Project Report on Telemedicine: What We Learned about the Administration and Development of a Binational Digital Infrastructure Project

Abstract

This article describes the development of a German-Polish cross-border telemedicine project. Funded by the European Union Interreg Program, a cooperation between several German and Polish hospitals was developed over the course of 16 years, starting in 2002. Subprojects, governance and outcomes are described, and facilitators and barriers are identified. These points are reviewed with regard to their influence on medical, technical, administrative and medico-legal realisation.

Keywords: European Union; IT infrastructure; Interreg; cross-border multiprofessional team; funding; project management; telediagnostic; telemedicine.

Figure 1

Influence of the boundary between Germany and Poland on the catchment areas of hospitals in the cities of Szczecin, Pasewalk, Prenzlau and Schwedt. It is apparent that the hospitals close to the border have small catchment areas and that there are areas without easily accessible hospitals.

Figure 2

Organigram of the association “Telemedicine Euroregion Pomerania”. The German project participants organised themselves in an association under German law; three Polish members were co-opted. Their assembly (one representative with voting rights from each of the participating hospitals) approved key decisions and the budget once a year. The assembly elected the association’s board. Additional Polish members took part in German–Polish working groups. The German side was the lead partner of the project. It organised the settlement of the funds. The board of directors had several employees for legal, financial and secretarial tasks. A technical advisory board staffed with independent technical experts met twice a year for three years to review the investments.

Figure 3

Geographical distribution of hospitals on both sides of the German–Polish border. Berlin, Warsaw and the Baltic Sea are also indicated for the better visualisation of the project.

Figure 4

A videoconferencing network was the backbone of the telemedicine project. On the German side, there was a northern (Greifswald), a central (Neubrandenburg) and a southern rail (Eberswalde) with videoconferencing links; in Poland, only Szczecin took part. A “bridge”, actually a switch allowing multi-point videoconferencing to be initiated, was located in the south rail. This limited use of the network required three bridges to be installed. The system also allowed for the simultaneous viewing of medical images (x-ray, real-time endoscopy and pathology slides) and various documents on additional monitors. Please note that not all hospitals that participated in the program also participated in the videoconferencing network, explaining the difference in numbers.

Figure 5

Tele-Tumour Conferencing. A sophisticated subproject included the tumour board of Eberswalde hospital, where smaller hospitals presented their cancer patients to specialists. Seated at the conference table are oncologists, a radiation oncologist and a radiologist. A pathologist in Pasewalk is discussing cases with a referring physician from the Templin hospital, approximately 65 km away. Documents, X-rays and pathology slides can be viewed by all participants simultaneously.

Figure 6

Cross-border meeting (Szczecin/Pasewalk). A working group of the project (in the front of the picture, three participants) and the German members (with modality pictures). From [12].

Figure 7

Geographical distribution of the German teleradiology network. The network has been running for more than 15 years. In Greifswald, there is a 24/7 radiological service in the university hospital. The surrounding city names represent the locations of connected houses that are also supplied in the network. According to German law, the backup method for downtime in teleradiology is a radiologist going to the relevant hospital and performing the examination there. Due to this restriction in German law, teleradiology was limited to hospitals that could be reached within an hour (Demmin and Karlsburg were not financed by the project). Conclusion: The loss of catchment areas of the hospitals due to a new territorial delimitation can be increased by the telemedical expansion of catchment areas. Telemedicine thus leads to better access to doctors in territorial states and to the better utilisation of medical services in the same regions (black circle, unbroken: catchment area of Greifswald University Hospital’s pathology department with telepathology. Red arrows: pathology connections.).

Figure 8

Enlargement of the catchment area of medical facilities through telemedicine. The inner, broken circle shows the direct catchment area of the pathology department at Greifswald University Hospital. Outside working hours, it is limited to the immediate area. Telepathologically, the catchment area is basically unlimited from a purely technical standpoint. The red arrows show telepathology connections in the pathology network.

Figure 9

Telepathology. The telepathology workstation of this pathologist shows the pathologist’s desk during a tumour conference. He can work on his microscope while following the conference on his monitor. During the few minutes that the pathologist is needed in a typical teleconference, he may be seen and heard and show slides (see Figure 5). The higher productivity that is achieved in this way is particularly important given the few pathologists commonly available.

Figure 10

Video endoscopy during an ENT consultation. A non-specialised physician inserted the endoscope and images were automatically transferred to the specialist in a university hospital—in our project, between Templin and Greifswald. The distance between the two cities was roughly 150 km, and the driving time would be nearly 2 h. Specialised diagnosis was thus possible despite the distance, and therapy recommendations could be given. The Greifswald ENT specialist in the image is seen from the back, the general physician in Templin is shown on the monitor of the videoconferencing unit, and the image generated by the endoscope is shown on a smaller monitor to the right.