Der Nutzen von Telemedizin und Telecare/Homecare ist heute nicht mehr umstritten. Es existiert eine große Anzahl von Lösungen und Konzepten. Zum Teil werden sie bereits in der Routine eingesetzt. Die Systeme sind in der Regel vom Typ "stand-alone" bzw. "Insellösung". Ansätze einer Plattformtechnologie sind bei einigen Systemen erkennbar. Gemeinsame Probleme der vorhandenen Lösungen liegen im Bereich fehlender Standardisierung von Dateninhalten und Verfahren sowie einer soliden gesetzlichen und abrechnungstechnischen Grundlage. Von diesem Zustand bis zum flächendeckenden Einsatz von Telemedizin/Telecare ist noch ein weiter Weg. Die vorliegende Arbeit beschäftigt sich vorwiegend mit einem Teilaspekt dieses breiten Themas. Es ist die Frage, wie Telemedizin und Telecare sich optimal in den Arbeitsablauf eines Allgemeinmediziners integrieren lassen. Die Analyse zeigte, dass die Probleme in folgenden Bereichen zu finden sind: * Fehlende allgemeine und internationale Telemedizin-Plattform * Fehlende zentrale elektronische Patientenakte * Unzureichende Offenheit der Praxissoftware * Unzureichende Ko-Existenz von herkömmlichen und telemedizinischen Lösungen * Unzureichende gesetzliche und abrechnungstechnische Grundlage Folgerichtig muss ein Anforderungskatalog aufgestellt werden, der hilft, diese Mängel zu beseitigen. Auf der Basis dieses Anforderungskatalogs wurde ein Konzept entwickelt, in dessen Zentrum die allgemein-medizinische Praxis steht. Im Hintergrund der Praxis ist eine auf vorhandenen Standards fußenden Plattform, die eine flächendeckende Kommunikation aller Teilnehmer ermöglicht, vom Patienten über den Arzt bis zur Fachklinik, Apotheke und Kassenärztlichen Vereinigung sowie Versicherungen. Der Anschluss der Praxissoftware an diese Plattform ist eine wesentliche Voraussetzung zur Implementierung. Ein wichtiger Bestandteil des Konzeptes ist der Vorschlag einer international anerkannten Ontologie (UMLS), die neben der Vereinheitlichung der Dateninhalte auch bei der Internationalisierung helfen wird. Hier werden die gesetzlichen Aspekte nur soweit behandelt, als sie der klaren Vorgabe der Konzeption dienen. Die Implementierung ist nicht in einem Schnellgang möglich. Der Grund liegt darin, dass hier neben den in der Regel langwierigen Gesetzgebungsprozessen eine große Anzahl von Verbänden Mitbestimmung geltend macht, deren Interessen oft in entgegengesetzte Richtungen wirken. Es wird daher notwendig sein, die Einführung erstens schrittweise und zweitens immer im Gleichschritt mit diesen Organen zu gestalten. Ist dies jedoch gelungen, eine solche Plattform zu etablieren, so ergibt sich hieraus ein breites Spektrum von Anwendungsgebieten, wie ein weltweites Gesundheitssystem, bei dem der Patient überall auf der Welt die gleiche medizinische Behandlung wie in seinem Heimatland erfährt. / Today there is no question that telemedicine and telecare/homecare can provide benefit to their users. A large number of such systems are available. Partially they are used for daily works. Normally they are stand-alone, without an underlying platform. In the last few years one can recognize the beginning of a platform technology. The most common problems of existing solutions are caused by the lack of standardisation of data items and procedures, the lack of a reliable legal basis and billing possibilities. It is a long way to go to get the telemedicine/telecare running. This document describes a sub-aspect of the large topic telemedicine/telecare. It includes the question how one can integrate telemedicine/telecare into the daily workflow of a private doctor office. The system analysis shows that problems occurring during the integration can be subdivided into following topics: * Lack of a general and international telemedicine platform * Lack of a generally accepted electronic patient record * Lack of a interoperability of the medical information systems * Lack of a harmonized co-existence of telemedicine and medical works * Lack of a legal basis and billing possibilities As a consequence of the analysis` results a catalogue of requirements must be established which provides the basis for a system concept. The central point of the concept must be the doctor office. Its background should be a set of standards which establishes the platform for the communication between every participant to the telemedicine: patients, doctors, clinics, pharmacy, medical invoice organisations and insurance companies. The most essential requirement to implement this platform is the connection of the IT equipment in private doctor offices to the applications and databases of the platform. The key feature of the proposed concept is the integration of a international accepted ontology. We recommend the UMLS concept of the NIH. UMLS provide a set of standardized terms, the so called "concepts", and the possibilities to implement multilingual applications. In this document legal aspects are discussed only if they can contribute to the construction of the platform. Due to the never ending legislative process and the opposite interest of the participants to the platform a high-speed implementation of the platform can not be expected. A stepwise implementation which continuously accompanies the legislative processes is therefore required. However based on a successful implementation of the platform the gate is open to a large range of applications in a widely used healthcare system which can provide medical care to every patient at any time and at any location - worldwide - on the same quality level like in his home country.

Telecare has been an approach to care that, internationally, has experienced a generally rapid development during the last ten years. There are many examples of successful pilot projects where ICT applications have been used in the care of elderly: for improved remote consultation with health professionals, to improve the communication and support of the elderly person’s social network, and as intelligent sensors intended to improve the safety of the elderly person. Despite these successes, implementation has been slow. This research project was set up to provide additional knowledge on some of the important questions regarding quality and implementation aspects of the use of ICT application on the care of frail elderly persons. The overall aim of the research project is to illuminate reasoning and experiences of using applications of telecare for frail elderly persons. The research project comprised five studies that were conducted using qualitative research methods. Four of them were carried out within the framework of three telecare projects. Different qualitative research approaches such as content analysis, phenomenological hermeneutics and conversational and discourse analysis were used, in accordance with the research questions of each study. The experiences revealed in the findings of the studies indicate that it is possible to have communication of good quality via videoconferencing with frail elderly persons, even those that have mild or mid-level dementia, provided the conditions are right. Technical limitations of the videoconferencing media in transferring communication cues and the limitations on what the camera can expose place special demands on those communicating with the frail elderly and on the general setting. On the other hand, these limitations on the context of interaction in some situations also seem to be an advantage for demented elderly persons and contribute to increased attention. One example of meaningful remote communication with frail elderly persons was family members’ videophone conversations with their demented relatives when they were placed in nursing homes or homes for respite services. This communication gave new possibilities of being involved in caring for, and of maintaining a relationship with, their demented relative. An introduction of teleconsultations in the care of frail elderly persons will, according to the experiences recorded, affect the professional role and the practical spheres of involved health professionals. The perceptions and experiences of participating health personnel indicate that in order for ICT applications to become valuable assets in the care of frail elderly persons they have to be part of a care alternative that is viewed by all concerned as the best alternative, as a whole, for all affected parties. Further research is needed in order to confirm or refute the findings of this thesis and in order to further broaden our understanding of the use of ICT applications in the care of frail elderly persons. This could facilitate a development of ICT applications suitable for the care of frail elderly persons and their introduction into regular care activities, to the benefit of both the frail elderly persons and their carers.

This thesis reports from a telecare evaluation in a Norwegian municipality (2012-2016). The project was established to provide domestic results from a hitherto new field in the country to underpin future policy. This evaluation includes pre- and post-implementation data collection, which has been scarce in telecare. The methodological approach was realist evaluation that seeks to explore how telecare works, for whom, why and in which circumstances – or why it does not work. The research aimed to explore the hypothesis elicited from national policy documents: ‘If telecare is used, then people are enabled to remain safe in their own home for longer’. Various methods were used to gather data from multiple stakeholders as they have different knowledge about how the implementation developed. The methods in this evaluation included literature reviews, observations, and sequential interviews with users and relatives in addition to sequential focus groups with frontline staff. Realist evaluation was particularly suitable in demonstrating how and why telecare is useful to some users but not to others. Telecare had to match users’ abilities and needs for them to benefit from it. Telecare operates in a dynamic context, and therefore requires adjustment according to the user’s current situation, taking into account changes as they occur. This appears to have been often underestimated. Telecare holds a different position from other devices and technologies in people’s everyday life, which also needs to be acknowledged. Correct assessment is significant for users to obtain the intended effect from telecare. When telecare is correctly adjusted to users, it increases safety, which is essential for enabling older people to remain living at home. Several challenges in establishing telecare projects are identified and alternative ways to understand multi-disciplinary partnerships are suggested. By using realist evaluation the findings are nuanced and point to elements that are significant for achieving the intended outcomes.

Cette thèse interroge principalement le régime temporel et la dimension psycho-émotionnelle des patients atteints de maladies chroniques (diabète, insuffisances rénale et cardiaque) engagés dans des protocoles de télésurveillance et d’auto-gestion de soins à domicile en France : un ensemble de pratiques que l’on nomme le télésoin. L’analyse phénoménologique de « l’expérience patient » de la dialyse à domicile, du suivi cardiaque à distance et de l’insulinothérapie, remet au centre de la réflexion éthique les valeurs de temporalité et de sensibilité affective, constitutives de l’identité du « sujet de soin ». Mis à l’épreuve des objets informatisés du soin et autres objets connectés captifs de la temporalité de la maladie, que l’on appelle « chrono-technologies », l’individu n’est cependant pas l’objet neutre d’un symptôme à décrypter. Le patient est en effet une personne, c’est-à-dire à la fois un être personnel et un cosoignant dont le savoir sur la maladie peut et doit être pris en charge par des pratiques « chronosensibles», soucieuses du régime temporel et de la dimension psycho-affective de la personne.Ces pratiques relèvent d’une éthique axée sur la vulnérabilité, la santé émotionnelle et la dimension relationnelle du soin, reconnaissant sa dette envers l’éthique médicale et l’éthique Ducare, qui vise un triple objectif : encadrer les bonnes pratiques du télésoin, définir les conditions de possibilité d’une nouvelle alliance thérapeutique respectueuse des personnes dans leurs valeurs propres et leurs préférence et réconcilier la technicité et l’humanité du (télé)soin. / This thesis examines primarily the temporalities and the psycho-emotional dimensions of diabetes, chronic renal and heart failures in French patients engaged in home telemonitoring and self-care management practices, also known as telecare. Based on patients experience, the phenomenological approach to home dialysis, heart telemonitoring and insulintherapy proposed in this thesis, brings the values of temporality and affective sensibility, whichare constitutive of the “care subject’s” identity, back to the center of the current ethical debate.Technologically-challenged patients, using computerized devices and other connected objects to collect time-sensitive data about their health, also known as “chrono-technologies”, are not neutral carriers of diagnosable symptoms. Indeed, patients are persons, or personal beings aswell as co-carers, whose know-how must be acknowledged in “time-sensitive” care practices. Such practices, which address patients’ temporalities and psycho-emotional issues, require a relational ethics, inspired by medical ethics and an ethics of care, focusing on vulnerability andemotional health. The aim of this relational ethics is threefold: overseeing telecare good practices, defining the possible conditions for a new therapeutic alliance compliant with patients’own values and preferences and reconciling the technical and human sides of (tele)care.

Syftet med den aktuella kvalitativa studienär att utifrån av empiriska datafördjupa förståelsen för äldre deltagares upplevelser av Må Bra TV(MBT). Metod: Sammanlagt sju äldre från Åboland skärgård som har använt sig av MBT har intervjuats. Data har analyserats enligt Corbin och Strauss modifierade version av grundad teori.Huvudresultat:Det centrala i MBT visade sig vara samvaron i de virtuella möten där deltagarna träffade varandra och studerandevid högskolan.”Att få och ge stöd genom interaktiva möten”framstod där med som en kärnkategori i analysen av data. I analysen av intervjuerna kunde ytterligare fyra kategorier identifieras som alla var relaterade till kärnkategorin. Dessa kategorier beskriver deltagarnas upplevelser av konsekvenserna av att delta i virtuella möten. De upplevde att trots att tekniken kunde vara en utmaning, så vidgades både deras vyer och deras aktivitetsnivå och dessutom ökade deras självförtroende av att de klarade av deltagandet. De kategorier som genererades i analysen benämndes ”Att lärasig använda ny teknik”, ”Att få möjlighet till vidgade vyer”, ”Att bli aktiv i vardagen” och”Att erhålla stärkt självförtroende” Slutsats: Kärnkategorin i den resursförstärkande metoden är social samvaro. Studien bidrar med kunskap om hur socialt stöd kan användas i utveckling av hälsofrämjande televård för äldre. Mer forskning behövs för att kunna utveckla ett multiprofessionellt resursförstärkande vårdarbete som kan förverkligas virtuellt / The aimof this qualitative study sought to deepen understanding of elderly participants’ experiences withMå BraTV (MBT). Method: Seven elderly individuals living in the Turunmaa Arcipelago, allthe participants in MBT, were interviewed. Data were analyzed according tothe Corbinand Strauss modified version of grounded theory. Main results: This study determined that the essence of MBT is the sense of togetherness accomplished invirtual meetings with other participants and university students."To get and give support through interactive meetings" became thecore category.Analysis also identified four related subcategories, including“learning to use new technologies, to have the possibility towiden own views, becoming activein everyday lifeand to obtain stronger self-confidence". All categories describe the participants' perceptions of the consequences of participating invirtual meetings. Even though the technology was challenging, they felt that they gained anopportunity to learn new things, became more active in daily living, and increased their level of self-confidence. Conclusion: The core category in the resource strengthening metho dissocial interaction. This study contributes knowledge about how social support can enhance the development of health promotive telecarefor the elderly.More researchis needed to develop a multi-professional, resource-strengthening model of care that could be realizedvirtuall / <p>ISBN 978-91-86739-37-9</p>

Contexte. La pandémie de la COVID19 (maladie à coronavirus) a entrainé une réorganisation rapide des services de santé en mars 2020, au Québec et dans le monde. La télésanté, qui ouvre de larges perspectives pour faciliter l’accès aux services de santé, a gagné en popularité durant cette période. Les systèmes de soins de différents pays ont mis sur pied des solutions de télésanté ; plus particulièrement des programmes de téléconsultation afin de maîtriser l’afflux des patients dans les centres de soins de première ligne, de gérer le nombre de lits disponibles et de limiter les contacts pour éviter la propagation du virus. Plusieurs travaux actuels décrivent le potentiel d’utilisation de la téléconsultation dans le contexte de la COVID-19 dans les soins médicaux et infirmiers, mais très peu dans les autres types de soins dispensés par d’autres professionnels de la santé. Objectifs. Cette étude vise à apporter des connaissances sur l’utilisation et la perception des professionnels de la DSM, ayant utilisé la consultation à distance durant la pandémie de la COVID-19 au Québec. Notamment à travers les facteurs qui ont influencé son utilisation. Nous ferons ressortir aussi les avantages et contraintes perçus de cette modalité de prestation de soins. Méthodologie. Le devis mobilisé pour atteindre cet objectif est une étude de cas qualitative descriptive, exploratoire et rétrospective. Cette recherche est basée sur l’analyse de 16 entrevues individuelles semi-structurées réalisées auprès de personnes affiliées à la direction des services professionnels d’un centre hospitalier universitaire au Québec. Ces entrevues ont été réalisées avec les professionnels qui ont recouru à la téléconsultation durant la crise de la COVID-19. Elles ont fait l’objet d’une analyse de contenu à l’aide du logiciel QDA Miner 5 selon une approche thématique émergente. Résultats. Au terme de cette étude, l’analyse des résultats montre une évolution de la perception des professionnels de la téléconsultation pendant la pandémie de COVID-19 et une nette augmentation de son utilisation. Les répondants ont partagé divers avantages perçus et améliorations à apporter. Les principaux bénéfices perçus concernaient l’amélioration de la continuité des soins, une meilleure observance du traitement par les patients et la personnalisation des soins par l’accès au milieu de vie des personnes. Les obstacles les plus importants étaient le réseau internet et l’augmentation de la charge de travail. Un modèle hybride de prestation de soins est en train d’émerger. Conclusion. L’expérience des répondants par rapport à la téléconsultation s’avère particulièrement positive, et ce, malgré les contraintes mineures rencontrées en contexte de pandémie de COVID-19. Ces résultats permettront d’élaborer des stratégies pouvant les aider dans leur pratique au-delà du contexte de COVID-19. / Background. The COVID 19 (coronavirus disease) pandemic led to a rapid reorganization of health services in March 2020. Telehealth, which opens great prospects for facilitating access to health services, gained in popularity during this period. Healthcare systems in different countries have developed telehealth solutions; more specifically, teleconsultation programs to control the influx of patients into primary care centers, manage the number of available beds and limit contacts to prevent the spread of the virus. Several current studies describe the potential for the use of teleconsultation in the context of COVID-19 in medical and nursing care, but very little in other types of care. Objective. This study aims to provide knowledge on the use and perception of DSM professionals, having used remote consultation during the COVID-19 pandemic in Quebec. In particular through the factors that influenced its use as well as the perceived advantages and constraints. Methods. The design used to achieve this objective is a descriptive, exploratory, and retrospective qualitative case study. This research is based on the analysis of 16 semi-structured individual interviews conducted with people affiliated with the professional services department of a university hospital in Quebec. These interviews were conducted with professionals who used teleconsultation during the COVID-19 crisis. They were subjected to content analysis using QDA Miner 5 software using an emerging thematic approach. Result. The results show that the main perceived benefits focused on improving the continuity of care, better adherence to treatment by patients, and personalization of care by having access to people’s living environment. The biggest barriers were the Internet and the increased workload. Conclusion. The experience of respondents with teleconsultation is particularly positive, despite the minor opposites encountered in the context of the COVID-19 pandemic. These results will make it possible to develop strategies that can help them in their practice beyond the context of COVID-19.

Recent years have seen an influx of medical technologies capable of remotely monitoring the health and behaviours of individuals to detect, manage and prevent health problems. Known collectively as personal health monitoring (PHM), these systems are intended to supplement medical care with health monitoring outside traditional care environments such as hospitals, ranging in complexity from mobile devices to complex networks of sensors measuring physiological parameters and behaviours. This research project assesses the potential ethical implications of PHM as an emerging medical technology, amenable to anticipatory action intended to prevent or mitigate problematic ethical issues in the future. PHM fundamentally changes how medical care can be delivered: patients can be monitored and consulted at a distance, eliminating opportunities for face-to-face actions and potentially undermining the importance of social, emotional and psychological aspects of medical care. The norms evident in this movement may clash with existing standards of 'good' medical practice from the perspective of patients, clinicians and institutions. By relating utilitarianism, virtue ethics and theories of surveillance to Habermas' concept of colonisation of the lifeworld, a conceptual framework is created which can explain how PHM may be allowed to change medicine as a practice in an ethically problematic way. The framework relates the inhibition of virtuous behaviour among practitioners of medicine, understood as a moral practice, to the movement in medicine towards remote monitoring. To assess the explanatory power of the conceptual framework and expand its borders, a qualitative interview empirical study with potential users of PHM in England is carried out. Recognising that the inherent uncertainty of the future undermines the validity of empirical research, a novel epistemological framework based in Habermas' discourse ethics is created to justify the empirical study. By developing Habermas' concept of translation into a procedure for assessing the credibility of uncertain normative claims about the future, a novel methodology for empirical ethical assessment of emerging technologies is created and tested. Various methods of analysis are employed, including review of academic discourses, empirical and theoretical analyses of the moral potential of PHM. Recommendations are made concerning ethical issues in the deployment and design of PHM systems, analysis and application of PHM data, and the shortcomings of existing research and protection mechanisms in responding to potential ethical implications of the technology.