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Telemedicine: Networks in the Service of Healthcare Michael J. Ackerman, Ph.D. Assistant Director High Performance Computing and Communications National Library of Medicine Telemedicine

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Telemedicine:Networks in the Service of Healthcare

Michael J. Ackerman, Ph.D.

Assistant Director

High Performance Computing and Communications

National Library of Medicine


Telemedicine

The use of electronic communications and information technologies to provide or support clinical health care at a distance

Telehealth

The use of electronic communications and information technologies to provide or support clinical health care, patient and professional health-related education, public health and health administration at a distance


TELEMedicine:


Telemedicine

Using telecommunications and computers:

To exchange information to support medical decision making

For signal processing and image enhancement

The arrangements for practicing medicine at a distance


Telemedicine

Using telecommunications and computers to exchange information to support medical decision making

Medical Records – EMR and PHR

Literature search

Decision support

Remote monitoring

Consultation and Conferencing


Telemedicine

Signal processing

Physiologic samples

Electrocardiogram

Blood pressure

Heart or chest sounds

Image enhancement

X-ray, CT, MRI

Ultra-sound

Skin lesions

Patient visage


Telemedicine

Arrangements to practice medicine at a distance

Network infrastructure

Licensure / Credentialing / Privileging

Start-up Costs / Reimbursement / Long Term Financial Sustainability

Re-engineering Practice / Clinical Acceptance

Liability

Security

Privacy

}HIPAA


History of Telemedicine

Long undocumented history of providing information at a distance

U. Nebraska: Psychiatry in the early 1960s

Massachusetts General Hospital project with Boston’s Logan Airport in 1968


1971

Telemedicine

to Alaska

via satellite


So what’s new?

1994

1924


TELEMedicine:

The Internet

Broadband


University Corporation for Advanced Internet Development (UCAID)sponsoredInternet2 Program

1996


University Members

212 Members as of March 2008


Internet2 International Partners

Europe

ARNES (Slovenia)BELNET (Belgium)

CARNET (Croatia)

CESnet (Czech Republic)

DANTE (Europe)

DFN-Verein (Germany)

FCCN (Portugal)

GARR (Italy)

GIP-RENATER (France)

GRNET (Greece)

HEAnet (Ireland)

HUNGARNET (Hungary)

NORDUnet (Nordic Countries)

PSNC/PIONIER (Poland)

RedIRIS (Spain)

RESTENA (Luxemburg)

RIPN (Russia)

SANET (Slovakia)

Stichting SURF (Netherlands)

SWITCH (Switzerland)

TERENA (Europe)

JISC, UKERNA (United Kingdom)

Middle East

Etisalat University College (UAE)

Israel-IUCC (Israel)

MCIT [EUN/ENSTINET] (Egypt)

Qatar Foundation (Qatar)

Asia-Pacific

AAIREP (Australia)

APAN (Asia-Pacific)

ANF (Korea)

CERNET, CSTNET, NSFCNET (China)

CDAC, ERNET (India)

JAIRC (Japan)

JUCC (Hong Kong)

MYREN/MDeC (Malaysia)

NECTEC / UNINET(Thailand)

PERN (Pakistan)

REANNZ (New Zealand

SingAREN (Singapore)

TANet2 (Taiwan)

Sub-Saharan Africa

TENET (South Africa)

Americas

CANARIE (Canada)

CLARA (Latin America & Caribbean)

CEDIA (Ecuador)

CNTI (Venezuela)

CR2Net (Costa Rica)

CUDI (Mexico)

REUNA (Chile)

RETINA (Argentina)

RNP [FAPESP] (Brazil)

SENACYT (Panama)


2003

www.nlr.net


Private non-profit nationwide optical Internet Service Provider

Network research channels available

No acceptable use policy (AUP)

University based membership network organization

Access for network management & research

Non-restrictive AUP

National LambdaRailInternet2

www.nlr.net www.internet2.edu


Networking Health: Prescriptions for the Internet

A 2000 study by the:U.S. National Research CouncilComputer Science Technology Boardhttp://www.nap.edu/catalog/9750.html


Commodity Internet vs. NGN

  • Current Internet

    • Passive, unintelligent

    • Best effort

  • Next Generation Network

    • Active, intelligent

    • Guaranteed effort

  • The difference:

    • “Quality of Service” - QoS


The notion of End-to-End “Quality of Service” - QoS

Highly subjective

application-dependent

user-dependent

Difficult to determine

often obscured by smart applications programming

often obscured by network architecture like caching


QoS Features for Healthcare

Bandwidthreservation ( DCN )

Low latency

Low jitter

Variable priority

  • Data Integrity

  • Selectable loss rate

  • Security


Common Network Speeds

Line TypeSpeedTextImage

25x801024x768x24

(mbps)(msec)(msec)

ADSL (down/up)1.4 / 0.12811.43 / 125.13,428. / 146,875.

T-1 - Cable 1.4 11.4313,428.

T-3 45. 0.36 418.

Wi-Fi (802.11g) 54. 0.3 348.

Ethernet (100 base-T)100. 0.16 188.

OC-3 155. 0.1 121.

OC-12 622. 0.026 30.2

Gig-E (1G) 1,000. 0.016 18.8

OC-48 2,500. 0.0064 7.5

OC-192 (10G)10,000. 0.0016 1.9

mbps = mega bits per second msec = milliseconds


Best case storage requirements and transmission times for radiological images

Digital chest film

Mammography

MRI study

Echo-cardiogram study

Via 100 mbps (100 base-T) Ethernet

  • 20 mbytes 2 sec.

  • 160 mbytes 16 sec.

  • 200 mbytes 20 sec.

  • 4,000 mbytes 400 sec. (6min. 40 sec.)


HIPAA - Security and Privacy

Security - assure data integrity, confidentiality and availability:

Administrative policies

Physical safeguards

Technical services to protect data in storage

Privacy - the claim of individuals, groups or institutions to determine for themselves when how and to what extent information about them is to be communicated - policy

For the Record:

Protecting Electronic Health Information

U.S. National Academy Press - 1997

http://www.nap.edu/catalog/5595.html


The Problem: The US has enough health care resources and expertise but they are poorly distributed

Some people have access to too much health care, some have access to too little

Sparsely populated and economically depressed areas lack full spectrum of health care

Generalists may be unwilling to practice in areas without specialty backup

Aging population has increasing health care needs with increased access difficulty

Increasingly ethnically diverse population


Some telemedicine facts…

Almost 50 different medical subspecialties have successfully used telemedicine.

There are approximately 200 active telemedicine networks in the United States, excluding radiology networks.

About half of these active networks are providing patient care services on a daily basis.


Global Benefits of Telemedicine

Potential reduction in health care costs

Keeping patients local retains direct and indirect health care costs

When patients leave the community for health care, their purchasing dollars go with them to the urban community


Healthcare and Next Generation Networking

The U.S. National Library of Medicine is funding test-bed projects to demonstrate the use of Next Generation Networking (NGN) capabilities by the health community. These capabilities include:

  • Quality of Service

  • Security and medical data privacy

  • Nomadic computing

  • Network management

  • Infrastructure technology as a means for collaboration

The demonstrations are designed to improve our understanding of the impact of NGN capabilities on the nation’s healthcare, health education, and health research systems in such areas as cost, quality, usability, efficacy and security.


A Comprehensive Tele-dermatology Program

Oregon Health Sciences University,

Portland, OR


University of Alaska at Anchorage, Anchorage, AK


Baby CareLink

Beth Israel Deaconess Medical Center, Boston, MA


Video house calls for patients with special needs

National Laboratory for the Study of Rural Telemedicine,

University of Iowa, Iowa City, IA


Providing Healthcare to the Underserved Center-City: Tele-ophthalmology

University of Southern California

Advanced Biotechnical Consortium

Drew University School of Medicine

Los Angeles, CA


Tele-Radiology

Most common form of telemedicine

Fits workflow of radiology departments

Reimbursable

First to have clear standards for Telemedicine

Imaging equipment

Communications (DICOM)


Tele-mammography for the Next Generation Internet, Phase II: The National Digital Mammography Archive

Provide a means to store and retrieve a complete clinical record, consisting of digital, mammographic images as well as radiology and pathology reports and related patient information in standard formats and using standard protocols

Multi-layered security

Input and retrieval from multiple locations

University of Pennsylvania, Philadelphia, PA

Y12 National Security Complex in Oak Ridge, Oak Ridge, TN

University of Chicago, Chicago, IL

University of North Carolina at Chapel Hill, Chapel Hill, NC

University of Toronto, Toronto, Canada


A Multicenter Clinical Trial Using NGI Technology

Test the network infrastructure capable of high speed transmission of high quality MRI images for a multicenter clinical trial of new therapies for adrenoleukodystrophy (ALD), a fatal neurologic genetic disorder

Ensure medical data privacy and security.

Kennedy Krieger Research Institute,

Baltimore, MD


Tele-Pathology

Has great potential benefits

Fewer providers need to view images

Reimbursable

Less common than radiology and more complicated

Color is important

Resolution required is much greater

Images take much more storage space

Most PACS systems are controlled by Radiology Departments


Emergency Surge Capacity

Disaster area lacks sufficient number of medical care specialists or providers

Hospital has capacity and equipment to care for patient, but patient needs a specialty consult not available at the facility

Extremely specialized medical expertise not typically available locally may be required

Pediatric Burn Surgeon

Infectious Diseases expert for a specific outbreak

Coordination with Public Health


SMS for Telemedicine

  • Appointment reminders

  • Monitoring chronic illnesses

    • asthma, diabetes, chronic heart failure

  • Health messages

  • Medication reminders

    • AIDS, elderly

  • Reporting laboratory test results

  • Surveillance reporting tool

    • SARS, avian flu, H1N1 flu

  • Emergency alerting tool

  • Personal Health Record (PHR)

  • Questions, consultation

  • Literature search


Medline® via SMS

Outbound SMS

Inbound SMS

Search carpal tunnel syndrome surgery vs. steroid randomized control trial

Surgical decompression vs. local steroid injection in carpal tunnel syndrome: A one year prospective randomized open controlled clinical trial

carpal tunnel syndrome. At one year local steroid injection is as effective as surgical decompression for symptomatic relief.

Lypen, D. Arthritis and Rheumatology, February 2005. “The bottom line”: Over the short

term local steroid injection is better than surgical decompression for the symptomatic relief of


Lessons Learned - Overview

Unanticipated social and economic barriers

Cost “savings” is based on how cost accounting is applied

Lack of equipment and communications standards

Patient demand, as a market force, will drive adoption of telemedicine

No business plan to support telemedicine after grant is completed

Healthcare system must adapt to benefit from the immediacy and quick turn-around afforded by telemedicine


Lessons Learned - Patient’s view

Acceptable to patient

Satisfied with encounters, perception of better quality of healthcare encounter

More personal responsibility for healthcare

Ploy by health care system to prevent referral to specialist


Lessons Learned - Provider’s view

Patient encounter were perceived as longer and more tedious but were actually shorter but more intense

Early provider involvement yields better provider utilization

Information sources made available to provider were under-used


Positive Trends

Better off-the-shelf lower cost equipment

Higher Internet bandwidth to the home

High patient / family acceptance

Applications that improve quality of care

Integration of information systems within institutions and across health care institutions

Wireless technology


Changes likely to drive the future models telemedicine

Reimbursement

Further expansion of Medicare

Home and workplace care

Employers and Payers demands

Leapfrog Group

Pacific Business Group on Health

Imaging devices/point of care lab tests

Electronic Medical Record (EMR)

Sensor technology

m-Health


Changes likely to drive the future models telemedicine: Governmental & Cultural

Consumer expectations of best practices and access to best specialists

Next generation’s acceptance of telecommunication technology

Government Efforts to increase telemedicine

California Prop 1D and Broadband Initiative

FCC grant program

Disaster communication and education networks: FCC 911 response committee


FCC Rural Health Care Pilot Program - 2007

To facilitate the creation of a nationwide broadband network dedicated to health care, connecting public and private non-profit health care providers in rural and urban locations.

$139M per year (Universal Service Fund) for 3 years to 69 projects in 42 states and 3 U.S. territories reaching over 6,000 health care centers.

Provides direct payment to telcos for up to 85% of an applicant’s costs to:

deploy (construct) and operate a dedicated broadband network connecting health care providers in rural and urban areas within a state or region;

connect the state or regional health network to a dedicated nationwide backbone (I2, NLR).

www.fcc.govwww.usac.org


FCC National Broadband Plan - 2010

  • Create appropriate incentives for e-care utilization

  • Modernize regulation to enable health IT adoption

  • Unlock the value of data

  • Ensure sufficient connectivity for health care delivery locations

www.broadband.gov


10.1: Create appropriate incentives for e-care utilization

  • HHS should identify e-care applications whose use could be immediately incented through outcomes-based reimbursement

  • When testing new payment models, HHS should explicitly include e-care applications and evaluate their impact on models

  • For nascent e-care applications, HHS should support further pilots and testing that review their suitability for reimbursement

  • As outcomes-based payment reform is developed, CMS should seek to proactively reimburse for e-care technologies under current payment models


Modernize regulation to enable health IT adoption

  • 10.2: Congress, states and the CMS should consider reducing regulatory barriers that inhibit adoption of health it solutions

    • Credentialing and privileging

    • State licensing requirements

    • E-prescribing

  • 10.3: The FCC and the FDA should clarify regulatory requirements and the approval process for converged communications and health care devices


Unlock the value of data

  • 10.4: ONC should establish common standards and protocols for sharing administrative, research and clinical data, and provide incentives for their use

  • 10.5: Congress should consider providing consumers access to – and control over – all their digital health care data in machine-readable formats in a timely manner and at reasonable cost.


Ensure sufficient connectivity for health care delivery locations

  • 10.6: The FCC should replace the existing Internet Access Fund with a Health Care Broadband Access Fund

  • 10.7: The FCC should establish a Health Care Broadband Infrastructure Fund to subsidize network deployment to health care delivery locations where existing networks are insufficient

  • 10.8: The FCC should authorize participation in the Health Care Broadband Funds by long-term care facilities, off-site administrative offices, data centers and other similar locations. Congress should consider providing support for for-profit institutions that serve particularly vulnerable populations.


Other:

  • 10.9: To protect against waste, fraud and abuse in the Rural Health Care Program, the FCC should require participating institutions to meet outcomes-based performance measures to qualify for USF subsidies, such as HHS’s meaningful use criteria

  • 10.10: Congress should consider providing an incremental sum (up to $29 million per year) for the HIS for the purpose of upgrading its broadband service to meet connectivity requirements

  • 10.11: The FCC should periodically publish a Health Care Broadband Status Report


Home (Consumer) Telemedicine:The Next Frontier

Technology is fostering consumer demand

Telemedicine – reimbursed

Consumer telemedicine – paid for by consumer

Consumer market is largely unregulated

Consumer electronic companies (Sony, Sharp, etc.) all have healthcare device divisions

Consumer awareness is being raised by vendors (Microsoft, Google, etc.)

“Smart Home” reimbursed outside of U.S.

“Smart Car” next?


“A non-profit, open industry alliance of the finest healthcare and technology companies in the world joining together in collaboration to improve the quality of personal healthcare”

“Our Mission is to establish an eco-system of interoperable personal telehealth solutions that empowers people and organizations to better manage their health and wellness”

“We believe that through the efforts of a collaborative industry organization, we can enable a personal health eco-system where many diverse vendors can combine their products into new value propositions with significant health benefits for people worldwide.”

www.continuaalliance.org


The Smart Home


NETWORK

  • Digestible

  • RFID Pills

  • Sphygmomanometer

    • Blood pressure

    • Pulse

  • Glucometer

    • Blood sugar

  • Bathroom Scale

    • Weight

    • Water loss/gain

  • Smart Band-Aids

  • - Chemistry


Teledoc

Robodoc®


Telesurgery

Davinci® robot


The Health - Smart Car

  • Seat

    • Weight

    • Blood pressure

    • Breathing rate

  • Steering Wheel

    • Pulse

    • EKG

    • Blood oxygen (PO2)


Telemedicine

People:

Patients

Providers

Payers


Telemedicine Resources

American Telemedicine Association (ATA)

www.atmeda.org

Association of Telehealth Service Providers (ATSP)

Telemedicine Information Exchange (TIE)

www.atsp.org

Office for the Advancement of Telehealth, HRSA (OAT)

www.hrsa.gov/telehealth

Center for Telehealth & E-Health Law (CTeL)

www.ctel.org

www.telehealthlawcenter.org


The only way to predict the future is to invent it.

Lister Hill Center National Center for Biomedical Communications

I wud b hapi 2 anser ur ??

http://www.nlm.nih.gov


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