International Development and Evolving Dimensions in Telemedicine : F. Lievens, Board Member and Secretary/Treasurer, ISfTeH, Switzerland & M. Jordanova, Solar-terrestrial Influences Laboratory, Bulgarian Academy of Sciences

International Development

Which is the correct terminology- eHealth, Telemedicine or Telehealth? Up till mid 1990’s the word ‘telemedicine’ was accepted without questions. But now many authors are trying to differentiate between telemedicine and eHealth. For some, telemedicine and eHealth are synonyms. For others- eHealth is a broader term and includes telemedicine. A third group believes that telemedicine incorporates telecardiology, teleradiology, telepathology, tele-ophthalmology, teledermatology, telesurgery etc., while eHealth comprises of e-Sant, ICT-Health, all types of health communication services, PACS, patient information systems, e-education, e-prescription, etc. With more involvement of the electronic communication systems, the major international organisations such as, World Health Organisation (WHO), European Union (EU), International Telecommunication Union (ITU) and European Space Agency (ESA), have officially adopted the denomination “eHealth”. “eHealth refers to the use of modern information and communication technologies to meet the needs of citizens, patients, healthcare professionals, healthcare providers, as well as policy makers.”

eHealth includes eCare, eLearning, eSurveillance and eAdministration. In the attempts to distinguish between various aspects of eHealth, several other terms have also been introduced:

  • mHealth or mobile health, i.e., efficient high-quality healthcare services for mobile citizens;
  • uHealth or ubiquitous healthcare, focusing on eHealth applications that provide healthcare to people anywhere at any time using broadband and wireless mobile technologies.
  • One more term is used lately as an even broader description for eHealth, i.e., telehealth.

eHealth is brought to life by contemporary changes of our world and summarises the entire range of services that are at the crossroad of traditional healthcare and information technology. eHealth affects the entire health sector – from general practitioner to the hospital manager, from nurses to software specialists, from social security funds to patients. It is believed that eHealth can help in solving critical issues of rising costs, care for the ageing and housebound population, staff shortage. It is a feasible tool to provide routine as well as specialised health service as it has the potential to improve both the access to and the standard of care. Its ultimate beneficiary is the Patient/Citizen via the Healthcare Professionals.

In a broader sense, eHealth is not only an application of technical achievements in healthcare, but it is also a state-of-mind, a way of thinking, an attitude, and a commitment for networking at all possible levels. eHealth is a global thinking plus the ambition to contribute to the improvement of health services at local, regional, continental and worldwide level by wide application of information and communication technology.

eHealth definitely acts at various levels within each country (local, regional, national activities and actors), between countries or at continental level as well as at a global level. But who are the main actors in eHealth? It is not easy to enumerate the players at various levels as the group is quite dynamic. At national levels these are various associations and societies, institutions, governmental and non-governmental organisations and foundations, Telecom and IT companies, military structures, etc.  Everyone knows some of the most prominent international players WHO, ITU, EU and EC (European Commission), United Nations Office of Out of Space Affairs (UNOOSA), United Nations Educational Scientific and Cultural Organization (UNESCO), United Nations Children’s Fund (UNICEF), associations and societies, international telecom and IT companies, etc. In addition, let’s not forget the unique role of science and research as well as the impact of business structures, industries (medical, pharmaceutical, etc.) and administration players. But only WHO is fully dedicated to health issues. All other organisations deal with health issues amongst several other activities, therefore WHO has the ultimate coordinating responsibility in eHealth.

With so many players and so many actors, it is not always easy to have a broader view on the eHealth field and to visualise which the new streams are. In the following paragraphs we will try to outline them.

1. Tele-nursing: this is the eHealth application to professional nursing practice. Tele-nursing has developed much in the last decade.2 A very good example is the US. Despite the fact that most health care services are reimbursed on a “per visit” basis and thus the use of tele-care has not been heavily embraced, there is a 600% increase in tele-nursing in less than 5 years. It is expected that tele-nursing will develop even more rapidly internationally, especially where socialised medicine provides a financial impetus for tele-care. However, with the demanding requirement to deliver the best care at the least cost, the increase to tele-nursing applications will be even more evident in the years to come. The International Tele-nursing Role Survey, performed in 2004-2005, gives more information on tele-nursing. The goals of this survey were to identify where tele-nursing is developed, whether tele-nursing is accepted, effective and whether tele-nurses are satisfied with their work. Results from 39 countries reveal that typical tele-nurse is white, female, married, with children, working full-time in telenursing. Telenurses experience less than average role stress, role ambiguity, and role conflict, and have the same work satisfaction as other hospital-based nurses. The most important factor contributing to telenurses’ work satisfaction are autonomy and interaction. Tele-nurses are happy with this less physically demanding situation and are sure that they are able to deliver, manage and provide better patient education, keep patients out of the hospital, provide better outcomes, decrease hospitalizations, save time, etc. 59% of International telenurses stated that they are more satisfied with their telenursing position than “regular” nursing positions they had!

2. Tele-psychiatry: this refers to the use of telecommunication technologies with the aim of providing psychiatric services from a distance, most often via videoconferencing in real-time. Thus, the patient and the therapist can see and hear each other in real time, via direct TV-transmission. Telepsychiatry connects patients and health professionals, permitting effective diagnosis, treatment, education, transfer of medical data and other activities related to mental health care. Several studies demonstrated high reliability and patients’ acceptance of telepsychiatry. Telepsychiatry is extremely helpful in moving towards a communitarian outpatient approach. An example to follow is the pilot project for tele-assistance of mental diseases in the city of Sao Lourenco do Sul, Brazil.4 Immediately after the staff that works with mental health patients overcame their initial skepticism and the method was validated through daily practice, the results became evident. The decisions about the therapeutic interventions are adopted immediately, avoiding unnecessary hospitalisations. The preliminary results showed that telepsychiatry can play a significant role in the management of mental diseases.

3. Tele-psychology: which is the provision of psychological services in a technology-assisted environment, including telephone, Internet media (written, voice and digital pictures) and video conferencing. No doubt this is the future of psychology due to two key reasons.

  • The obvious trend of increasing of psychological disorders in the years to come and the heavy burden that these kinds of disorders place on individuals, families and communities all over the world. No country is immune to them, although some disorders may differ in frequency.
  • While many people suffer from a variety of psychological disorders, care is not available to all who need it. A simple example is depression. According to WHO5 in only the European Region, 33.4 million people per year have been estimated to suffer from severe depression, which means 58 out of 1000 adults. Of all the disability-adjusted life-years lost, depressive disorders account for the largest share. Care providers recognise the problem in less than 50% of all depressed patients seeking medical care. Only about 18% of such patients get correct and specific treatment. And this is in Europe, where the situation with human resources is much better than in other regions of the world, with about 3.0 psychologists and 2.4 social workers per 100,000 of the population.

4. Application of Short Messages Services (SMS): for management of chronic diseases is another emerging area. Most of the mental and behavioral disorders are associated with a considerable risk for relapse after reaching the state of recovery. Unfortunately, once finishing the inpatient treatment most of the patients never seek after-hospital help. GSM and Internet offer easy and user-friendly ways to support these patients during the recovery period at home. A success story is the “On Cue” 2002 project in South Africa sending SMS reminders to patients with tuberculoses for drug regimen compliance. SMS were sent out every half hour within a chosen time-frame to remind patients to take medicine. As of January 2003, the city of Cape Town has paid only US$ 16/patient/year for SMS reminders. In this pilot, only 1 patient out of 138 was non-compliant (99.3% compliance rate). This is something worth trying. Besides management of chronic diseases, eLearning, sharing eHealth intellectual property, fostering health security are also in the pipeline.

Within the world of eHealth, it is crucial for all the players to be aware what is going on globally. Therefore, cooperation and networking are important factors. Let’s focus on a few specific networking enabling initiatives:

The International Society for Telemedicine and eHealth (ISfTeH, is a not-for profit membership organisation of national, regional, international associations and other institutions, organisations, corporations, individuals and students, established under the Swiss law. ISfTeH is the international representative body of national and international Telemedicine and eHealth organisations and is dedicated to broadly promoting telemedicine, telecare, telehealth, eHealth around the world. ISfTeH supports the start up of National Associations or Societies and facilitates their international contacts. Its aim is to disseminate knowledge, information and experience and to provide access to recognized experts in the eHealth field worldwide.

As part of ISfTeH educational activity, a Working Committee “Education” is now functioning, chaired by Prof. M. Mars, South Africa. The mission of this Committee is:

  • Listing existing programs on eHealth
  • Establishing basic eHealth templates for fundamental training programs]
  • Coordinating eHealth educational efforts around the Globe
  • Assisting the setting up of new courses in eHealth
  • Defining the needs of universities and specialists for basic and continuous education.
  • eHealth science, practice and market need a meeting place. Such a place is Med-e-Tel (The International Educational and Networking Forum for eHealth, Telemedicine and Health ICT

eHealth is no more an optional choice. It already is a must, a fantastic challenge for the future but it requires cooperation and coordination at all possible levels. The main challenge is to be sure that these options are used optimally and in a coordinated manner to ascertain that the desired effects do come through and that resources are indeed not diverted away from basic needs.

1. (European Union Ministerial Declaration, eHealth 2003, High Level Conference, Brussels 22 May 2003,

2. (L. Schlachta-Fairchild “International Telenursing: A Strategic Tool for Nursing Shortage and Access to Nursing Care”, Med-e-Tel 2008,

3. (For more information refer to L. Schlachta-Fairchild, D. Castelli, R. Pyke International Telenursing: a Strategic Tool for Nursing Shortage and Access to Nursing Care, pp. 399 405; R. S. Gundim, R. Q. Padilha Research Project: A Remote Oncology Nursing Support at Hospital Sï Libanï, SïPaulo Brazil, pp. 406 -408; D. Castelli, L. Schlachta-Fairchild, R. Pyke Telenursing Panel: Telenursing Implementation Strategies and Success Factors pp. 409-414 all In Jordanova M., Lievens F. (Eds.) Global Telemedicine / eHealth Updates: Knowledge resources, Vol. 1, Publ. Luxexpo, Luxembourg, 2008).

4. (F. Resmini et al. Telepsychiatry: A New Tool for Remodeling Mental Health Assistance in South Brazil, In Jordanova M., Lievens F. (Eds.) Global Telemedicine / eHealth Updates: Knowledge resources, Vol. 1, Publ. Luxexpo, Luxembourg, 2008, pp. 395-398).

5. [The world health report 2001: Mental health: new understanding – new hope


Follow and connect with us on Facebook, Twitter, LinkedIn, Elets video