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IMR 655: MANAGEMENT OF MEDICAL RECORDS

TELEMEDICINE: VARIOUS COUNTRY PERSPECTIVES

1.0 INTRODUCTION

In this day and age, technologies are widely use in many sectors. The
rapid changes and development of communication technology lead to the improvement
in managing information in health care. Nowadays, telemedicine is an emerging field
within medicine with potential to alter the delivery of health care. The term telemedicine
can be defined as the delivery of healthcare services, where distance is a critical factor,
by healthcare professionals using information and communication technologies for the
exchange of valid information in diagnosis, treatment and prevention of disease an
injuries, and for the continuing education of health care providers as well as research
and evaluation, all in the interest of advancing health of individuals and their
communities (World Health Organization, 1997). It means to facilitating access to
medical information and expertise. Based on the definitions above, I believe the
telemedicine goals are to improving of health care and by means in reducing cost
because the medical practitioners are able to manage their data systematically.
The concept of telemedicine are based on the convergence of computers and
telecommunication technology in the form of images, text and audio, the amount of
information and interaction that can be shared during a consultation changed (Forster,
Caring, 1997). Telemedicine are generally refers to the use of communications and
information technologies for the delivery of clinical care and will assist in transforming
the way healthcare services are delivered in the future. It is also can be use in remote
are.
In Malaysia, the telemedicine concept was still under development process.
Although it was in developing process, some of the hospitals in Malaysia have been
launched the telemedicine by the management of information and the operation in
surgery room. This includes the convention among Malaysian medical practitioners with
other country by using videoconferencing. Improvement of healthcare services in the
country requires continuous restructuring and process advancement. The most
innovative feature of Multimedia Super Corridor (MSC) telemedicine is its broad
definition and all-encompassing scope beyond the traditional point-to-point data
exchange model useful primarily to healthcare professionals in well-equipped urban
hospitals and laboratories. The role foresee for telemedicine includes personal self-help
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AN ESSAY ON MEDICAL RECORDS ISSUES
TELEMEDICINE: VARIOUS COUNTRY PERSPECTIVES
IMR 655: MANAGEMENT OF MEDICAL RECORDS

with health problems and choices for a health-promoting lifestyle through availability of
sound information and virtual health services. Telemedicine is also expected to equalize
imbalances in the distribution of physical health services.

2.0 TELEMEDICINE ISSUES OR CHALLENGES

There are various issues pertaining to the telemedicine. These issues that will be
discuss may be related with Malaysia situation which includes privacy, confidentiality,
security, information and medico legal cases, standards, legal and regulatory
requirement and technology and change management. Other issues that can be
highlighted also comprise of social and rural considerations.

2.1 PRIVACY, CONFIDENTIALITY AND SECURITY


Today, major events and transition occur between an individual and
organization. Each transaction results in records. The issues may
comprise of privacy, confidentiality and security. The privacy,
confidentiality issues should be addressed in development of
infrastructures to support use of data sets for health planning and quality
improvement. The individual loses control of the collection, use and
disclosure of information about himself. He may not even be aware that
such an activity is occurring for instance the cookies on computers that
extract information about the users and sent it to a central database
without the user’s knowledge or permission and he may not have any
procedure to ensure accuracy of information. Medical encounters
constitute one form of such transaction and carries grave implication for
the individual in terms of employment, finance and health care (Scot,
1994). Privacy has been characterized as the “right to be left alone”.
Privacy of medical data comes under one concept of information privacy
(Yeo Khee Quan, 2000). This can be defined as controlled access to
personal information. An individual’s right to such privacy has to be
balanced against the need for medical information to be available for
activities of benefit to the public. Next is confidentiality. Data
confidentiality refers to disclosure or non-disclosure of information. It is a
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AN ESSAY ON MEDICAL RECORDS ISSUES
TELEMEDICINE: VARIOUS COUNTRY PERSPECTIVES
IMR 655: MANAGEMENT OF MEDICAL RECORDS

status accorded to medical data indicated to be protected and must be


treated as such. Confidentiality in health care is established under the
doctor’s obligation to respect the privacy and confidentiality of his
patients. Doctors and medical organizations acknowledge this as
essential pillars of medical practice if the doctor is to gain the full
confidence of the patients (Yeo Khee Quan, 2000). The issues of
confidentiality and the protection of patient medical records were
recognized as magnified by the advances in telemedicine because of the
amount and site of information generated. But still the confidentiality of
the data stored or transformation can be questioning. Who are the
authorized person that have the right to access the data? Who is the
responsible person during transformation process? As far as I concern,
long-distance transmittal, storage and access, the developments of
technology that enhance the provision of healthcare, also raised anxiety
about the privacy, security and confidentiality of patient information. I
strongly agree with the author’s opinion because the patients have a right
to make their health information are kept secure and should be kept
secret. This is due to respect the patients’ requirement. Other issues that
can be related to privacy subject are security. These are include
unauthorized access or use of a computer, service, or data, manipulation
or alteration of data, programs or a computer system’s hardware and
misappropriation of information via a computer or telecommunications
system. Security features should make it possible to allow only authorized
individuals to access data, with different levels of access being
recommended to ensure greater system security (NHS Executive, 1998).
For example, this can be seen from the situation of British Army, using
either anonymous data or encryption techniques can protect confidential
Patient Information. Anonymous data is inappropriate for networks with
high volumes of similar referrals. The use of the National Health Service
(NHS) network is thought to be the best medium for the transfer of clinical
information according to the Information for Health strategy by reducing
the need for data encryption although it is acknowledged that no system

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AN ESSAY ON MEDICAL RECORDS ISSUES
TELEMEDICINE: VARIOUS COUNTRY PERSPECTIVES
IMR 655: MANAGEMENT OF MEDICAL RECORDS

is entirely safe (Jones, Banwell, Shakespeare, 2004). To ensure privacy


and confidentiality of medical information, principles that ensure the
security in the maintenance of such information has been established.
The principles of security encompasses to physical security of storage
and archiving, security of storage media and electronic security which
mean by rights of access and audit trails. Upon on these issues, I believe
that steps are necessary to be taken to ensure public trust in system by
demonstrating real effort on privacy concern.

2.2 INFORMATION AND MEDICO-LEGAL CASES


This issue is about the timely availability, the content by means of high
quality and evidenced-based. The link between information and health
care quality is a recurrent theme in the literature “… a major bottleneck to
improving health service delivery is a lack of access to quality health
information. We need leadership within academic medicine to promote
access and use of information communication technologies addressing
global health issues” (Sewankambo, 2004). When information is
integrated at source, studies have found communication between staff to
be more effective (Mercadante, Lanza,1994). Electronic health records
are to serve and to combine patient information from all health and social
care records. This ensures that patients and nurses do not waste time
repeating medical history or other information, such as medications
prescribed. Many avoidable limitations in the health sector that result in
poor quality are due to inaccessible data, information, and knowledge.
Records should be contemporaneous. They should be made during or
soon after the encounter. The reasons for the delay should be noted. This
is because the closer the record is made to the time of the event, the
more likely the court is willing to accept that it is accurate. However,
under the pressure of work, the doctor often cannot find the time to make
detailed and accurate records at the time of the event, for instance, during
surgery or in an emergency. Otherwise, patient registration and tracking
systems, telemedicine electronic order entry systems, and the advent of

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AN ESSAY ON MEDICAL RECORDS ISSUES
TELEMEDICINE: VARIOUS COUNTRY PERSPECTIVES
IMR 655: MANAGEMENT OF MEDICAL RECORDS

electronic health records are some examples of applications that


influence patient care in emergency departments. Modern equipment
such as dicta-phones and computer software for voice to text conversion
has been used to facilitate the process of note making. In an emergency,
the doctor and nurses have no time to make records at the time of the
event. Memory of events becomes inaccurate very rapidly. Delays may
lead to important facts being omitted or being distorted. Accurate records
in these situations often save the day for the doctor in court. Evidence-
based medicine combines clinical epidemiology, biostatistics, research
methods and medical informatics into clinical practice. It has occurred in
part because the medical practices need to translate the evidence from
research into clinical practice . In medico legal cases, the emergence of
telemedicine as a technique for health services raises many issues.
Medical practices realize that with new customs and practices create new
dangers. Areas of concern identified include patient consent, the creation
of the electronic record, transmission, physical risk, professional
indemnity and litigation, ISDN security, the National Health Service (NHS)
network and encryption (Jones, Banwell, Shakespeare, 2004). It is the
aim of the information health strategy to ensure that the technology
brought is available to help patients receive the best possible care
through the use of IT. Undeniably, the introduction of telemedicine is a
high priority in current governmental legislation. Electronic records by
their nature can give rise to medico-legal problems because of ease of
rapid dissemination to multiple sites, ease of copying, ease of access and
need third parties to access records which mean by these would include
non-medical persons such as the vendors for the electronic record
system and data entry personnel can access to the record. Electronic
medical record systems are important in medico-legal case as the
electronic information would be submitted as evidence for the court. To
qualify as evidence, it must satisfy the laws of evidence. The primary rule
of evidence requires that the original evidence can be collected and
preserved in its entirety. In my opinion, the information must be available

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AN ESSAY ON MEDICAL RECORDS ISSUES
TELEMEDICINE: VARIOUS COUNTRY PERSPECTIVES
IMR 655: MANAGEMENT OF MEDICAL RECORDS

when it’s needed. This is to ensure the services meet the requirement of
the objective telemedicine is made. It also means that based on the
technology uses, it will facilitate the retrieval of the information health in
the point of need of both patients and medical practices. However, the
ethical codes are needed to conduct for publication of health information.

2.3 STANDARDS
Standards are made falls into two categories which defined by industry
and identify and defined for use in national network. It also command the
development and implementation of national identifiers for patients,
providers, payers, and employers, and the adoption of security and
privacy standards appropriate for the protection of individually identifiable
healthcare information. For instance, we can adapt by United States that
came along with the Standards for Privacy of Individually Identifiable
Health Information formulated under ‘Privacy Rule’ which includes
standards to protect the privacy of individually identifiable health
information. The rules apply to health plans, healthcare clearinghouses,
and certain healthcare providers, and present standards with respect to
the rights of individuals who are the subjects of this information,
procedures for the exercise of those rights, and the authorized and
required uses and disclosures of this information (Volkert, 2000). There
area number of different groups involved in developing international
standards for health informatics by means of both technical standards
and standards relating to terminology, coding and classification. The
International Organization for Standardization (ISO) has a technical
committee (TC 215) dealing with standardization in the field of information
for health, and Health Information and Communications Technology
(ICT). The aims are to achieve compatibility and interoperability between
independent systems, to ensure compatibility of data for comparative
statistical purposes and to reduce duplication of effort and redundancies.
The telemedicine policy and standards that were aligned by Malaysia
situation are firstly, common standards which use standards set by

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AN ESSAY ON MEDICAL RECORDS ISSUES
TELEMEDICINE: VARIOUS COUNTRY PERSPECTIVES
IMR 655: MANAGEMENT OF MEDICAL RECORDS

Electronic Government. Another standard is the use of International


Health Informatics standards is based on the additional standards specific
to telemedicine which include Medical Image Storage and
Communication and Health Data Structure and Communication. In Manila
situation, for example, there is an issue of standards in transmission
especially with pathology and teleradiology and the other clinical sciences
vis-à-vis the quality of images that are transmitted. This is relevant
because quality of images will have a bearing on the decisions that you
may have to make (Pesigan, Ofrin, 1998).

2.4 LEGAL AND REGULATORY REQUIREMENT


Legal are crucial for community safety. Law is the product of social
interaction and it exists to serve the community. It reflects the political,
economic, social and moral values of a particular society (Wu Min Aun,
2005). According to Simpson (1988), the English “Legal system do not
merge out of nothing; they possess a history, and reflect ideas, and make
use of institutions, which have developed over time, and been moulded
by cultural and political forces.” The Malaysian legal system is a plural
system so it is far more complex and varied than say the English legal
system from which it drives so many of its tradition. The government in
Malaysia is not only putting in place the necessary infrastructure to
enable the establishment of telemedicine, but it is also introducing four
enabling legislation for the successful practice of telemedicine. There are
laws pertaining to the telemedicine practice, digital signature, computer
crime and intellectual property. Intellectual property is the legal protection
which usually in the form of exclusive rights governing works that result
from some creative work process. It is protected by a specific set of laws
both statutory and common that impart exclusivity to the right holder.
Copyright is the set of rules governing the right to copy a work. Copyright
also protects the right to publish and perform a work, as well as other
more specific manifestations, such as the right to make mechanical
contrivances, telecommunicate works to the public, and authorized

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AN ESSAY ON MEDICAL RECORDS ISSUES
TELEMEDICINE: VARIOUS COUNTRY PERSPECTIVES
IMR 655: MANAGEMENT OF MEDICAL RECORDS

rentals of computer program (Johnston, Handa, Morgan, 1997). The legal


requirement that needed by the implementation of telemedicine in
Malaysia also includes the Lifetime Health Record and lifetime Health
Plan. This aspect of telemedicine aims to keep people as long as
possible in the wellness paradigm. To facilitate continuum of care for the
life time of an individual, his or her health data both in their state of
wellness and illness will be systematically captured and made available to
practitioners through the national telemedicine network (Dato' Dr Abu
Bakar Suleiman, 1997). The legal is compliance to international standards
which included by data structure, content, coding, vocabulary,
transmission and exchange. However, there are other regulatory
framework that needs to be formulated by the relevant authorities and the
various healthcare fraternities. For example, code of ethics in the practice
of telemedicine, agreed protocols and practice guidelines.

2.5 TECHNOLOGY AND CHANGE MANAGEMENT

Telemedicine is an area in which it is notoriously difficult to conduct


scientific assessment and success with the telemedicine depends as
much on the skills of the medical practices involved as it does upon the
reliability and suitability of the technical components of the telemedical
systems (Field, 1996). Technologies such as personal digital assistants,
which integrate data at source, reflect one of the government’s priorities
(NHS Executive 1998). Telemedicine sites will have to be equipped with
appropriate multimedia telemedicine equipment and software.
Telecommunications infrastructure will be a critical technology. For
instance, in Kuala Lumpur General Hospital Malaysia, the Urology
Department has been launched the system named ‘Sistem Pusat
Kawalan Arahan Teleperubatan’ (TCCC) which been used as a survey on
the surgery room and videoconferencing for the use of convention.
Videoconferencing technology is used to establish link between two sites
which the specialist at one generally with the specialist at the other. The
TCCC system also act as integrator on making survey and linking which

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AN ESSAY ON MEDICAL RECORDS ISSUES
TELEMEDICINE: VARIOUS COUNTRY PERSPECTIVES
IMR 655: MANAGEMENT OF MEDICAL RECORDS

enable the local specialist to cooperate with other international specialist


for operating in surgery room, doing practical and conferencing. In UK
hospital, the Teleconsultation Networks allow for transmission of film
based radiological images as well as scanned paper documents, voice
annotation, digital picture images and electrocardiogram scans. Using
both a ‘store-and-forward’ method of consultation as well as real time
consultation for emergency cases, the Teleconsultation Network aims to
encourage continuing education as well (Chumbler, Grimm, 2001). The
store-and-forward method involves the acquisition of information at one
site (PCP and patient) that is then transmitted to the specialist who
reviews the material and responds when convenient. Other aspect of the
technology issue is changing in management. This means by the
transformation of health system. The change management means of
facilitating the internal transition by process incorporating new network
processes, training end users and urging for the revision of policies
governing the system. Specifically, change management involved in the
process of identifying possible obstacles during implementation,
developing strategies and placing enablers to overcome these obstacles.
This also emphasis on health promotion, disease prevention, early
detection and proactive management of illness, and patient involvement
in own care. I agree that technologies are essential to the implementation
and improvement in telemedicine or telehealth. This is because the
technology plays important role for the interaction between the medical
practitioners and his patients.

2.6 SOCIAL AND RURAL CONSIDERATIONS

As what I have explained before, telemedicine are used as medicine


practiced across distances and involves the electronic transfer of
information. Telemedicine can make possible transmission of
electrocardiograms from a rural hospital to a tertiary center for
interpretation. Example of interactive video includes teleconferencing
(videoconferencing) and teleconsultation. Teleconferencing can expand

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TELEMEDICINE: VARIOUS COUNTRY PERSPECTIVES
IMR 655: MANAGEMENT OF MEDICAL RECORDS

the knowledge base from which physicians approach diagnosis and


treatment decisions. Continuing education via teleconferencing has has
the potential to attract rural doctors, who otherwise might not have
exposure to a broad spectrum of cases, and to the latest scientific and
medical information. Telemedicine could be also useful adjunct for
medical students, providing opportunity for distance learning from a
specialist. In the criminal justice system it is cheaper and more efficient to
treat patients in a prison setting using telemedicine, than to transport
them under guard with the increased risk of escape (Huffman, Strode,
Allen, 1999). Apart from telemedicine’s potential, significant regulatory
and policy barriers threaten to disrupt the development of distance
medicine. These barriers include reimbursement limitations and uncertain
funding, cumbersome credentialing requirements, legal liability
uncertainties and malpractice exposure, unclear data on cost-
effectiveness, and a lack of uniform national practice standards and
telemedicine standards. Additionally, telemedicine has neither practice
guidelines nor measurement criteria, and scant information exists
regarding clinical efficacy. There is even debate in the medical community
regarding telemedicine’s direction and infrastructure. Based on what I
have read in the article that wrote by Nykanen (2006), there are several
barriers that lead to the technological which are firstly, lack of
commitment by health care authorities, missing interoperability of health
information systems which is due to lacking conceptual models,
ontologies, and sharable vocabularies. Additionally, the development of
teleheath by far have been rather technology oriented and thus the
development and the systems are not easy to use, technology is
expensive and the systems are vulnerable to changes in the environment.
The applied technology should be user acceptable, cheap and not too
cumbersome to use, and vulnerable to changes. The system and
application should be evaluated to assess the effects and impacts and to
find reasons for success of failure.

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TELEMEDICINE: VARIOUS COUNTRY PERSPECTIVES
IMR 655: MANAGEMENT OF MEDICAL RECORDS

3.0 CONCLUSION

In conclusion, based on the Malaysia scenario, telemedicine as it is being


currently implemented is still in the stage of managing the information distribution of
electronic records of patients and increasing consultations between specialists around
the nation in order to enhance the healthcare opinions and service for patients. By
concerning to the issue of privacy, confidentiality, security, information and medico legal
cases, standards, legal and regulatory requirement and technology and change
management and social and rural considerations, it is necessary to identified the
solutions to overcome the challenges in order to enhance the improvement of the
telemedicine implementation as it can be successful to be implied for the whole country.
If we applied the telemedicine correctly, we can improve both access to care and
continuity of care when distance and time represent major obstacle for patients.

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IMR 655: MANAGEMENT OF MEDICAL RECORDS

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