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Charting the Course of Telemedicine: An International Perspective

November 8, 2013
by John DeGaspari
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The CMIO of UPMC’s International and Commercial Services Division speaks about how telemedicine is taking shape at home and abroad

Driven by the broad availability of mobile devices and health apps of all kinds, telemedicine is taking the center stage as a game changer when it comes to patient engagement, care coordination and extending the reach of care. The fast-growing trend has gained a lot of interest from provider organizations in the U.S. as well as in Europe, as evidenced by the first European Telemedicine Conference that was held in Edinburgh, Scotland on Oct. 29 and 30. The four organizations behind the event—the University of Pittsburgh Medical Center (UPMC), HIMSS Europe, Odense University Hospital in Denmark, and NHS 24 Scottish Centre for Telehealth and Telecare—describe the conference as a platform for all stakeholders to share success stories and challenges across borders.

Andrew Watson, M.D., CMIO of UPMC’s International and Commercial Services Division, who was a presenter at the conference, said in an interview with HCI prior to the conference that the various stakeholders had both a global presence and represented unique perspectives, adding up to an important learning opportunity for all involved. Among the questions addressed at the conference were how telemedicine allowed care coordination, how does it enable access to the right level of care, and how should the value of telemedicine be defined. 

“We wanted to present a view of telemedicine and where it’s headed,” said Watson, who is also on the board of the American Telemedicine Association. From the American perspective, “We have significant issues of access to care and we also have a significant issue of care coordination,” he said. Watson noted that UPMC does thousands of consults in the rural areas of Pennsylvania. Scotland, which also includes remote areas, has its own access issues that are different than those of Denmark, which has a homogeneous, fairly well-connected population, he said.

Watson observed that care coordination is a universal issue. Denmark is investing heavily in analytics, access to care and patient registries, which fall broadly into care coordination and predictive care. In the U.K., coordination is critical for controlling costs for the National Health Service, its national system. In the U.S., where, according to the Centers of Disease Control and Prevention, 75 percent of healthcare dollars go to the treatment of chronic diseases, care coordination is key to controlling costs as well. “There is no doubt that telemedicine can enable us to put all of these pieces together in the cloud, so that a patient can be in one location with a nurse or a primary care physician, and can bring in specialists or consultants, through telemedicine, right to the bedside,” he said. “Telemedicine puts the pieces of the puzzle together like never before.”

One of the questions that need to be explored further is the value proposition of telemedicine, Watson said. Is it a question of giving the patient access to more consults, which can drive up the costs of care, or is it better care coordination as a way to keep the patient out of the hospital by managing care in the home and having access to online portals, he asked.

In Watson’s view, healthcare has made significant progress in providing better access to care, which he said is as much a consumer electronics phenomenon as it is healthcare reacting to that and leveraging it. At UPMC, the trend has made itself felt in its hospitals and rural clinics, he said. The next step in care access is to bring the technology into the home. “I would think, as a practicing surgeon, I can do my follow-up in the house and not have the patient come to my clinic,” he said.

Watson acknowledged that care coordination is a complex undertaking, with patients requiring several caregivers; but when a patient has to travel a long distance to a rehabilitation clinic, that’s an extra hurdle. Video can help to coordinate care, but is still limited by major capital costs, he said.

Watson believes the biggest impact of telemedicine will be in chronic disease management, which he said goes hand in hand with patient engagement. Using telemedicine technology, “We can do primary care at home; we can do sub-specialty consults at home; we can do screening care, well care at home, or in employer on-site telemedicine clinics. The concept of engaging the patient and doing care coordination at home or through mobility is the latest potential of telemedicine,” he said, adding that in addition to being an important theme at the Scotland conference, it will also be highlighted at the American Telemedicine Association meeting in May.

If telemedicine can increase patient access, does that hold true for all patient populations, including the elderly? Watson said there are two sides to that answer. In his own experience, he said has been practicing telemedicine for nearly five years in a rural hospital. “What caught me off guard the most about my own personal journey in telemedicine was the acceptance of telemedicine by the elderly,” he said. He has used telemedicine when advising very elderly patients on complex surgical decision-making. He observed that elderly patients are among the least likely to drive; many are hesitant to ask their son or daughter to drive them; and hiring a car is an added expense. “The elderly are actually one of the biggest adopters of this,” he said.

He acknowledged that in the case of patients who are truly resistant to using technology, the burden does fall on other family members, who are usually very adept at using technology. For patients without that support and who eschew technology, assistance can come from a health plan, which is the case at UPMC, he says.

Watson said technology will continue to drive interest in telemedicine with smaller, lighter and more powerful devices and applications. “At some point you are going to have devices that you put on your skin or in your pocket, akin to the Fitbit but with 10 times the capability,” he said. “They are going to call that PAN or BAN for personal area network or personal body network, and it will be unobtrusive, fully capable, and give us the capability of working with the elderly and with chronic diseases, because health, healing and wellness starts at home and should always stay at home.”

One challenge to the wider adoption of telemedicine is interoperability between various electronic medical record vendors, which holds back wider telemedicine adoption, Watson said.

Watson also drew attention to certain similarities between large integrated health systems and health systems in countries that have national health systems. “They are already developing and working with telemedicine under the mantra of the payer-provider,” he said. In the U.S., large integrated health systems such as UPMC can link payers and providers under accountable care organizations. His point was that there are lessons to be learned from both models, and can be adopted by small or rural hospitals and even large academic medical centers that are not integrated.


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