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The Telemedicine Center at East Carolina University Division of Health Sciences. Salutes our Military abroad, stateside, and in Eastern North Carolina. ECU Telehealth Mission.

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the telemedicine center at east carolina university division of health sciences

The Telemedicine CenteratEast Carolina UniversityDivision of Health Sciences

Salutes our Military abroad, stateside, and in Eastern North Carolina

The Telemedicine Center

ecu telehealth mission
ECU Telehealth Mission

Improve health care quality & accessby appropriate application of health information & communications technologies and practices

in Eastern Carolina

across our nation

Dr. Dawd Siraj with John Hopkins University connecting to Ethiopia

and outreach to other nations worldwide.

The Telemedicine Center

current ecu telehealth applications
Current ECU telehealthapplications
  • Teleconsultation/Specialist Referral Services
    • patient accompanied by a presenter who’s at a clinical site equipped with peripherals collaborates with a MD or other consultant at a center of medical expertise
  • Distance learning and distance education
    • lecturer or instructor who delivers presentation materials to multiple locations for courses, grand rounds, or continuing education, may need to support student/participant Q&A. May be focused on adult health education/health literacy.
  • Multi-specialty health care collaboration
    • subspecialists at multiple locations collaborating on single case or groups of cases, e.g. tumor board, to discuss treatment options; physician to physician collaboration
  • Patient interview/follow-up/compliance/education
    • direct communication with a patient and/or care giver in situ (e.g. home care) for following up on problems related to a known diagnosis, ascertaining compliance with treatment plans, and/or patient education
  • Meetings/Administrative

The Telemedicine Center

ecu integrated network with local bridge capability
ECU Integrated Networkwith Local Bridge Capability

IP T-1 1.5 Mbps

Internet2, Abilene, National Lambda Rail

Distance Educ & Instructional

Microwave & IP 1.5 Mbps

NCREN - 180 sites

Distance Education/Learning

IP Video

384 kbps - 2 Mbps

REACH-TV - 27 sites

Telemed & Distance Educ

ECU Bridge

Direct / MCUs

ISDN

128 kbps – 1.5 Mbps

Telemed, Dist Ed, Consulting, Mental Hea Dept,Disaster Relief

IP Video 384 kbps

NCIH - 186 sites

Distance Education

POTS 28.8 Kbps

Home Health

Telemedicine, Disaster Relief

The Telemedicine Center

ecu telemedicine history
ECU Telemedicine history

“Go ahead and tee off. Then I want you to listen to this wheezing”

The Telemedicine Center

ecu telemedicine history1
ECU Telemedicine history
  • First consults with State Prison in 1992 – Consult # 00001:Vascular surgery
  • Expansion of existing distance education network to cover residency program and first clinical rooms in rural hospitals -1994

Seventeen“17”

The Telemedicine Center

ecu telemedicine history2
ECU Telemedicine history
  • Established Advanced Telemedicine Training with more than 600 attendees representing 28 countries since 1997
  • Awarded “Center of Excellence” status by University of North Carolina General Administration in 1999

The Telemedicine Center

ecu telemedicine history3
ECU Telemedicine history

Research & development

  • “Tele” diagnostic tools
  • Physician work stations
  • Technical interface development for IP technologies with video tools
  • Development of requirements for distribution of specialty care
  • Telecommunications varieties, wireless, cable, cell, radio, etc.

Dr. Bill Burke in the custom TM station

The Telemedicine Center

ecu telemedicine history4
ECU Telemedicine history
  • Research in Disaster Relief and Bioterrorism Exercises since 1998

Telemedicine Team transports medical supplies and equipment to shelter sites via helicopter

Flood waters consume Eastern North Carolina homes and businesses in 1999

The Telemedicine Center

ecu telemedicine history bioterrorism refugee exercise in 2000
ECU Telemedicine historyBioterrorism/refugee exercise in 2000
  • US Military, the United Nations, ECU and other civilian organizations worked together for the first time in a refugee management exercise at Puu Paa, located on a lava plain on the big island of Hawaii
  • ECU tested tele-medical applications with “live” link to NC physicians

The Telemedicine Center

telemedicine
Telemedicine
  • Not a separate medical specialty.
  • Products and services related to telemedicine are often part of a larger investment by health care institutions in either information technology or the delivery of clinical care.
  • Even in the reimbursement fee structure, there is usually no distinction made between services provided on site and those provided through telemedicine and often no separate coding required for billing of remote services. Presently, in NC only Medicare/Medicaid services use a special telemedicine modifier.
telemedicine history
Telemedicine history
  • Australian Royal Flying Doctor Service 1928
  • NASA 1960s
  • Nebraska Psychiatric Institute 1964
  • Logan International Airport Medical Station 1967
  • Alaska Applied Technology Satellite Biomedical Demonstration 1971
  • STARPAHC 1972-1975
  • Memorial University of Newfoundland 1977
  • North-West Telemedicine Project 1984
  • NASA Space Bridge to Armenia 1988

The Telemedicine Center

telemed delivery mechanisms
Telemed Delivery Mechanisms
  • Point-to-point connections
    • Hospitals and clinics that deliver services directly or contract out specialty services to independent medical service providers at ambulatory care sites may use private networks or secured telecommunications or encrypted technologies (e.g. radiology, pathology, interactive tele-consultations, ICU monitoring services provided under contract, etc.)
  • Primary or specialty care to the home connections
    • Connecting PCP, specialists and home health nurses w/patients over single line phone-video systems for interactive clinical consultations.
  • Home to monitoring center
    • Links used for data collection of cardiac, pulmonary or fetal monitoring, home care and related services that monitor patients in the home.
  • Web-based e-health patient service sites
    • Provide direct consumer outreach and services over the Internet.
    • Electronic medical records
basic telemedicine types
Basic Telemedicine Types
  • Interactive (Synchronous)

-Two way video, real time

- high-bandwidth telecommunication

  • Store and Forward (Asynchronous)

- Images, audio or video files stored and transmitted, like e-mail, usually not real time

- lower bandwidth telecommunication

The Telemedicine Center

ip advantages
IP advantages
  • IP already part of your existing network
  • Can serve multiple applications
    • Telemedicine
    • Electronic medical record
    • Internet interface – E-prescribing, medical info
    • Personal workplace
    • E-mail
    • Other networked functions (databases, printing, file sharing, etc.)
    • Voice or other communication conferencing

The Telemedicine Center

slide16

IP challenges

  • IP networks not designed/optimized for v/c
  • IP video is bandwidth-intensive
    • Cisco recommends video B/W + 20% for IP
  • Technical issues:
    • Congestion/packet loss
    • Variable bit rate
    • Security
    • Firewall issues across networks
    • Integrated vendors/port assignments
    • Peripheral integration
    • Directory services

The Telemedicine Center

security
Security
  • Mandated with HIPAA regulations
  • Circuit-switched N/W’s inherently secure
  • Packet-switched (IP) more challenging, but several solutions:
    • Completely isolated (private) IP N/W
    • Video encryption w/in codec
      • Now interoperable across major H.323 platforms
    • Virtual private N/W (VPN)
    • Firewall
      • Really only protects within your N/W

The Telemedicine Center

tm reimbursement from traditional payors
TM Reimbursementfrom Traditional Payors
  • Interactive (Synchronous)

-Two way video/audio, real time

- high-bandwidth telecommunication driven by specialty

    • Must meet HIPAA requirements
    • Mode for all “lower 48”

Store and Forward (Asynchronous)

- Images, audio or video files stored and transmitted (Radiology, Pathology, Ultra-Sound)

- Lower bandwidth telecommunication

- Exception is Alaska & Hawaii

The Telemedicine Center

reimbursement
Reimbursement

Fee for Services

Rural

Hospitals

Doctor’s

Office

Telemedicine

Specialized

Care Facility

Military Base

Hospitals

Clinical Room in the Naval Hospital

Camp Lejeune, NC - 1996

The Telemedicine Center

revenue contracted services
RevenueContracted Services

Central Prison used 28 types of specialties

Correctional Prisons

Short/Long Term

Telemedicine

School/Child

Care Facility

Home / Office

Travel/ Air

Cruise

The Telemedicine Center

slide21

Sunbury– Happy, Inc.

Ahoskie – Roanoke-Chowan

Ahoskie – Roanoke-Chowan

CNC/ACCESS-Jackson-Proposed

Ahoskie–Roanoke-Chowan Heart Center

Tillery-Community Ctr

EC Behavioral Health- LME

PORT – Rocky Mount-Proposed

Rocky Mount -Nash

Windsor– Bertie Memorial

Edenton – Chowan Hospital

Edgecombe Co. Proposed Spoke

Tarboro - Heritage

Bertie County Proposed Spoke

Tarboro-Heritage Heart

Nags Head - Outer Banks

Raleigh – Central Prison

Wilson - School for Deaf

PORT- Wilson-Proposed

Greenville –Health Steps 4 Units

Raleigh-Governor Morehead School for Blind

BSOM

UHS

Greenville –ECU Cardiology 2 Units

Belhaven - Pungo District Hospital

Greenville-ECU Psychiatry 2 Units

Morganton- School for Deaf

Taylorsville- Alexander Correctional

Maury – Maury Correctional

Goldsboro - Cherry Hospital

Avon - HealthEast Family Care

Lenoir County Proposed Spoke

Goldsboro – Goldsboro Pediatrics

Kinston – Caswell Center

RHA –New Bern-Proposed

Faison - Goshen Medical Ctr

Clinton - HITC

Hospital Site

Medical Center Site

School Infirmary Site

Correctional Sites 2009

Kenansville – Duplin General

Jacksonville – Onslow

Sites with Nurse Presenters

Sites with Trauma Rooms

Cardiology Network- 07-09

Psychiatry Network - 07-09

REACH Network

Rural EAstern Carolina Health – Network

Telemedicine Clinical Sites

RHA – Wilmington-Proposed

top current clinical applications at ecu
Top Current Clinical Applications at ECU
  • Dermatology
  • Pediatric Services
  • Cardiology Adult & Pediatric
  • Radiology
  • Mental Health/ Psyc
  • Rehab/ TBI Clinic/ EMG
  • OB/High Risk/ NCIU “Hello Mommy”
  • Neurology
  • Endocrinology/ Diabetic
  • Home Health Care

James Finley, MD Dept of Pathology with tele-pathology unit to Outer Banks Hospital

The Telemedicine Center

telecardiology network
Telecardiology network
  • Initial 4 sites: (6 additional sites 2008)
    • Heritage Hospital in eastern NC
    • Ahoskie Heart Clinic in eastern NC
    • Health Steps (Local Cardiac Rehabilitation Center)
    • ECU Medical Pavilion, Department of Cardiology
  • Use desktop videoconferencing appliance to coordinate care for Cardiac Heart Failure patients between cardiologist and primary care MD’s
  • Collaboration with Pharmacist, Nutritionist, and Psychologist

Dr. Mariavittoria Pitzalis connects from her office to outpatient clinic in regional Cardiology Rehabilitation Center.

The Telemedicine Center

tele psych network
Tele – psych Network
  • Initial 6 sites:
    • Goldsboro Pediatric Services, Goldsboro, NC
    • HAPPY, Inc, Sunbury NC
    • Cherry Hospital, Goldsboro, NC
    • TarHeel Services, Beulaville
    • ECU Psychiatry Out Patient Clinic
    • ECU Telemedicine Center
  • Use desktop videoconferencing and bridging to coordinate mental health services for patients between primary care MD’s, case managers and other providers
  • Collaboration with other Psychiatrists, Pharmacist, Psychologist, and other Team Members to include primary care giver with patient/family

Dr. Kaye McGinty, ECU child psychiatrist collaborates with psychiatrist at Cherry Hospital, state psychiatric hospital

The Telemedicine Center

traumatic brain injury
Traumatic brain injury
  • TBI Telemedicine Clinic established in June 1998 on monthly basis
  • Six (6) different sites
  • Approximately 45 min-1 hr N/W time/patent including both nurse & physician
  • Total of 156 patients seen
  • No-show rate of 14% * compared to 38% no-show Rate in PCMH Rehab Ctr **

Dr. Jacinta McElligott & Elsie Siebelink, TBI Nurse

  • * including some cancelled clinics due to No physician or Network time during 1998-2000
  • ** Percentages vary annually. This is average of collective years

The Telemedicine Center

ecu teleconsultation outcomes
ECU Teleconsultation Outcomes
  • High patient satisfaction
  • Patient convenience
    • Reduced travel
    • Less time away from work/school
    • Quicker to see specialist
  • Patient compliance
    • e.g. better show rates for TH visits
    • 7 - 10% general no-show rate for all TH as compared to 35 – 42% No Show rate (TBI percentages)
  • Continuity of care
    • Referring MD in the loop
    • Faster turnaround of consultant’s findings

The Telemedicine Center

system integration
System integration #*!
  • Evaluate Need
  • Service Model (24/7)
  • Identify technology
  • Choose telecommunication
  • Participants
  • Design implementation

The Telemedicine Center

telemed clinical tools
“Telemed” Clinical Tools?
  • Patient/Spoke site
  • Medical Specialty Driven
  • Additional switch or inputs

for video sources

  • Mobile capability
  • Patient Room Camera Control
  • Diagnostic tools?

The Telemedicine Center

videoconferencing endpoints
Videoconferencingendpoints
  • “Hard” endpoints
    • Dedicated hardware/appliance
  • “Soft” endpoints
    • S/W and/or peripheral on PC
    • May include hosting service

The Telemedicine Center

hard endpoints cont d
Hard endpoints (cont’d)
  • Several form factors
    • Desktop/executive
    • Small room
    • Large room
    • Roll-about
      • Tandberg Intern
      • Polycom Practitioner
  • In-room or rack mounted outside room
  • Integrate with 3rd party control systems and A/V devices

The Telemedicine Center

soft endpoints
Soft endpoints
  • Numerous vendors, e.g.:
    • Polycom
    • Apple iChat AV
    • Cisco
    • AOL Video Messenger
    • Sightspeed
    • WebEx
  • Improving quality
  • Difficult to integrate TM peripherals
  • Share PC with other apps
  • Limited interoperability
  • Inexpensive

The Telemedicine Center

technical configuration
Technical Configuration
  • Peripherals
    • Otoscope
    • Electronic stethoscope
    • Hand held camera
    • Pan/Zoom/Tilt camera w/far-end control
typical remote site
Typical remote site
  • Usually both TM exam & conference rooms
  • Video instruments
    • Otoscope (ear)
    • Derm camera (skin)
    • Ultrasound, other aux.
  • Electronic stethoscope

NEW ! Mobile desktop unit for clinic connectivity

Legacy units (1994) continuing with ECU engineering support

The Telemedicine Center

new mobile models
New mobile Models
  • Network/Power connectivity
  • Video instruments

Interoperability?

  • Electronic stethoscope
  • Video switcher for Auxiliary inputs including ultrasound
  • HD codec, camera, and display
  • Stereo Microphone
  • Increased Audio Frequency range (up to 22kHz)
  • UPS

The Telemedicine Center

telemedicine suite
Telemedicine suite

Four Tele-exam rooms

each equipped with:

  • Engineer & MD entrances
  • EHR (Logician)
  • PC capability
  • Stethoscope capability
  • House phone
  • Remote control at sites
    • PZT camera
    • Recorders
    • A/V devices

The Telemedicine Center

current th services
Current TH services
  • Specialty tele-consultation
  • Engineering Consultants for NC State Mental Health Network
  • Re-installing/Expansion of NC Department of Corrections
  • HIV/AIDS case review c/ Ethiopia & Johns Hopkins
  • Cardiac Heart Failure Distributed Network
  • Tele-psychiatry Network
  • Neonatal Intensive Care Unit “Hello Mommy”
  • Telepathology
  • Distance learning, meetings, training
    • Medical Missions for Children
    • Telehealth project consultation
  • UHS telehealth services
    • Teleradiology (PACS)
    • Tele-cineangiography (HeartLabs)
    • Home care
    • Disease management

The Telemedicine Center

ecu telemedicine consultants
ECU Telemedicine Consultants

Current applications

  • NC State Division of Mental Health
    • Ten Main Points of Location across the State
    • Network/Infrastructure Research Design
    • Protocol Development for State Mental Health Telemedicine Guidelines
    • Training and Support to 38 additional connecting agencies
    • Network Directory Development
    • Business Hours On-line or Toll Free Support
  • NC State Division of Mental Health
    • Equipment Enhancement/Install Design
    • Fourteen Sites Training and Support
    • Clinical Services
  • UHS/ ECU Medical Campus
    • Emergency/ Trauma / ICU Design
    • Audiology Services with patent Internet system
    • Video Teaching with Medical Skills Simulation Lab

The Telemedicine Center

future telemed at ecu
Future Telemed at ECU

Dental TH applications

  • Specialty consultation
  • Primary dental care
    • Mentoring -- “tele-attending”
    • Screening/prevention
    • Patient education
  • Pre/post-surgical follow-up
  • Interdisciplinary collaboration
  • Continuing Education/Training

Establishing Non-Traditional points of care

    • “Virtual” co-location in primary care
    • Extended care facilities
    • Schools with Tele-Nurse station
    • State facilities

The Telemedicine Center

vision
Vision
  • Available to everyone
  • Health care @ the point-of-convenience
  • Patient is informed & empowered
  • Telehealth/e-health applications assure patient compliance, continuing education, ease of access into health care system, healthy behaviors
  • Clinical data integrated w/ longitudinal EHR
  • Data available to patient (personal electronic medical record) & authorized clinical providers
  • Data & transactions secure to greatest practical extent
  • System components (S/W & H/W) readily interoperate w/o modification

The Telemedicine Center

vision1
Vision

Apply telehealth & IT technologies, systems, principles & practices to enable the provision of health care where it’s needed, when it’s needed

Artist: Francisco Caceres

From MIT Technology Review (Mar. 2000)

The Telemedicine Center

trends observations
Trends/Observations
  • Multidisciplinary chronic disease mgt.
  • Divergence from distance learning techs.
  • Improving consumer infrastructure
    • Broadband connectivity
    • Home wireless
    • High utilization of web & e-mail
    • Consumer electronics
    • Video messaging (SIP)/”soft” endpoints
  • Health consumerism
  • Diffusion of point-of-care technologies

The Telemedicine Center

health consumerism
Health consumerism
  • Consumers attitudes toward healthcare (Arthur Anderson)
  • Health consumerism will drive additional telehealth applications and use
  • Consumers evaluate physicians and medical centers via information available on the web (Healthgrades)
  • Increased computer literacy and net usage
  • Physician/patient e-mail
    • 93% of MD’s w/ access, 14% e-mail w/ patients (Baker, 2003)
    • AMIA guidelines for physician/patient e-mail
  • Electronic personal health record (PHR) applications
    • Internet-based systems
    • Individual enters data & decides who can access their PHR
    • PHR @ Kaiser Permanente NW, Beth Israel, VA, & U. Colo.
    • COTS PHR applications/services (Cerner, GE Med. Sys.)
    • Connecting for Health Initiative’s PHR Working Group (2003) identifying standard elements of PHR systems

The Telemedicine Center

slide43

Health Information

  • Technology
    • Electronic Health Records
    • Practice management systems
    • Clinical decision support
    • e-Prescriptions
    • Alerts/reminders
    • Digital imaging/PACS
  • Telehealth/
  • Telemedicine
    • Specialty teleconsultation
    • Telecare
    • Remote monitoring
    • Distance learning
    • Multidisciplinary care
  • Consumer Health
  • Informatics
    • Personal Health Records
    • Health web sites
    • e-Visits
    • e-Journals
    • Virtual health/support communities

Connected health?

Common denominator is

the network

The Telemedicine Center

challenges
Challenges
  • Lack of physician

education, knowledge and

training

  • Reimbursement
  • Technical interoperability
  • Lack of Directory of ‘Tele’-

Medical Services

  • NO Integrated Med Record
  • NO Integrated Pharmacy services
  • NO inter-pharmacy records
  • NO easy assess center for TH resources
  • Telecommunication Costs
  • Scheduling
  • Slow or limited physician adoption
  • Lack of patient education and demand

The Telemedicine Center

in closing
In Closing
  • Extensive experience in telehealth research, practice, & policy
  • Existing infrastructure (physical & personnel)
  • ECU & institutional support for TeleHealth
  • Myriad opportunities:
    • Effects on access, convenience/efficiency, quality
    • Innovation in health education
    • Development of new clinical services and service models (esp. consumer)
    • Device & software development

The Telemedicine Center

contact info
Contact info

Gloria Jones

Assistant Director

Clinical Operations Manager

ECU Telemedicine Center

(252) 744-3855

jonesgl@ecu.edu

http://www.ecu.edu/telemedicine

The Telemedicine Center