How mobility affects the “space and time” of existing telemedical practice
Nicolini [i] uses a helpful metaphor for telemedicine as a way to “stretch out” existing medical practices in space and time and change how and when clinical decisions are made. A live video teleconsultation then could be considered a “stretch” in space, removing the requirement that the caregiver and patient be collocated at the time of the consultation. “Store and forward” telemedicine is a stretch in time, enabling previously-collected health data to be assessed at a time convenient to the analyst.
In conventional wired-network telemedicine, the data may travel long distances but the endpoints are generally stationary and associated with a specific place. The addition of mobility technologies to telemedicine breaks this association–the endpoints are no longer fixed. Perhaps a modification of Nicolini’s metaphor is appropriate. Mobility can allow us to advantageously “compress” time in time-critical situations by removing latencies due to the need for collocation or for parties to be at fixed network endpoints. Mobility changes the temporal aspects of medical workflows; adding synchronous aspects to formerly asynchronous workflows.
One example of this may be observed in the technologies used for real time ambulatory cardiac surveillance. The most well-known device for this purpose is the Holter monitor, an ambulatory electrocardiographic (ECG) recording device that typically record 24-hours of ECG data to aid in the diagnosis of arrhythmias. However limitations in recording capacity and the delay between data collection and subsequent data review hampers the Holter monitor’s ability to detect infrequent cardiac events. This can be a diagnostic problem in situations where atrial fibrillation (AF) is suspected as a cause of cryptogenic stroke, because even 24-hours of recording time can miss AF episodes occurring at a rate of 1- 6%[ii].
Typcial Holter device, an example of store-and-forward telemedicine
Mobility has allowed cardiac surveillance systems to evolve beyond the Holter monitor By using cellular networks and automatic arrhythmia detection algorithms, modern cardiac surveillance systems can detect and immediately transmit abnormal ECG waveforms to a remote monitoring center, increasing the likelihood of detecting intermittent cardiac events (for example, Cardionet). This is an example of a beneficial “compression” of the time interval between the occurrence of a cardiac event and the notification of medical professionals that has been enabled by mobility.
Mobile technologies can also compress “space”—the physical distance preventing rapid movement of medical information between two endpoints. One example of this is Welch-Allyn’s SmartLink system, which transmits data from a multi-parameter patient monitor used by first responders in the prehospital setting to an on-call cardiologist over a cellular network. Systems such as these can help reduce the “door to dilation” time–the elapsed time between a patient’s arrival at the hospital door and the dilation of a blocked coronary artery by angioplasty. This use of mobility has in effect, compressed the “space” between the patient and the cardiologist who need to see the patient’s ECG data to begin the workflow for cardiac catheterization.
[i] D. Nicolini. Stretching out and expanding work practices in time and space: The case of telemedicine
Human Relations, June 1, 2007; 60(6): 889 – 920.
[ii] Bell C, Kapral M. Use of ambulatory electrocardiography for the detection of paroxysmal atrial fibrillation in patients with stroke: Canadian task force on preventive health care. Can J Neurol Sci 2000;27:25-31.