Technology Needs In Telemedicine

1. Technology Needs In Telemedicine Rick Craft Lead, Telemedicine Reference Architecture Project Principal Member of the Technical Staff Sandia National Labs rlcraft@sandia.gov 505-844-8873

2. Telemedicine’s Past and Immediate Future First Wave Second Wave Third Wave Early 90’s to present Coming decade Timeframe 60’s-70’s Clinical Development Emphasis Feasibility Industrialization Fringe populations Mainstream Care Delivery Scope Very limited Nature Video links + Instrumentation + Informatics Telemedicine is still young and evolving. Maturing it fully will require vision and deliberate attention to the technical foundations on which it rests.

3. Assessment Plan Control Stimuli Clinical Device Status Observables Clinical Data Aide Doctor Patient Teleconsultation Traditional Encounter Assessment Order Plan Status Control Stimuli Patient Station Doctor Station Observables Clinical Data Clinical Data Automated Assessment Doctor Patient Plan Stimuli Smart Patient Station DoctorStation Observables Assessment Assessment Control Status Doctor Patient Telemedicine Is About More Than Distance

4. Telemedicine Technology State of Affairs • Systems are too expensive to enable wide-spread diffusion • Systems from independent vendors do not interoperate • What can be done “over the wire” falls far short of what can be done in face-to-face encounters • Most systems are sold as turnkey capabilities that are not easily customized to meet end user-specific needs • Reliance on COTS devices designed for traditional clinical environments limits range of settings in which systems can be used This Way To “Anywhere, Anytime” Ubiquity Capability Affordability

5. Less expensive Usable in more places by broader range of people Rich set of clinical capabilities Integration with EHRs Greatest Need Addressing healthcare delivery from a systems perspective Key Telemedicine Technology Needs A New Generation Of Devices Mechanisms for Knowledge Diffusion Interoperability • Vendor neutral station-to-station • Plug-and-play devices • Dynamic federation of distributed components • Self-configuring • Self-calibrating • Education and training for non-traditional actors • Tech-embedded, process-specific decision aides • Intelligent devices • Standardized user interfaces to allow portability of skills

6. Payers Laws & Policies Business Processes Clinical Processes Tools Resources Knowledge People Facilities Diseases/ Conditions Geography Improving Healthcare Delivery Is A Systems Problem • Healthcare systems are complex • Their performance (cost, access, outcomes, etc.) is affected by many factors • Delivery system organization • Business and clinical processes • External policies and financing • Geography and demography • Technology • Small perturbations can yield big changes • Finding the good ones and avoiding the bad can be challenging

7. Fully Optimized Version of Current Delivery System Fully Optimized, Redesigned Care Delivery Structures And Processes Systems Thinking Quality Reengineering Optimization of Care Delivery Current Care Delivery System Redesigned Care Delivery System Transformation of Care Delivery It Must Involve Both Optimization And Transformation This sentiment is echoed in the recent IOM/NAE report on the role of engineering in healthcare

8. Optimization Approaches Have Their Limits Ford’s Woodhaven Stamping Plant Performance Status Assessment Using Up Slack Among Independent Variables A B Safety Training Hit-to-Hit a b Productivity/Yield Ergonomics Inventory Reduction d c Total Product MNT Total Overhead Organizational Dev. Material Utilization D C Quality Systems 0 1 2 3 4 5 6 7 8 9 10 Initial Condition = 0 World Class Performance = 10 1st Survey (4/90) 2nd Survey (11/91) From Systems Thinking by Jamshid Gharajedaghi

9. Why Is This Important? Age Distribution of the US Population Age groups where care burden is greatest Big problems at this level !! Source: 2000 US Census 50,000,000 45,000,000 Current workforce shortages pose difficulty with care burden at this level 40,000,000 35,000,000 Population shift will increase care burden 30,000,000 Population 25,000,000 20,000,000 15,000,000 • We have four choices: • Reduce demand • Raise premiums / taxes • Limit benefits • Extract more value 10,000,000 5,000,000 0 5 to 14 under 5 15 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 to 84 85 and over Age (in deciles) Courtesy of Kaiser Research and HealthTech

10. Healthcare System Modeling and Analysis Requirements for new drugs Proposed regulatory & financial approaches Engineering & Informatics R&D New policy & finance environment Requirements/Specs for new devices & other components New care delivery concepts Devices and other components for clinical evaluation New care delivery concepts New products to market Research findings Policy & Finance Development Clinical Trials New education methods Education methods to be evaluated Healthcare Education The National Healthcare Delivery Sciences Program • Mission: • Identify high-payoff care delivery concepts • Develop resources needed to implement these concepts • Promulgate supporting policies Vision: A “science of healthcare delivery” as advanced as our science of medicine

11. Final Thoughts • The medical establishment is not currently equipped to address this final problem • A partnership between medicine, engineering, law, business, economics, social sciences, and other disciplines is required • No entity currently owns the problem • Not NIH, NSF, DoD, DOE, nor any private concerns • This work could be “birthed” at the local level and then “raised” at the national • Workshops / pilot initiatives would help provide insights needed to engender a national dialog • If successfully cultivated, healthcare delivery science will necessarily drive industry