Introduction
 
1. The development of telemedicine in the Hong Kong Hospital Authority may be shaped by two forces, the demand of telemedicine on one hand and the supply of available infrastructure, technologies and resources on the other. In one sense, the basic demand for provision and support of healthcare at a distance is always there. Therefore, progress depends on the provision of information infrastructure, application systems, content of information and knowledge, and imaginative and innovative application of clinical expertise in telemedicine. In Hong Kong, the first three key components on the supply side of telemedicine are increasingly being provided by the key components of the Hong Kong Health Information Superhighway initiated by the Hospital Authority.

 
Telemedicine and the Health Information Superhighway
 
2. According to the US Institute of Medicine, telemedicine is defined as the use of electronic information and communications technologies to provide and support healthcare when distance separates the participants.
 

3. The term "Information Superhighway" was first introduced when the US Administration accorded top priority to the creation and development of a National Information Infrastructure (NII) in September 1993. The Progress Report by the Information Infrastructure Task Force in September 1994 stated that "the NII will reduce health care costs while increasing the quality of care, especially in under-served areas". It was estimated that the nation-wide use of information technologies could reduce healthcare cost by $36 billion every year.

 
4. The Information Superhighway can be defined as "seamless set of competing, interconnecting, high-speed networks, delivering omnipresent interactive data, text, sound, voice, video, and motion services, accessible to all providers and consumers." "Telecare" can be viewed as a vehicle on the Superhighway and described as "the management of patient care with the help of information and communications technologies that give access to expertise and patient information irrespective of where the expert, information, or patient is located". It is possible to change the practice of the medicine by bringing, through telemedicine, the medical expertise and even facilities to the patients.

 
Hong Kong Health Information Superhighway

5. In September 1994, the Hong Kong Health Information Superhighway was introduced as a concept to denote "a seamless web of communications networks, computers, databases and consumer electronics that will put vast amount of information at healthcare providers?and eventually end-users? fingertips".

  
6. The Hong Kong Health Information Superhighway is a Community Health Information Network (CHIN) linking the different healthcare providers and consumers/clients in the healthcare market. The key providers in Hong Kong are the Hospital Authority (HA) comprising 44 public hospitals and 57 SOPCs, the General Outpatient Clinics of the Department of Health, private hospitals and general practitioners in the private sector and other institutions (e.g. the Family Planning Association, University clinics etc. which are partially public funded). The consumers/clients are the patients and the citizens at home, offices and anywhere that can be reached through modern telecommunication links. (Appendix 1)

 
7. The Hong Kong Health Information Superhighway can be described in terms of its content, context and infrastructure. Infrastructure refers to the Hong Kong Health Information Network (HIN) comprising WANs and LANs; the systems architectural framework comprising middleware and applications interface; and core competence development. Content refers to both the evolving Computer-based Patient Record (CPR) and the informational data repository being aggregated as a by-product of the operational databases. Context refers to the applications which support the functional requirements of the various operational processes ranging from patient administration to clinical management processes of diagnosis, therapy and prognosis across the continuum of care.

8. The key components of this Information Superhighway are depicted in Table 1. Hong Kong Health Information Superhighway.

Content

•  HKPMI (Community-Based)

• CPR (Operational Repository)

•  Informational Repository

• HK Patient Card (Portable Abstract of CPR)

• Clinical Information Systems (comprising Clinical Management Systems and Clinical Departmental Systems)

•  EIS/DSS

•  Office Systems (including Internet/Intranet applets)

•  Administrative/Financial Information Systems

•  Information Technology
• Client-server
•  Network-centric
 
• Communications Technology
• HIN
• Internet/Intranet Technology
 
•  Core competence
• attitudinal
• professional

Infrastructure ?Enterprise Information Architecture, Communications, Client/Server & Internet Technologies

9. The Enterprise Information Architecture (depicted at Appendix 2A) is to support distributed data capture and access functions at all points of care delivery and information decision –making throughout the HA institutions and its external healthcare partners. Since 1992, the HA has adopted an open, standards-based, client-server and internet networking platform linking mainframe, Unix-based and PC servers and front-end workstations (Appendix 2B).

 

10. Since 1994, the Internet platform has been progressively introduced, progressing from internet-enabled e-mail and remote access to distributed web-sites on WWW (http://www.ha.org.hk), to corporate Intranet for workgroup functions and access to corporate databases, to Extranet between healthcare partners and in the near future to a CPR-net for secure, authenticated and certified access to personal clinical records (Appendix 2C). The structure of the HA Internet to-day and the current firewalls are depicted at Appendix 2D.

Content - Computer-based Patient Record

11. The Computer-based Patient Record (CPR) provides the key content to the Hong Kong Health Information Superhighway. It provides an operational clinical data repository that conceptually centralizes the entire longitudinal patient care record. It is a physically distributed system with logical central control of the clinical data, information and, in future, knowledge necessary to support the clinical process and decision-making at the time and place it is needed.

12. The CPR builds its content through the following:-

• the Integrated Patient Administration System (IPAS) and the Hong Kong Patient Master Index (HKPMI) containing indexes to all patient episodes for inpatients and outpatients;
• the clinical information systems

 
Content ?Web-casting & Hong Kong Health Channel

14. In March 1997, the HA used the Web-cast Technology to provide every 5 minutes real-time information of all 15 A&E Departments in Hong Kong. This comprises the average waiting-time, disaster news and patient attendance information and helps to provide a high-level triage of patients seeking A&E services.
 

15. In October 1997, the HA completed a beta version of a Hong Kong Health Channel Telemedicine Education web-casting health-related information in English and Chinese to clients using desktop PCs. There are topics of ongoing interest (e.g. family planning, child health, chronic diseases, heart diseases) and hot health topics. The content providers include HA, HK Medical Association, HK Anti-Cancer Society, HK Anti-Tuberculosis Society and others.

 
Context-Clinical Management and Other Information Systems

16. Information Systems in HA are developed and implemented according to a flexible 3-stage HA IT/IS Strategy summarised below: -
 

(a) Stage 1 (1992-1997): The corporate databases and information infrastructure

Stage 1 is to establish the infrastructure for data collection and access, the initial networking within and between hospitals and the key corporate databases of patient, staff, finance and assets.
 
(b) Stage 2 (1995-2002): The Clinical Information Systems at the Ward and Clinical Departments
 
Stage 2 is to introduce computerisation at the ward, clinical departments and other ancillary departments to provide direct support to the integrated delivery of patient care by the clinical management team (doctors, nurses and allied health personnel). This stage will greatly increase the size and scope of the network within the hospitals as computerisation would be introduced to diagnostic, therapeutic and prognostic functions. Stage 2 is sub-divided into stages 2A, 2B and 2C with Stage 2A focusing on major acute hospitals, Stage 2B for medium sized and psychiatric hospitals and Stage 2C to support the full integration and content of the Computer-based Patient Record and the scheduling of services around the patient.

(c) Stage 3 (1997-2002): Integrated Healthcare Information System
Stage 3 is to complete the full integration of health information systems to support seamless health care in Hong Kong. One of the two areas of emphasis will be the provision of informational systems comprising corporate data warehousing and subject data marts to support executive decision making in clinical, financial, costing and management areas (Appendix 4). The other area is to extend the HA Health Information network to become the HK Health Information superhighway for holistic patient healthcare and community-based health.

17. The development of HK Health Information Superhighway (HKHISH) with its key components of infrastructure, context and content commenced in September 1994. As the basic infrastructure was in place by April 1995, the focus of development has been on the integrated Clinical Management Systems (CMS) and Computer-based Patient Record (CPR) since September 1995. By 4Q96, the first integrated CMS (Version 1.0) was developed and the content of the CPR progressively established through this system and the key Clinical Departmental systems of LIS, RIS and PMS. By 1Q97, CMS Version 2.0 (Appendix 5) will be completed for implementation.

 
18. The development and implementation of CMS for Major Acute Hospitals in Hong Kong is planned in the following table. The functions of different versions of CMS are outlined at Appendix 6.
 

CMS Implementation Plan for Major Acute Hospitals (1996-2000)
 

		Hospital		Version		Planned Implementation Commencement Date
i.		PWH		Ver 0.5 (pre-release version of CMS)Ver 1.5		2Q963Q97
ii.		QMH		Ver 1.0		4Q96
iii.		QEH		Ver 1.5		2Q97
iv.		AHNH		Ver 1.5		4Q97
v.		PYNEH		Ver 2.0		1Q98
vi.		TMH		Ver 2.0		2Q98
vii.		PMH		Ver 2.0		3Q98
viii.		YCH		Ver 2.0		4Q98
ix.		KWH		Ver 2.0		1Q99
x.		UCH		Ver 2.5		2Q99
xi.		CMC		Ver 2.5-3.0		3Q99
xii.		NDH		Ver 2.5-3.0		4Q99
xiii.		TKOH		Ver 2.5-3.0		1Q00
xiv		RH		Ver 2.5-3.0		2Q00

 

Recent New Developments

19. There is a new attempt to begin the development of a prototype of CMS Version 3.0 to provide a framework using computer-assisted tools for patient care planning and management by the hospital clinical management team of clinical specialists. This is due to commence in 1Q98 for the O&G specialty in PYNEH for completion of development and implementation by 4Q98. The components of this framework are given below:

 Clinical Protocols

• Clinical problem
•  Patient care items
• Care process elements

• Mechanism to link outcome to Clinical Protocol

• Mechanism to link problem to Clinical Protocol
• Facilitate evidence-based clinical practice

 (A) The establishment of a CPR-net as a secure net trasversing the different HKHISH technologies (client-servers computing, network-computing, and internet platforms) with the following 3 dimensions:
 
Part A          Networking horizontally within each speciality;
Part B          Clustering vertically within a regional community health services provision;
Part C          Extending beyond HA to all HK care-providers on a community health basis.

Other considerations are:

Under Part A, there will be a project linking all A&E departments to all 14 major acute hospitals having CPR and CMS. This is now on the drawing board for Part A of the CPR-net. Parts A, B, C can proceed in parallel.
 

(B) The HK Health Channel for multi-media communications of information and knowledge is established with the use of push technology on the HKHISH. Both concept of the CPR-net and the HK Health Channel have helped to refocus the leverage of IT on CPR, CMS and multi-media internet platform within the context of the HKHISH.
 
 

21. The early Telemedicine Projects in HA are in the area of patient care review through transfer of CPR.
 

HK Patient Card System (HKPCS)

22. A key application of Telemedicine in Hong Kong is the Hong Kong Patient Card System. Optical cards are a typical product of the current tendency of dispersed computing, supported by the infrastructure of information networking.
 

23. The Hong Kong Patient Card is a portable, patient-owned, credit-card sized, optical memory WORM (write-once-read-many) card containing the key contents of the CPR (Appendix 7 - HK Patient Card - DISPLAY). It has a multi-medium storage capacity equivalent to 4.4 M bytes. Since its successful introduction to two specialties (RT & Oncology Department of QMH and Internal Medicine of QEH) in December 1994, it has been issued to about 3,500 patients of 5 specialties in HA hospitals. There are read/write devices installed in all fifteen A&E departments in Hong Kong and medical alerts of the card holders are immediately made known during emergency. As this card is self-funded and depends on the availability of the CPR and the Clinical Management Systems (CMS), it can only be progressively introduced.

 
24. The HKPCS has a 4-phased implementation plan. Phase I development and implementation at QMH was completed in 4Q94 and by 1Q97, the HKPCS was implemented in 5 specialties in 2 hospitals. Phase II will extend card implementation after review to all HA acute hospitals with read devices provided to all Admission Offices. Phase III will extend to all HA convalescent and rehabilitation hospitals and specialist outpatient clinics. Phase IV will be for extension to other external organisations after due consultation.

 
25. In July, 1996 the Hospital Authority completed and published a specification of the following 6 levels of open standards used for the HKPCS and made available to all users and value-added resellers and developers the open specifications of the first 3 levels of:

Level 1 (Open) - Optical Memory Card Standard

 
Transfer of Neuro-surgery (NS) CPR including Data and Images between 5 NS Specialties

 27. In September 1994, a PC-BASED Neurosurgery Clinical Information (NS-CIS) System (Appendix 8) was designed, developed and implemented at QEH by the HA. The primary objective of the NS-CIS was to create a local PC-based long term storage for all the Neurosurgery patient records including patient demographics, clinical and discharge information as well as CT diagnostic images.
 

28. The system employs an HP scanner together with the scanning software to store the CT diagnostic images in TIFF format. The application software was developed utilizing Visual Basic. The image viewer is an off-the-shelf product from "Image Knife" with functionality to decompress the stored images for display to the neurosurgeons.
 

29. By January 1997, this system has been extended to 4 more hospitals, i.e. PMH, PYNEH, QMH and PWH. Through the Hong Kong Health Information Superhighway, a complete set of neurosurgery patient record including both data and scanned CT images can be transferred between any two of the five neurosurgery specialties.

 
Telemedicine Applications for On-line Consultation and Diagnosis

30. These include the following:
 

Teleradiology for Neurosurgery Patients

31. Before the introduction of a Teleradiology System in 1995, A&E patients in Caritas Medical Centre (CMC) with concussion and severe head injuries would have to be transferred to the Neurosurgery Department of Kwong Wah Hospital (KWH) for diagnosis and treatment. This may be unnecessary when less severe cases can be treated at CMC if tele-diagnosis is possible.
 

32. In early 1995, a remote diagnostic workstation (manufactured by Siemens) was installed at KWH for viewing the diagnostic images captured by the Siemens CT at the CMC. This system (Appendix 9) enables the attending physician at CMC to consult with the neurosurgeon at KWH on the severity of the patient case using similar Siemens CT Diagnostic Workstation and consultation over the phone. The consultation ensures that patients are transferred only when necessary after due consultation.
 

Teleradiology for On-call Radiologists

33. In 1995, 4 HA hospitals (RH, UCH, CMC & YCH) implemented a Teleradiology System from EMED (E-Systems Medical Electronics) for on-call radiologists.
 

34. This system uses a frame-grabber to perform direct video capture of CT and MRI images and a laser scanner for scanning X-Ray films, converts the captured images into digital format and format and stored on a PC-based image server (Appendix 10). Medical images including X-Ray, CT and MRI are transferred from the attending physician on non-prime shifts to on-call radiologists via dial-up telephone lines. The diagnostic images can be reviewed with the EMED "Multiview" software installed on the radiologists?portable PCs at home. This system eliminates the need for on-call radiologists to travel to the hospital when the cases can be resolved by the use of teleradiology.
 

Global Access to the HA Computer-based Patient Record via Internet
 
35. Providing global access to the vast amount of operational clinical information collected by the Clinical Management System and Clinical Department System of the Hospital Authority will be a part of the CPR-net programme which is outlined in para. 20A. Besides technology issues of interoperability, inter-connectivity and security, the provision of content and its updating are the key issues to be resolved.
 

Networking of Results Reporting within a cluster of hospitals

36. One of the first projects of authorised information sharing of the CPR is the access to laboratory results generated by a hospital to all other hospitals within that cluster. Hospitals in the Hong Kong West (HKW), New Territories South (NTS), New Territories East (NTE) and Hong Kong East (HKE) clusters have the capabilities to access the laboratory results produced by the laboratory at QMH, PMH, PWH and PYNEH. This service will be extended to the remaining 4 clusters by end 1999.
 

Use of DICOM III Standard for Diagnostic Radiology Images Distribution

37. HA hospitals have been experimenting on the use of DICOM III standard for archiving and distributing CT and MRI diagnostic images. A UNIX-based mini-PACS (Picture Archiving and Communication System) was recently acquired for archiving and distributing CT and MRI diagnostic images in DICOM III format. Pilot experimentation has been conducted to distribute DICOM III images to the Neurosugery Department. In collaboration with the Radiology Department, the UNIX-based Surgery Planning Workstation located at the Neurosurgery Department has been upgraded with the capability to receive and manipulate images in DICOM III format distributed from the Radiology mini-PACS. A prototype NT-based system equipped with an off-the-shell DICOM III Server together with a Windows-based DICOM Viewer will be experimented for pilot implementation by 1Q98. The WEB Server and Browser technology will also be exploited and considered for pilot implementation by 2Q98.

  
ATM Connection Between PWH and CUHK

38. The HA is in close collaboration with the Chinese University of Hong Kong (CUHK) which launched in August 1996 the long term CUHK telemedicine programme. The HA ATM connection for the PWH can also be used for the CU Network, thus reducing the expenditure otherwise required of CUHK. The telemedicine network (Appendix 11) installed enabled the transfer of images (e.g. Endoscopy), video, data, etc via the same network and broadcast to overseas in the recent International Telemedicine Conferences held on 1 July 1997.
 

The Future

39. Together with the Universities and the HK Telemedicine Association, the HA will begin in 1998 the required rigorous and systematic evaluation of its telemedicine initiatives in order to embark on a further telemedicine programme. Questions will be asked about the effects on the clinical process of care, health outcomes and access as well as aspects of costs and user perceptions as compared to alternative health services. The purpose of evaluation is to endorse the development and use of good information for decision making.
 

40. The HA will continue the launching of its Telemedicine projects in Stage 3 of the HA IT/IS Strategy while it presses forward with the CMS and CDS of the Stage 2 Strategy. However, the pace and degree of success will surely depend on both the results of evaluation of telemedicine and also the collaboration between the HA and all other healthcare practitioners and providers, academic institutions and vendors here in Hong Kong and abroad. The groundwork for supporting further Telemedicine initiatives for shared care and medical education is now ready as a result of the progress achieved in the development and implementation of the HK Health Information Superhighway in Hong Kong.