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Telemedicine. Steven D. Johnson, M.D., M.S. President Voyageur Radiology. The World is Flat Thomas F riedman. How advancing technologies and changing market dynamics are creating new services, products and more importantly a platform and virtual culture to allow innovation.

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telemedicine

Telemedicine

Steven D. Johnson, M.D., M.S.

President Voyageur Radiology

the world is flat thomas f riedman
The World is FlatThomas Friedman

How advancing technologies and changing market dynamics are creating new services, products and more importantly a platform and virtual culture to allow innovation.

innovation and disruption
Innovation and disruption

The development of new technologies may arise from existing technologies in one field applied to a new field or the convergence of several technologies to create a new technology.

magnetic resonance imaging
Magnetic resonance imaging

Magnetic resonance of nuclei discovered in the 1950s

Explosive growth in the study of Molecular structure in chemistry and biochemistry

In the 1970s Paul Lauterbur discovered how to spatially localize magnetic resonance signal

New field of medical imaging born

overview
Overview

Telemedicine defined

Current state of art of telemedicine

Current technologies

Barriers to service

Future directions

telemedicine1
Telemedicine

“The use of telecommunications and information technologies in order to provide clinical health care at a distance.”

early adaptors
Early Adaptors

African villagers used smoke signals to warn people to stay away from villages infected with serious diseases.

Australians used two-way radio’s in the early 1900’s to communicate to flying medical services.

communications technology
Communications Technology

Similarly the advent of the Internet age and personal computers has redefined Society in the 21st century.

Information is now freely available to remote regions with social networking including oral and video communications transmitted across the globe and often independent of international borders.

how internet has changed modern medicine
How Internet has changed Modern Medicine
  • History of data communications
  • How data comminications impact remote medicine
  • How mobile networks are impacting remote medicine
history of data communications
History of data communications
  • ISDN
    • Provides a data communication channel across existing copper telephone lines at a rate of 144 kbit/s,
    • By 1990, due to a world wide effort, National ISDN 1 (NI-1) was made compatible with existing proprietary equipments for telecommunication services.
history of data commincations
History of data commincations
  • T1
    • Provides a data communication channel across existing or new copper telephone lines at a rate of 1.54Mbps.
    • By 1980s T1 was industry standard for communications for businesses and governement entities.
history of data communications1
History of data communications
  • DSL
    • Provides a data communication channel across existing or new copper telephone lines at a rate of 512kb-12mbs.
    • First developed in 1989, ADSL has become an industry standard for many communications for homes, and businesses.
history of data communications2
History of data communications
  • Broadband (Cable/Satilite)
    • Provides a data communication channel across existing cable lines or satiltes at a rate of 512kb-30mbs.
    • First developed in late 1990's, Cable/Satlite has become an industry standard for many communications for homes, and small businesses.
history of data communications3
History of data communications
  • National LambdaRail
    • Established in 2009
    • 12,000 miles fiber optics
    • 1.6 Tbits/s aggregate
    • 99.99% high availablity
    • Transcontinental
    • Over 280 research Universities and Laboratories
    • Private non Corporate funded
history of data communications4
History of data communications
  • Wireless (Wifi, Bluetooth, 1G-4G)
    • Provides a data communication channel across airwaves at a rate of 128kb-54mbs.
    • First implimented in the late 1980's, Wireless has become the industry standard for personal communications.
    • Wifi has become the industry standard for home, business, and governement entities.
    • Mobile Smartphones now offer 4G with data rates of 3-10mbs in remote areas (Hotspots).
summary of bandwidth
Summary of bandwidth

ISDN 128kb/s

T1 1.44mb/s

DSL 512kb-12mb/s

Cable/Satellite 512kb-30mb/s

LambdaRail 1.6Tb/s

Wireless 128kb-54mb/s

communications and medicine
Communications and Medicine

The ability to provide medical services to ever growing numbers of people, in wider and more remote locations, with greater knowledge based sophistication of services is one of the challenges of our Era.

teleradiology1
Teleradiology

Teleradiology is greater than 50% of all telemedicine

“Store and forward” telemedicine

“CLOUD”

Distributed client/ server applications

Data in server, local or cloud

work list can route data to appropriate reading

radiologist, distributed model

teleradiology continued
Teleradiologycontinued

Complex

Work rule driven software

Data transmitted twice

Thin client data viewing technology

Viewing software resides on servers

Remote PC monitor systems view via internet

The image data on the server where the viewing

software also resides

process continues
Process continues

Transmission of image to server for storage and routing out to interpreting network radiologists.

Radiologist interpretation transmitted back to facility and primary care provider for treatment decision

distributed
Distributed

Data in

Tech Support

Upgrades

Add software $

thin client technology

Thin Client Technology

“Zero footprint client”

“Streaming Video”

ramifications of technology
Ramifications of technology

Tech support upgrades

DATA IN

ramifications of technology cont
Ramifications of technology cont.
  • No remote read site Software to support all Thin client data packet viewing
    • Lower Cost
    • Faster movement of data and interpretations
ultrasound
Ultrasound

Minuaturized

Traditional

mobile diagnostic imaging
Mobile Diagnostic Imaging

Services

Digital Radiology

Ultrasound

Cardiac Echo

Electrocardiogram(EKG)

Location

Care facilities of any type

Now possible due to increasing sophistication of technologies and data transfer bandwidths

current state of the art of telemedicine

Current State of the Art of Telemedicine

Technology communication platforms

Patient service requirements

Medical service provider level of training and knowledge

Geographic locations of all the above

tele something
TELE-SOMETHING

Through a technology called telepresence, it creates the illusion that students miles apart are in the same classroom.

Interactive television isn't new. Schools have been doing distance learning for years. But the Ojibwe language telepresence classroom at Deer River High School goes well beyond a simple TV monitor and a camera.

At a pair of long desks, teacher Gerald White and eight high school students recently recited Ojibwe phrases. They faced three huge, high-definition screens at the front of the room. In an identical classroom 25 miles away in Remer, Minn., a classmate was in a room with the same furniture, tan walls and carpet. She also recited Ojibwe phrases, giving the impression that they were all a few feet from each other.

White is the only Ojibwe language teacher within the seven districts that comprise the Itasca Area Schools Collaborative. He said telepresence technology makes him a more effective teacher.

telecommunications continues
Telecommunicationscontinues

Video conference

Mobile device

monitoring

data transfer

communication

telepathology
Telepathology
  • The practice of pathology at a distance
  • Telecommunications technology used to facilitate image-rich pathology data.
  • Systems:
    • Static image
    • Real time
    • Virtual slide systems
    • Digital slide scanners
telepathology cont
Telepathology cont.

Frozen section specimens

Primary histopathology diagnosis

Subspecialty pathology expert diagnosis

teledermatology
Teledermatology

Using audio, visual, and data communication exchange medical information about skin and skin conditions to provide diagnosis, consultation, and treatment.

Digital images

Video conferencing

Teledermoscopy

Mobile teledermatology

current services
Current Services

Teleradiology

Telepathology

Teledermatology

Emergency Medicine

EICU

Telenursing

Telepharmacy

internet interactive services
Internet Interactive Services
  • Patient and healthcare provider, how it works
    • Log On
    • Pay
    • Give History (text or email returned in 30 minutes)
    • Get treatment Plan
    • Get prescription
    • Phone interaction possible
    • Provider Level Nurse 24/7 or Physician M-F 8-8
    • weekends, holidays 9-5
list of diseases nurse support
List of Diseasesnurse support

Acne

Bladder infection

Breast Infection

Burn & sunburn

Cold cough and allergy

Deer tick bite

Ear pain

Flu

Lice

doctor on line
Doctor on line

M-F 8-8 weekend/holidays 9-5

Cough, cold & Flu

Sinus, ear & eye infections

Headaches

Bronchitis

Acne skin conditions

Stomach ache

Allergies

Urinary tract infections

Register and choose a M.D.

Webcam, chat or phone, videoconferencing

Internet or telephone

Home or office no appointment

Compliments traditional healthcare

current services cont
Current Services cont.
  • Telerehabilitation
    • Neuropsychology
    • Speech-language pathology
    • Occupation therapy
    • Physical therapy
  • Telecardiology
  • Telepyschiatry
  • Teledentistry
  • Teleaudiology
the internet age
The Internet Age

New designs of service :

On Line

Technology capabilities on line?

Skype: Voice over Internet provider

Webcam video transmission ( real time)

Any formatted digitized data ( Images)

Streaming Video ( view data before all is sent)

visions of the future
Visions of the future

The environment of telemedicine is moving from its infancy to being a more mature and important component of medical service.

The instrumental components that have allowed the initiation of telemedicine will inevitably expand and become more sophisticated. The continued technological, organizational, and political components that will foster telemedicine will be complex and likely evolving over time.

To understand, anticipate, or envisioning of the future requires a look at where we have been and where we are today.

examples
EXAMPLES

Phone from home, call the Doctor , get the receptionist, get appointment, still sick, maybe call back from Nurse, time delay of hours?

Poor efficiency

Lacks timely service

key components
Key Components

Patient needs

Provider availability

Nurse

Physician

Rad Tech

Ultrasonographer

key components continued
Key Components , continued
  • Data Acquisition technology
    • Phone, patient voice history
    • video, visual appearance
    • Diagnostic Imaging
    • Digital radiograph, ultrasound, CT
    • MRI, nuclear Medicine, PET CT
    • EKG
    • Vital signs, physiologic monitoring
key components continued1
Key Components continued

Transmission Technologies

Phone

wireless

Internet

servers (data centers) (cloud)

routing technology

storage technology

viewing and interpreting technology

how to improve
How to improve?

Efficiency of service

Quality of service

Outcomes!

future
Future

Equipment Add on Apps

barriers to service technology
Barriers To Service Technology
  • Bandwidth and stability of Modes and transmissions
    • Mobile bandwidth capacity and saturation
    • Open access to more bandwidth government controlled.
    • Quality of cell phone coverage
    • Quality of Internet speed and stability
  • Hardware
    • Video
    • Data capture technology (Servers)
    • Desktop or Laptop PC
    • Tablet PC’s
    • Smartphones
regulation barriers
Regulation Barriers
  • Restrictive Licensure Laws
    • State level control limits national level services
    • Anachronistic reimbursement regulations
    • Required to reside in state or spend time at facility
  • New Age Regulation Review
    • Required at state and national legislative level
  • State Licensure – costs, examinations, Facility Licensing
future directions
Future Directions
  • Technology
    • Video telephony
    • Integrated “Cloud” based Technology
    • Robotics
  • Telesurgery
telemedicine2
Telemedicine
  • Increase patient access to medical services
    • Monitoring, diagnosis, treatment
  • Increase timeliness of patient access to medical services
  • Expansion of sophisticated medical expertise
    • Timeliness and location
    • New provider service business models
  • Improvement in medical system efficiency and productivity
telemedicine3
Telemedicine

COST CONTROL!?