Telehealth: Potential and threat13/06/2019
Isabel Ituria Caamaño
Information and Communication Technologies (ICTs) and the use of networks arising from the technological possibilities of the Internet and the web represent a new field of possibilities and challenges in health for the planet: a new field of possibilities for democratization, participation and solidarity, and for individual and collective health, but also a new field of possibilities of violence (the abusive exercise of power), or for the deepening of domination strategies and inequities. Like nuclear energy, it can be at the service of health from the individual (radiotherapy oncology, diagnostic methods with radioactive isotopes, sterilization with radiation of different products for use in health, just to give some examples), or from the collective (by example, the nuclear power plants that provide people with electricity) or turn against them.
Very different technologies: nuclear and communication and information, share their beneficial or destructive potential of catastrophic proportions. The comparison may seem disproportionate, but it is a parallel between the potentialities and threats that some technological leaps can bring to health and life, particularly in the area of power and violence. Without the need for atomic bombs like those of Hiroshima or Nagasaki, a small nuclear detonation 40 km above the surface of the planet can bring enormous destruction to health and life, through the electromagnetic pulses affected by computer systems and of energy and its immediate impact on health.
The use of internet in health, and its potential for interaction between institutions and people, of people among themselves and between institutions, was initially called “e-health” by extension of a terminology coming from business and marketing (Eysenbach, 2001), and it includes health professionals with their peers, patients with each other and health professionals with patients (individually or in their different possibilities of virtual communities), and with unidirectional or bidirectional relationships. The term “health 2.0” is related to more interactive and participative applications such as blogs (Oliver-Mora, 2017, p 951), with formation of support groups between patients and with the health team, and to increase the informed autonomy of the patients. particular patients, and the power of the collectives, in making health decisions. And even the term “m-health” is used by the WHO, referring to the potential that the more than 7,000 million mobile phone subscriptions in the world represent for the provision of health services and public health (WHO, 2016 , p3). Seven billion opportunities to transmit accurate information instantly, and coordinate responses to health situations: disaster risk management, unhealthy products, epidemiological alerts, popular participation in health and stop counting. From the field of clinical epidemiology huge databases can be made, where multiple variables are linked with algorithms that allow early warnings; and even generate precise epidemiological information georeferenced in real time, based on the automated analysis of the searches made by users with certain health keywords on the web.
Only the inventory of the potentials of Information and Communication Technologies in health leads us to a complex list.
Let’s give some examples in the collective health, and on the other hand (with a deep network of links) in the individual health care, but without forgetting that the beneficial potential has its opposite: the world of communication and information technologies and social networks is in the center of the economic interests of those who see health not as a right, but as an opportunity for their business.
In collective health issues, the use of the large amount of storable and manageable data (big data) for clinical and epidemiological research, tele-education (of health personnel, patient and community groups), clinical practice guidelines or protocols integrated care, health management (including, but also advancing beyond reducing costs and increasing numerical productivity), patient referral and counter-referral systems, management of automated waiting lists (transplantation and others), anticipation, alerts and responses to emergencies and disasters, strategies for the prevention and control of noncommunicable diseases, to mention some areas.
Clinical practice guidelines or integrated care protocols (“Clinical Pathways”) are multidisciplinary care plans that adapt evidence to the local structure, with sequences of actions in the care plan with time criteria that standardize care for a specific problem. in a specific population. (Kinsman, 2010 and Lawal, 2016). They represent an extraordinary opportunity to improve the quality of care, reduce errors (diagnosis, therapeutic, indication of complementary studies, drug interactions, among others) and support the comprehensive individualized management of patients, as well as facilitate group training and the multidisciplinary interaction of the work teams. Its areas are very wide, from the automated management of transplant waiting lists (for example), to the prescription of medicines (including the automation of strategies for the rational use of adequate therapeutic alternatives within national standards), or the rational indication of paraclinical studies among others, based on general guidelines, obviously with the individualization that the therapeutic relationship requires.
In the subjects of individual health: tele-diagnosis, teleconsultation (including prescription), electronic medical record (with its multiple standards and proposals for harmonization for Europe and in the United States ASTM, HL7, and DICOM for medical images), possibilities of organ generation and artificial tissues, three-dimensional impressions of prostheses, support mediated by information and communication technologies of treatment and control of diabetes, pacemakers, arrhythmias, supervision of antituberculosis treatment, virtual consultations specialized in remote places, are just a few areas.
The list of concurrent spaces for information and communication technologies, internet and health is very broad, but also wide and complex is the list of issues that emerge from that confluence for reflection, and that ultimately come together in ethics and power as Michel Foucault would tell us. Let’s just state a few:
-The privacy and its invasion and use (exemplified by the massive espionage on the part of some States put in sight by Snowden and Assange, or the electoral political influence strategies via social networks, through automatic equipment and paid people to distribute messages repetitive), and more if it is in such sensitive and intimate topics as health;
-Equity: and its counterpart by perpetuating inequalities, with access gaps (country, gender, ethnic group, social class, educational level, even language) from the cost of equipment, or internet services, to collection by access to health publications, databases, softwares for medical image management, or the Internet itself, to name a few examples;
-Property of information that circulates through the network about health and its use: for health or for manipulation purposes and marketing strategies (political, products sales, etc.);
-Patients’ chances of accessing health information to make better decisions of their own (or becoming ill with poorly informed distress);
– Illnesses related to the use of ICTs at the individual level: addictions, childhood obesity (related to daily screen times of more than 2 hours, usually sitting), bullying and even induced suicide;
-Potential of manipulation or, on the contrary, of organization of popular power;
-The possible reduction of communication capabilities and true social face-to-face relationships with the excessive and exclusive use of social networks and virtual communities.
But perhaps the greatest danger comes from the potential exercise of power by large corporations that manage cyberspace to generate impact on collective health: Violence, anguish, fear, stress, “Fake news” and its effects, and even the the possibility of a massive cyber attack capable of paralyzing a state, and of seriously affecting public health, by blocking (for example) computer systems or control of electric power in a massive way in large geographical areas and generating more deaths than an atomic bomb, by immediately affecting the information systems, communications, health equipment, lighting of health services, health personnel (urban and vertical transport in health facilities).
It might seem like delirium, but the electromagnetic pulses (according to Donald Trump in the executive order of March 26, 2019), have the potential to affect the technological systems of large areas, detonating a nuclear device 40 km above the surface of the Earth (and just thinking about it produces chills), and the threat is so real that it commands in 90 days: identify the functions, networks and priority infrastructures with a greater risk of (if affected) generating “national or regional catastrophic effects on security.” or public health, economic security or national security “(Trump, 2019, Sec 6 i).
It is also not about succumbing to apocalyptic scenarios, but about posing some questions with Breilh:
“In the sphere of domination, is there what some are calling cyber-control or cybernetic repression? If these new conditions of life under capitalism are true, that is, they are part of the social determination of health and become the object of epidemiology.
A central challenge of the epidemiology of the 21st century is to rethink the power relations that determine life and distribute inequity, incorporating new concepts that capture the new forms of exploitation, submission, subordination, persuasion and conditioning, which contribute to the determination of social order in the current period of accelerated accumulation of capitalism. “(Breilh, 2015 p 977) and also highlights the effects on the ability to engage in multidimensional social relationships (in which the look, physical contact, gestures and experiences shared enrich the verbal language) impose social networks based on the web.
Much remains to be raised in this complex world of cybernetics for the health of peoples (or for their destruction), but without a doubt that from our Southamerican reflection we can generate some proposals beyond the alienation to the consumption of the virtual, and the pueril alternative to ignore it. And it seems that the only possible shield against the cybernetic threat to health, is peace.
Breilh J. Epidemiology of the 21st century and cyberspace: rethinking the theory of power and the social determination of health REV BRAS EPIDEMIOL 2015; 18 (4): 972-982 Available at: http://www.scielo.br/pdf/rbepid/v18n4/1980-5497-rbepid-18-04-00972.pdf Lecture delivered at the IX Brazilian Congress of Epidemiology, Centro de Convenções da Vitória, Federal University of Espírito Santo, Brazil; September 9, 2014; proposal for publication. Simon Bolivar Andean University – Ecuador.
Eysenbach G What is e-health? J Med Internet Res 2001; 3 (2): e20 DOI: 10.2196 / jmir.3.2.e20. Available at: https://www.jmir.org/2001/2/e20/ Based on the author’s speech delivered at UNESCO (Paris), June 2001, Conference of the International Council for Global Health Progress: Global health equity – Medical progress & quality if life in the XXIst century.
Kinsman L, Rotter T, James E, Snow P, and Jon Willis. What is a clinical pathway? Development of a definition to inform the debate. BMC Med. 2010; 8: 31.Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2893088/ doi: 10.1186 / 1741-7015-8-31
Lawal A, Rotter T, Kinsman L, Machotta A, Ronellenfitsch U, Scott S et al. What is a clinical pathway? Refinement of an operational definition to identify clinical pathway studies for a Cochrane systematic review. Lawal et al. BMC Medicine (2016) 14:35 DOI 10.1186 / s12916-016-0580-z
Oliver-Mora M Iñiguez-Rueda L. The use of information and communication technologies (ICTs) in health centers: the practititoners’ point of view in Catalonia, Spain. Interface (Botucatu). 2017; 21 (63): 945-55. Available at: http://www.scielo.br/pdf/icse/v21n63/1807-5762-icse-1807-576220160331.pdf
Trump D. USA EXECUTIVE ORDERS. Executive Order on Coordinating National Resilience to Electromagnetic Pulses INFRASTRUCTURE & TECHNOLOGY Issued on: March 26, 2019. Available at: https://www.whitehouse.gov/presidential-actions/executive-order-coordinating-national-resilience-electromagnetic-pulses/
WHO. EXECUTIVE BOARD EB139 / 8 139th session 27 May 2016 Provisional agenda item 6.6 mHealth: use of mobile wireless technologies for public health Report by the Secretariat
 Eysenbach,2001 “e-health is an emerging field in the intersection of medical informatics, public health and business, referring to health services and information delivered or enhanced through the Internet and related technologies. In a broader sense, the term characterizes not only a technical development, but also a state-of-mind, a way of thinking, an attitude, and a commitment for networked, global thinking, to improve health care locally, regionally, and worldwide by using information and communication technology”
 Trump D. USA EXECUTIVE ORDERS. Executive Order on Coordinating National Resilience to Electromagnetic Pulses. 26 de marzo de 2019. “Electromagnetic pulse” is a burst of electromagnetic energy. EMPs have the potential to negatively affect technology systems on Earth and in space. A high-altitude EMP (HEMP) is a type of human-made EMP that occurs when a nuclear device is detonated at approximately 40 kilometers or more above the surface of Earth. A geomagnetic disturbance (GMD) is a type of natural EMP driven by a temporary disturbance of Earth’s magnetic field resulting from interactions with solar eruptions. Both HEMPs and GMDs can affect large geographic areas.”