Using Technology in Urban Areas: Preparing for the Future

1. Using Technology in Urban Areas: Preparing for the Future April 26, 1999 Frank Ferrante Senior Manager Mitretek Systems, Inc. Presented to The Emerging Health Information Infrastructure Conference (HII99) Improving Health in a Digital World Sponsored by the Friends of the National Library of Medicine (FNLM) Washington, D.C.

2. Agenda • Technology: Changes and Trends • Digital Healthcare Products • Applications • Current and Future Technologies • Summary

3. 9.6 Kbps Technology: Changes Exponential Multimedia applications: Messaging, documents, desktop conferencing, image storage/retrieval, TV distribution ATM/SONET WDM Networks 100+ Gbps Data Rates 100+ Gbps ATM/SONET Networks 1 Gbps+ 10 Gbps IP Switching 1 Gbps FDDI 100 Mbps 1 Gbps Fast Ethernet 100 Mbps 100 Mbps Ethernet (IEEE 802.3) 10 Mbps 10 Mbps IBM's Token Ring 16 Mbps 1 Mbps • ISDN X.25 56 Kbps 100 Kbps Early Modem Access 10 Kbps 1200 bps Dial-Up Modem Access 300 bps 1 Kbps 100 bps Direct Access 75bps 10 bps 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

4. Technology:Internet Trends • Internet consumer market to reach 43 million in 2000 from 30+ million households in 1998 {INTERNET2 reaching Gbps Rates) Source: The Age of Internet: Capitalization on the Data Opportunity, Information and Interactive Service Report, January 9, 1998

5. Technology:Bandwidth Cost Trends Legend: OC - Optical Carrier Rates (155 Mbps to 4.8 Gbps) WDM - Wavelength Division Multiplexing TDM - Time Division Multiplexing Source: NGN - 1998 Conference Proceedings

6. Technology: Digital Healthcare Products • Digital Blood Pressure Monitor (Sphygmonometer) - less than 10 Kbits of data per second (required transmission rates) • Digital Thermometer - less than 10 Kbits of data (required transmission rates) • Digital Audio Stethoscope and integrated electrocardiogram - less than 10 Kbits of data (required transmission rates) • Ultrasound, Angiograph, - 256 Kbytes (image size) • Magnetic Resonance Image - 384 Kbytes (image size) • Scanned X-Ray - 1.8 Mbytes (image size) • Digital Radiolography - 6 Mbytes (image size) • Mamogram - 24 Mbytes (image size) • Compressed and full motion video (e.g., Nasopharyngoscope, Opthalmoscope, Proctoscope, Episcope, ENT Scope) - 384 Kb/s to 1.544 Mb/s (speed)

7. 8 to 24 bits per pixel 512 to 4096 pixels 512 to 4096 pixels Technology:Teleradiology Applications - Imaging

8. Technology:Image Transmission Times Note: Service classes changing faster than ever 29.1 min. • 2048 x 2048x 12 bit image • No compression Coaxial Modem Range High-Speed Services (45 Mb/s - 4.8+ Gb/s) Medical/Scientific Visualization Medium-Speed Services (384 Kb/s - 45 Mb/s) Medical Images Slow-Speed Services 15.0 min. Assumptions: 32.6 sec. 5.0 sec. 325 ms 1.1 sec. 10.5 ms 21 ms 28.8 Kb/s (Modem) 56 Kb/s (Modem) 1.544 Kb/s (T1) 10 Mb/s (Ethernet) 45 Mb/s (T3) 155 Mb/s (ATM OC-3) 2.4 Gb/s (ATM OC-48) 4.8 Gb/s (ATM OC-96)

9. Technology:ATM Collaborative Computing Desktop Video Teleconference Live or stored video image transfer Collaborative Work Board {Sample: tissue sample from patient} {Sample: discussing telemedical application}

10. WDM Technology • Pre-WDM: • On a single strand of fiber, a point-to-point backbone link would carry an OC-48 SONET signal at a single wavelength • With WDM: • On a single strand of fiber, a point-to-point backbone link could carry multiple wavelengths (color bands) each wavelength capable of carrying an OC-48 SONET signal • Point-to-point throughput increases by a factor equal to number of wavelengths accommodated by the WDM equipment (4-8 in 1995) • Next development trend in WDM is true optical networking via optical cross connects where direct switching of optical signals rather than time slots are performed • Technology trend towards direct IP over WDM (bypassing SONET equipment)

11. Dense Wave Division Multiplexing (DWDM) Cost Savings Versus SONET • Take advantage of DWDM bit-rate independence and lack of scaling capital expenditure as compared to SONET Source: NGN - 1998 Conference Proceedings

12. Technology:Smart Cards • Definition • Plastic card with embedded silicon chip, 1 to 8 kilobytes of memory, microprocessor, operating system in ROM (Read Only Memory). • Capabilities • Typical 1- 8Kbytes storage memory • 32kByte chips being developed • Price range now $2 to $25 per card (8Kb cards @$2) • Medical Applications • Military experimenting in triage situations (Dog Tag replacements) • Insurance firms considering usage to • reduce cost of accounting for medical • future storage of patient records (assuming medical records policy changes takes place) • Progress • Slow, with focus on billing/accounting • Expected to take off in near future if policy on records change • Future • Could be useful in remote areas given inexpensive readers available (current readers cost $300 +) Reference: 3GI home page -http://www.3GI.com/

13. Technology:Wireless • Future Services • Digital Voice and Data services • Fax / Paging (two-way) • Full High Speed E-mail / internet access • 28.8 Kbps to n x 1.5 Mbps • Today’s Services • Basic voice service • Fax / Paging (one-way, two-way) • Limited e-mail and internet access • 9.6 Kbps to 14.4 Kbps H.320 3G Wireless Switch VLR/HLR/ AUC/EIR n X DS1 or DS-3 PSTN Air Interface: MSC 3G l CDMA Based l BSC l 5 MHz RF Channels Base Station IP Gateway Future Corporate Intranet IP Network Video Server Key: AUC Authentication Center BSC Base Station Controller EIR Equipment Identification Register HLR Home Location Register ISP Internet Service Provider MSC Mobile Switching Center PSTN Public Switched Telephone Network VLR Visitor Location Register

14. Technology: Other Available Services Supporting Telemedical Applications • Digital Subscriber Loop Services • Cable Modems • Frame Relay (predecessor for IP networks) • Wireless services (cellular, satellite, other) • Faster CPUs and memory storage explosion • Future growth of digital record keeping acceptance

15. Technology: Summary • Technology is changing exponentially • Internet services in urban areas represent a possible outreach approach to the public with high bandwidth offerings and ubiquity of the services • Cost of bandwidth is dropping rapidly • Telemedicine requires bandwidth which is now becoming more affordable and available in urban areas • Urban areas are ripe for considering new technology applications as never before (e.g., wireless beyond the pager and cell phone explosion

16. Technology:Recommendations • Perform the cost-benefit tradeoff studies now to identify longer term applications of new technologies in telemedicine • Due to the explosive nature of technology changes be flexible in buying into the new offerings (2 to 3 year contracts with options to change or get out; lease as much as possible, don’t own your systems) • Finally, encourage changes in insurance and legal restrictions to allow more telemedicine as facts prove their benefits.

17. Contact Information • Frank E. Ferrante Mitretek Systems, Inc. Senior Manager, Systems Engineering and Acquisition Center for Telecommunications and Advanced Technology 7525 Colshire Drive McLean, VA 22102-7400 Ferrante@Mitretek.org Tel: (703) 610-2905 fax: (703) 610-2984