Telemedicine’s greenhouse gas emissions

There’s occasionally speculation about the environmental impact of remote care but not much detailed research. A team from Imperial College London have evaluated  the direct and indirect greenhouse gas emissions from 21,000 telemedicine consultations performed over a seven year period in Alentejo, Portugal. The results were dramatic. Telemedicine may have led to a 95% reduction in distances travelled – or 2.3 million kms of travelling by patients – saving a total of 455 tonnes of CO2 equivalent. How we factor such environmental impacts into cost-benefit assessments of remote care remains to be seen. The research was conducted by Tiago Cravo Oliveira, Steffen Bayer and James Barlow, with support from Luis Gonçalves from the Administração Regional de Saúde do Alentejo.

The published paper is available at

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Who’s exhibiting at ATA?

More from the American Telemedicine Association conference, by James Barlow.

A tour of the cavernous exhibition hall at the Austin Convention Center and a rigorous back of envelope analysis of the catalogue reveals where the corporate action is: of the 229 or so exhibitors, the runaway top health condition targeted by companies is (surprisingly?) mental health, with 34 exhibitors. Cardiology, diabetes and the other conditions forming the basis of remote care trials around the world all make an appearance, along with other familiar tele-applications.

The 2013 Exhibitors League Table:
Mental health and telepsychiatry (34 exhibitors)
Telecardiology (16)
Telestroke (16)
Paediatric telehealth (16)
Diabetes management (15)
Teleneurology (14)
Teledermatology (10)
Telerehabilitation (6)
Telehospice / palliative care (4)
Oncology (3)
Teledentistry (3)
‘Infectious disease management’ (2)

And by application? Home healthcare (63 exhibitors) beats mHealth (49) – well served with its own conference circuit – with ‘remote monitoring'(48) and ‘videoconferencing’ (36) hot on their heels.

Other reports by James Barlow.

Where the real remote care innovations are

Another report by James Barlow from the ATA Conference.

More evidence that the really innovative thinking in the remote care world is coming from lower income countries. Dr Sikder Zakir from the Telemedicine Reference Centre (TRC – in Bangladesh reported on the use of mHealth to improve access to underserved populations. Usually this would involve telemedicine – in its m- or non-mHealth guises – bringing healthcare to remotely located rural populations. Bangladesh is no exception, with 40,000 doctors and 25,000 nurses for 160 million people. But as is only too obvious to anyone who has been to countries in the Gulf there is a huge population of migrant workers living there. The 5 million expats from Bangladesh have 20 million dependents back home dependent on remittances, but neither side is well served for healthcare. The TRC is using mHealth to provide expats with access to doctors in Bangladesh via SMS messaging and voice calls, and extends the service – free – to up to five of their family members. Funding is via a $3 a month subscription paid via the migrant worker’s mobile phone network. The scheme is being tried out with 80,000 migrant workers in Singapore, before moving to Saudi Arabia and the UAE.

We also heard from Dr Zakir about AMCARE (, an example of mHealth being used to extend diabetes care from hospitals to villages. This uses microinsurance payments (50 US cents / month) to cover the costs, a business model that is now gathering momentum in developing countries’ health systems.

Other reports by James Barlow.

Surgical telemonitoring – the next milestone for telemedicine?

The first in a series of real-time reports from American Telemedicine Association annual conference in Austin, Texas, by James Barlow, Imperial College London.

The ATA conference has just included an interesting session on surgery as the next milestone for telemedicine. While telesurgey has long been an area of interest in remote care, pressures in the health system and developments in technology are combining to create new opportunities for supporting surgeons in their work. But many of the familiar implementation challenges are also looming large. So what were the reflections from the panel and discussion?

The consensus was that we need to shift the state of the art in operating room practices from considering volume and quality to broader notions of ‘value’ embracing cost, quality and access. Hospitals will be increasingly rewarded on outcomes and patient satisfaction, and telesurgery potentially helps improve both.

Two kinds of broad telesurgery model are envisaged – the expert surgeon ‘broadcast’ their operations to a wide audience and a more 1:1 relationship where the expert is remotely located and provides support for a specific operation. The ‘new telesurgery’ will involve three things.

  1. Just phoning another surgeon for advice in the middle of an operation is no longer good enough. There will be much more collaboration between surgeons, using new collaborative tools for bringing people together at a distance. The possibility of virtual environments around the operating room is already here and should be widely embraced.
  2. Large peer-supported integrated surgery networks will emerge with surgeons paid for the time they spend providing advice or moderating discussions. Spending 10% of your time mentoring other surgeons – perhaps around the world – will become part of the norm.
  3. A pool of recognised expert mentors will develop. Mentors can be ‘in the room’ virtually during the procedure. Or they can be invited to participate in situations where there is an ‘index case’ – a rarely encountered procedure – where the pool of knowledge is spread thinly.

All this is going to clash with the inherent conservatism of surgeons and their unwillingness to change tried and trusted approaches and technologies. The big challenges for moving forward in telesurgery are:

  1. ‘Network effects’ need to kick in – there has to be a critical mass of users and installed technology to generate the biggest benefits.
  2. Inevitably there are incompatibilities in technical standards for data transfer.
  3. The focus so far has been on audio and video, but integrating patient data into telesurgery and back into patient record systems is also essential.
  4. Tools for virtual collaboration are rapidly developing, allowing crystal clear video, remote access to laparoscopic images, virtual laser pointers, and doing all this on tablets. These need to be made widely available.
  5. Reimbursement and business models – who pays for what? Can we find ways of reimbursing hospitals / surgeons providing experts? How do we schedule expert mentor time and build this into their contracts?
  6. Medico-legal. There are cross border (or cross state issues here in the US) licensing issues and big problems of responsibilities in the event of problems arising in a telesurgery procedure.

Other reports by James Barlow.