The FIEEC

The FIEEC (Fédération des Industries Electriques, Electroniques et de Communication – Federation of Electrical, Electronic and Communication industries) is an Industrial Federation that includes 23 professional organizations in the energy, automatic systems, electricity, electronics, digital and consumer goods sectors. The sectors that it represents include more than 2300 companies, employ close to 400,000 people and have revenues of more than 96 billion euros.

More specifically, in the field of telehealth, the FIEEC includes industria-lists in medical technologies (SNITEM), electronic components (GIXEL and SITELESC), software (AFDEL) and home automation (IGNES). It thus covers a wide field ranging from telemedicine to home support and issues of dependency.

ASIP Santé

ASIP Santé (Agence nationale des Systèmes d’Information Partagés de Santé – National Agency for Shared Health Information Systems) was founded in 2009, at the incentive of the Ministry in charge of Health, to reinforce the public coordination of health information systems and to contribute to the improvement of the coordination, quality and continuity of care.

The missions of the agency, under the supervision of the Ministry of Labor, Employment and Health, include the definition, promotion and authorization of reference systems for interoperability, security and uses of health and telehealth information systems.

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THE FIEEC/ASIP SANTÉ STUDY

Objectives and method of the FIEEC/ASIP Santé study on the deployment of telehealth applications in Europe:

The goal of the Telemedicine and Telehealth study, carried out with the participation of the Decision firm at the request of the FIEEC and ASIP Santé, was to do an appraisal of the various telehealth/telemedicine solutions deployed in Europe and to try to identify the critical success factors of these deployments.

The study was carried out in three phases, under the supervision of a Steering Committee which very broadly included the actors involved in this area (industrialists, health professionals, health agencies, National Health Insurance authorities, etc.).

Phase 3: Critical analysis of all of this information to identify the common elements accounting for the success of the industrial development of this type of application.

Projects visited in Europe:

Phase 2: Visits to the selected application sites. Members of the study group made visits to the application sites to become acquainted with the reality of the situations and to gather information regarding their modes of implementation and functioning.

Phase 1: Documentary phase involving inventorying the experiences in deployment of telehealth described in the European sources. This phase allowed the steering committee to select 10 applications that were of particular interest.

• United Kingdom (England) Whole System Demonstrators• United Kingdom (England) NHS National Program for IT• Belgium VINCA Project I and II • Norway Teledialysis - Nett i Nord • Denmark Remote monitoring in pneumology• The Netherlands Ksyos (Teledermatology)• The Netherlands Portavita (Digital logbook)• Germany SHL Telemedezin (Monitoring Medical Center)• Germany Vitaphone (telemedical platform)• Germany TEMPiS

Steering Committee: FIEEC (Joël KARECKI, Olivier GAINON, Yoann KASSIANIDES), ASIP Santé (Michel GAGNEUX, Jean-Yves ROBIN, Jean-Marie PICARD, Philippe SIMIAN, Mathieu MAHR), ALCATEL-LUCENT (Nicole HILL), CATEL (Pierre TRAINEAU), DGOS (Pierre SIMON, Laurence NIVET), CGIET (Robert PICARD), CNAMTS (Nathalie ROYANT, Nathalie SCHNEIDER), CSMF/UMESPE/SNSMCV (Jean-François THEBAUT), CNOM (Jacques LUCAS), CNR Santé (Bruno CHARRAT, Joël MERCELAT), CNSA (Annick MARTIN), DGA (Arnaud DE LA LANCE), FEFIS (Bénédicte GARBIL), FHF (Pierre LESTEVEN), FHP Thierry BECHU, Philippe BURNEL, David CASTILLO, Laurent CASTRIA), FHP-MCO (Fatiha ATOUF), FNEHAD (Elisabeth HUBERT), FNI (Philippe TISSERAND, Maryse GUILLAUME), GIXEL (Joseph PUZO, Michel SCHALLER), HAS (Isabelle BONGIOVANNI, Hervé NABARETTE), HEGP (Guy FRIJA), HOMMES & PROCESS (Jean-Michel DAVAULT), INSERM/ITMO TS (Jacques DUCHENE), LESSIS (Bernard D’ORIANO, Yannick MOTEL), OPTICSVALLEY (Jean-Claude SIRIEYS), PHILIPS (Sylvie TRUCY), SNITEM (Anne JOSSERAN, Jean-Bernard SCHROEDER)

3 studies phases

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Lessons learned from the study

Strategic thinking between public authorities and private actors.

At the end of the joint study, a detailed abstract of which is available in appendix, ASIP Santé and the FIEEC drew the following lessons for health care actors in France.

The factors for success involve:

Increase in users’ knowledge and familiarity of these new techniques.

Flexible and collegial gover-nance suited to the scope of the projects.

Concern about addressing the needs of health care professio-nals and patients.

Adapted and interoperable infrastructures and technologies.

Persistence in the efforts to develop them.

A comprehensive evaluation of the contributions of telemedi-cine and telehealth solutions.

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Telemedicine and telehealth involve stakes in public health policy for all of our fellow citizens and also industrial stakes. As it implies modifications in the organization of care and substantial training efforts, the development of telehealth can also create major industrial opportunities for French companies. For this reason, an industrial strategy rationale must be applied to this field:

The time for experiments is over: it is now time to establish the conditions for the development of telehealth in the country, and then for its exporting.The challenges to be faced, especially the aging of the population, require that telehealth be seen with a comprehensive vision (from home support for vulnerable or dependent people to medical interventions in the strict sense). These considerations must be integrated in a European dimension. The European organization Orgalime thus integrated telehealth as a “lead market” in a report cosigned with the European Commission (Electra report).

The actors in the field (health care professionals, patients, industrialists, National Health Insurance, administrations, ministries, research, etc.) must be closely involved in the elaboration of the strategic orientations for development. They must express their needs and take part in the search for sustainable economic models, because the study demonstrated that addressing these needs is a key factor for success and, conversely, projects with a “top-down” rationale, from top to bottom without consultation, tend to fail.

Need for collaborative strategic thinking between the public and private sectors in France, both in terms of health benefits and for the level of industrial competitiveness that could stem from it.

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Lesson: Have telehealth identified as a major strategic factor within the framework of the National Conference for Industry. Maintain the efforts to lead the industry alongside the agencies and competitive clusters.

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The telemedicine and telehealth projects are innovative and protean. Their multidisciplinarity and the evolutions that they imply in the organization and practice of health, as they exist, also require adaptation of the framework of governance of telemedicine and telehealth.

The study clearly demonstrates that flexible supervision and collegial decision- making are critical success factors for the deployment of telemedicine and telehealth. All of the applications reviewed have implemented this collaborative approach in various forms.

Moreover, the fact that the applications are often small (limited to a region or to a specific pathology) requires regional autonomy in supervision that takes into account the specific factors of the application and the territory, but the coherency of all the regional deployments must be ensured through nationwide supervision dedicated to telemedicine and telehealth.

Flexible and collegial governance suited to the scope of the projects

Lesson: Implement nationwide supervision of telemedicine and telehealth that can coordinate all actors, private and public. This supervision must have the necessary legitimacy and authority so that it is acknowledged by all actors and initiatives. It will be in charge of guaranteeing the coherency of the implementation of telehealth applications, vertically, through regio-nal entities (the establishment of Regional Health Agencies can constitute a coherent territorial network compatible with the scope of the telehealth projects) and also horizontally, through various public and private actors working on deploying applications on a nationwide scale. This supervision should provide incentive, coordination and orientation without taking the place of the actors working directly in the field.

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Telemedicine and telehealth solutions must demonstrate their contribution to the country’s health care system. Only in this way will the authorities be able to accelerate the implementation of this type of projects and financing bodies agree to take the risks necessary for its industrialization.

However, it seems clear that the evaluation of the applications presents difficulties everywhere in Europe inasmuch as it must take into account benefits of different natures, such as qualitative improvements (patient well-being, improved care practices, improvements in terms of public health, etc.) or the gains or savings achieved.

The economic models of these new solutions must therefore be sought and made explicit with many parameters, both in terms of the initial financing and the functioning of the applications.

Evaluation and harnessing, in a comprehensive and decompart-mentalized way, of the advantages brought by telemedicine and telehealth solutions

Lesson: Develop research on relevant economic models based on an evaluation of telehealth applications from both economic and health care standpoints. Demonstrate the feasibility and viability of the solutions over time by integrating these modes of evaluation. Thinking about sustainable business models which bring together all of the stakeholders is certainly necessary: The State, national health insurance authorities, insurers, industrialists, patients, health care professionals, etc.

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The study demonstrates that the most successful experiences have been running for about ten years. This means that efforts towards the industrialization of telehealth must be maintained over a relatively long period.

The deployment of such solutions is medium-and long-term and goes beyond the political time frame. That is why it is absolutely necessary that this development be based on a complete evaluation of the expected benefits and on a strategic will oriented to the long-term.

Persistence in efforts to develop telemedicine and telehealth

Lesson: Maintain the human and financial investments in the projects throughout their maturation (R&D, pilot phase, routine opera-tion). Take a medium-term rationale supported by recognition of the strategic nature of telemedicine and telehealth..

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Lesson: Operationally continue the implementation of the measures recommended by the “Living at Home” project initiated by Mrs. Nora Berra. Deploy, with the main representative orders and organizations of health care professionals, procedures for user-involvement and expression of people’s expectations, so that industrialists could aim to meet them.

Successful telemedicine and telehealth projects have all had in common a relatively long period of gestation, and especially of appropriation by health care professionals or patients, sometimes independently of the initial intention of the project.

Listening to “customers’ needs” is thus fundamental for the deployment of telemedicine and telehealth projects. The “customers’ needs” may be those of health care professionals in the broad sense (nurses, doctors, etc.), or those of patients or the target audiences.

For this reason, it would be valuable to launch a major program around issues of the aging of the population and especially home support for the elderly, addressing the recommendations of the “Vivre chez soi” (living at home) project initiated by Mrs. Nora Berra.

Telehealth technologies, particularly those for home automation and information technologies, can serve as a basis to build solutions that will evolve tomorrow towards telemedicine.

At the same time, there must be an expression of needs process with health care professionals in order to define and offer them simple, user-friendly and effective tools.

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Some of the application sites visited had difficulties because of the reticence to new solutions from users, whether they are patients or, more frequently, health care professionals or even administrations.

It therefore seems essential to inform the groups involved regarding the contributions of the new technologies and give them guarantees of improvement in their daily lives, together with greater security and comfort.

The application sites visited often have professional training programs, R&D skill centers, etc. However, these appear to be relatively insufficient which could hinder the development of the project.

Conversely, when users have become familiar with the telemedicine and telehealth tools, it guarantees their dissemination and continuity. For this reason, increasing knowledge and familiarity is a critical success factor. For health care professionals, it is important to demonstrate how their working conditions will improve thanks to the new technologies. For all users, data security guarantees must be provided for the projects.

This appropriation also involves making explicit the responsibilities of each actor and elaborating contracts with regard to the existing texts, in which the telemedi-cine and telehealth solutions will be integrated.

Increase the knowledge and familiarity of users regarding these new techniques

Lesson: Include users’information and training in all telemedicine and telehealth projects, as of their conception. Increase the number of exchanges with all users. Include modules on Information and Communication Technologies in initial and continuing education programs for healthcare professionals. Make explicit the legal conditions for practicing telemedicine and telehealth.

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All of the applications examined have different technological supports (networks dedicated to telemedicine and telehealth or not, use of high-speed or very high-speed, mobile or wire networks). Nevertheless, they must be compatible with the required use and the desired security conditions.

Consequently, it seems that several conclusions can be formulated:Interoperability is the key factor in industrial deployment of telemedicine and telehealth. The role of industrialists and public authorities in the esta-blishment of reference systems and norms is essential.It is neither necessary nor sufficient to have a national dedicated technical network to develop telehealth and telemedicine applications. Telemedicine and telehealth solutions can be launched on all types of infrastructures, even if certain functionalities are only usable beyond a certain data rate of the telecommunication network. Construction of fiber optics throughout the country is thus a priority.The certification of hardware and software can be an advantage.

Adapted and interoperable infrastructures and technologies

Lesson: Develop cooperation between public authorities and industrials in the standardization of telehealth in order to ensure interoperability of these applications but also to favor the exporting of these techniques by contributing to the work on European and international standardization. Maintain high-level electrical and digital networks (very high speed), in order to meet the requirements in terms of quality and security of the telehealth applications. Work to make the French standardization system more effective and efficient in the service of companies.

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Added-value technology industries seem to be ready to invest in this market of the future to create growth and jobs.Industrial know-how – resulting from both large international groups and innovative SME’s – as well as the quality of research and the health care system in France are favorably involving French companies in world competition.

Conclusion

At the end of the study, carried out in six European countries and covering ten telemedicine and telehealth systems, the FIEEC and ASIP Santé share the conviction that there are industrial opportunities in the field of telemedicine and telehealth.

France could aspire to world leadership in this field if:

Telehealth is recognized as a priority within the framework of a national, long-term industrial strategy;Light, efficient and high-level public / private supervision is imple-mented for the development of telehealth (the dispersion of projects and responsibilities is a major inhibitor). All of the actors involved must take part in this supervision;The action is developed as close to the field as possible, particularly through the regional health agencies, with national oversight proposed by the existing organizations;The interoperability of the systems and equipment is implemented thanks to the standardization and production of reference systems;Telehealth solutions are evaluated from both economic and health care standpoints;On-going economic models can be proposed;The legal framework of telehealth is made explicit;The cultural obstacles to telehealth are removed through greater sensitivity to the expectations of health care professionals, reinforcement of information and trust for the public.

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The aging of the population and the growing demand for care are creating sustained, long-term and global demand (high potential for exporting) for technologies that can improve the efficiency (ratio of quality of patient care / cost) of the French health care system, which is threatened by its growing debt.

The Odense University Hospital Center (10% of Danish hospital services) is an international reference in the carrying out of telemedicine research and development programs in various clinical fields.

This institution, which operates in a “cluster ”, is thus able to find its source of financing, to design and implement systems in partnership with industrialists, to carry out the necessary clinical and economic evaluations and to industrialize qualified systems.

At a time when there is discussion in France about how to finance telemedicine, it seems necessary to have scientific and acknowledged means for evaluation of the systems that are being used today throughout the country.

Three of the telemedicine and telehealth systems observed within the scope of this study in Europe stood out for the FIEEC and ASIP Santé because of their innovative nature and their industrial mode of functioning:

“Cluster” in telemedicineInter-hospital telemedicine networkIntermediation systems

The idea here is not to propose the importing as is of foreign systems that were developed in their specific legal and cultural models, but rather to provide sources of inspiration and to open perspectives to accelerate the development of telemedicine in France.

“Cluster” in telemedicine

The “cluster” organization implemented by the Odense UHC for telemedicine could inspire such collaboration in France, bringing together industrialists, research laboratories and health care institutions to work towards goals in research and development.

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Tempis has demonstrated that the network formed by 2 specialized centers (München and Regensburg) and 13 hospitals for stroke management (expertise based on telediagnosis and teleconsultation) can produce remarkable effects in both clinical and economic terms and also with regard to professional practices.

The network organization allowed for the creation, around two centers of expertise, of a local care center in each of the member establishments, called “stroke units”.

Inter-hospital telemedicine network

These results are based on on-going management of quality and professional training, grounded on dedicated medical coordination.

In the Netherlands, the Portavita intermediation systems (self-management of patients taking anti-coagulants) and Ksyos (putting generalists in touch with specialists carrying out acts of telediagnosis) provide standard on-line services intended for health care professionals.

These intermediation systems have successfully demonstrated their added value to health care insurers, thereby allowing them to stabilize their economic model: Portavita is financed within the framework of “disease management” programs and Ksyos obtained remuneration of both the acts of telediagnosis and of the service rendered. These two systems are extending their range of services to other pathologies. The next level they will tackle is interoperability.

The American “clusters” inspired in France the approach of competitive clusters (cf. Les clusters en France: Pourquoi les pôles de compétitivité ? by Patrick Dambron, L’Harmattan, 2008). On the international level, the notion of “cluster” means the capacity to bring into a network, within a limited area (urban area), innovation, research and higher learning and the capacity to assemble scientific and technical knowledge for the marketing (according to short cycles) of technological products and high added-value services.

Intermediation systems

These intermediation systems bring national and industrial solutions to national needs

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DETAILED ABSTRACT OF THE STUDY “TELEMEDICINE AND TELEHEALTH”

1 - Telemedicine is progressively being introduced into European health systems and few systems are currently stabilized, industrialized and generalized.

1.1 The dimensions of the systems remain limited in terms of the number of patients.

The system, which is the largest one, includes 15,000 patients suffering from diabetes and/or exposed to the risk of venous thrombosis. It is a biological self-control system operating in the Netherlands.Two inter-regional telecardiology systems, allowing for the remote monitoring of pa-tients suffering from cardiovascular disease, were visited in Germany: the first one has 7,000 patients, the second one, 9,000.On the territorial level, the systems visited are of variable sizes:

Teledialysis in the north of Norway: the number of patients involved was not reported to the study delegation, but the managers that we met indicated that between 30 and 40 patients were monitored (as an annual average) by the nephrology department of the Tromsø University Hospital;Medical in-home Telemonitoring of patients suffering from chronic diseases:245 patients receiving care in the United Kingdom between 2008 and 2010 (County of Kent),338 patients have been receiving care in Denmark since 2008 (Province of Funen);Tele-Strokes in the South of Bavaria: in 2009, the Tempis inter-hospital network carried out 3187 tele-diagnoses and administered 431 treatments of thrombosis.

1.2 The economic and organizational models of the systems are not stabilized and remain mostly experimental::

Inter-hospital cooperation.New services financed by the private sector still in the investment phase.Major public projects.

1.3 These systems are evolving in contexts of definition of national “e-health” strategies which aim to:

Establish coherent governance of innovation (in its political, technical, scientific and medical dimensions),Distribute the roles and coordinate the assignments of public bodies (government agencies, expertise and research centers, local authorities, etc.),Make and promote “technical choices”,Maintain or revise investment priorities, under budget constraints.

Appendix

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2 - The recourse of telemedicine systems to public infrastructures remains poorly developed.

2.1 Security:The use of systems of professional cards for the identification, authentication and electronic signature of health care professionals is defined in terms of targets on the European scale.But such systems are very little used in the countries visited (2 systems out of 10 use them, one in the Netherlands, the other one in the United Kingdom).

2.2 Identity::Only one country has unique identifiers for patients (identification number of the national register of individuals on the electronic identity card used in Belgium).The issue of directories of professionals and health care structures is presented marginally within the framework of the systems studied.

2.3 Interoperability:The tools used for carrying out remote medical practices or the sharing of medical data are most often specific solutions.Professional applications (medical office management software and hospital informa-tion systems) are not integrated with these tools.The health data is stored locally and is accessible on line.

3 - However, as they are aware of the necessity of interoperability of health care infor-mation systems, some of the countries have launched standardization policies.

3.1 Several of the countries visited (Denmark, Belgium, United Kingdom…) have underta-ken a “middle out” type standardization policy:

Choice and publication of national standards (derived or adapted from international norms and standards) within the interoperability reference systems.Taking into account of national components, linked in particular to the development of security and trust services allowing for access to data, management of identities and authorizations attributed to health care professionals.Modeling of generic and structuring processes (in particular for the management and sharing of data between health professionals).

3.2 Two other approaches appeared:In Belgium, the authorization of business software is assigned to a legal entity, placed under the supervision of public authorities (according to a formalized procedure of testing, approval and registration).

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In England, a public purchasing policy (choice of solutions) has been implemented within the framework of a national computerization program (one single example among the countries visited: the National Programme for IT in the NHS).

This centralized policy has allowed for more rapid deployments (particularly in the public hospitalization sector).It threatens the interplay of competition and innovation by concentrating the market for software publishing in the hands of a few referenced companies.

These standardization policies are not motivated by telemedicine, but the absence of interoperability of the health care information systems does appear to be an obstacle to the generalization of telemedicine applications.

4 - In terms of the application of telemedicine, telemonitoring of patients with chronic diseases appears to be a major concern in the countries visited, but they are having difficulty finding the right economic model.

4.1 Medical telemonitoring of patients suffering from chronic diseases addresses the following public health issues :

The “Whole System Demonstrator” request for proposals covers both social telemonitoring of dependent persons and medical telemonitoring of elderly patients suffering from chronic diseases (cardio-vascular diseases, type II diabetes, chronic obstructive broncho-pneumopathy). Organized by the Department of Health in England, the operation illustrates a public will to carry out such projects. The pilot projects involved on the local level nonetheless agree on the existence of limitations:

Without subsidies, they are unable to maintain the system in place;The dependency of elderly people calls for structural reforms in terms of the functioning of the health – social welfare sphere and modes of care.

Hospitals, such as the Odense University Hospital (Denmark) for pulmonary care, have become involved in in-home telemonitoring projects. These hospitals acknowledge that organizing on-going, in-home care goes beyond their role and thus is something of a pilot program for them.

4.2 The legislations of several of the countries visited (Germany, The Netherlands, United Kingdom, etc.) are made to organize integrated care programs for chronic diseases. However, this legal framework doesn’t tackle the challenge of a business model.

The reallocation of savings made from decreasing the number of consultations and hospital stays is not sufficient in itself to finance the costs of telemonitoring (medical time, acquisition of equipment, installation, maintenance, training, accompaniment...).In the private sector of telecardiology in Germany, the two service operators we met with stated that they had not reached financial equilibrium, despite the financial compensation that can be negotiated with the national health insurance authorities for the monitoring of chronic diseases.

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4.3 However, along the lines of telemonitoring, Portavita in the Netherlands is a national service (web-based) that allows patients, taking anticoagulants in self-management, to take their measurements and possibly also adjust their medication dosages, under the supervision of specialist doctors via an electronic logbook. The financing has been fully covered since 2002 by the health insurance authorities within the framework of national “disease management” programs. There is a goal of increasing patients’ responsibility, and the measurements are said to show that the results are better than with the classic methods of monitoring, marked by a decrease in the number of consultations.

5 - Teleconsulting and teleassistance open up new paths for development.

5.1 Some of the systems observed are intended to overcome problems of geographic isolation of patients, situations that are found in some countries of northern Europe in particular. These pioneering telemedicine systems are nonetheless mainly for local use.

5.2 On a local-regional scale, inter-hospital cooperation with multiple goals (research, drawing up of protocols, etc.) in Germany, Denmark and Norway, includes telemedicine systems:

Principles: this collaboration between hospitals is implemented without the creation of additional structures but is based on dedicated medical personnel. There is a “headend” hospital, an expertise center for telemedicine. The regional oversight bodies (health authorities and health insurance services) exercise a right of review based on the eva-luation of the results achieved on the medical level and in the reduction of health care expenses. This type of collaboration exists in Germany, Denmark and Norway.Tempis in Bavaria constitutes a successful example of inter-hospital cooperation based on telemedicine for strokes management. München and Regensburg are the two exper-tise centers linked to 13 local general hospitals. Both centers assist the other hospitals in teleconsultation for the diagnosis of strokes and for treatment monitoring. The benefit for the patients and for the health authorities was evaluated: early treatment of strokes decreases the sequelae and thus the cost of on-going care and reeducation and also the costs in specialized establishments or for home care.

5.3 On a national scale, the Ksyos intermediation system (The Netherlands), which puts generalists and specialists in touch with each other, negotiated with health insurance companies the remuneration of acts of telediagnosis in exchange for a reduction of the number of patients referred to specialist doctors. This innovative system introduces an industrial model which, starting with dermatology, plans to broaden its range of applications.

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Table of applications

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Contact : Yoann KASSIANIDESykassianides@fieec.frPhone : +33 1 45 05 70 11

Contact : Anne-Adélaïde SEGUYAnne-Adelaide.SEGUY@sante.gouv.fr Phone : +33 1 58 45 32 90