report something to a public entity like: “At these geocoordinates, a person is experiencing an atrial fibrillation and will soon have an emergency.” Or when blood pressure gets out of hand, a cardiologist is immediately notified. That would improve the quality of care and treatment substantially.
But to what extent is a lack of standards a sticking point?
That’s a sore spot, a real plague, if you like. Let’s take just emergency vehicles. Regardless of who builds the vehicle – there’s no standard regarding the medical technology installed in it that would make it possible to use a normal industrial PC to connect to hospitals. It would only take a political directive that says: By 2022, we will only use medical technology in emergency vehicles that is compatible with this dedicated industrial PC. I would already have a standard, then. The PC establishes the encrypted connection to the dispatch centers and communications technology practically becomes a standard feature from the manufacturer. If the vehicles could then roam from one network provider to another without hitting a dead zone, that would be ideal. That would also be a political directive no one would be against.
And what about your own homework? Have you done it at least?
No, even we at the hospitals need to lead the way. There aren’t any standards for, say, hospital information systems. With a standard HIS, doctors and nurses would immediately be productive after changing employers. Today, it can take days before they’re familiar with a new system. The result of this is the resources of 1,000 fulltime positions spent at German hospitals every year amount to new induction training only. An unjustifiable absurdity.
There needs to be massive interest in this topic from health insurance providers and in terms of health care policy. What’s lacking is a political decision about which HIS on the market – for cost reasons and due to the fact that we have a massive skills shortage – will be used for the next 10 years. The question we’re asking ourselves is: “What needs to happen for health care policy to intervene in this market? How many patients still need to be examined two or three times before this jungle of hospital systems is brought to an end?